Peri-Implant Therapy for the Dental Hygienist. Susan S. Wingrove

implant dentistry that the implants do not decay.

      A smoker can also be a good candidate for implant therapy if he or she first attends a smoking cessation program and agrees to the risks associated with possible loss of the implant. Immunosuppressed patients, such as HIV‐positive patients, who want to improve digestion can be considered for implants, but would need to be controlled and monitored.

      Age, osteoporosis, and periodontal bone loss may also be an obstacle that can be hurdled. Periodontal maintenance patients who are compliant with home‐care can be excellent candidates, but should be placed on 3‐month recare for implant maintenance. The same bacteria that caused the periodontal disease will still be present in their oral cavity. If a patient enquires about having an implant, review all the options and let the patient know that the doctor will determine if he or she is a candidate for implant therapy.

      An edentulous patient at any age can benefit from implant dentistry; there is no cutoff age. As a general rule, it is recommended that growth be completed prior to implant placement for children younger than 16 years of age, but younger children can be considered for implants on an individual case‐by‐case basis.

      The hygienist is the ideal person to assist the dentist in the selection process to determine the patient’s motivation, dexterity for home care necessary for the selected treatment and expectations of therapy outcome, as well as to identify patients with risk factors, habits, and conditions that place patients at a higher risk for implant failure. The hygienist can talk to the patients about their needs, expectations, and questions to share with the dentist. Due to the hourly schedule that most hygienist have, if a patient is interested in implant dentistry a separate appointment can be made with the dentist to have an implant consultation.

The patient’s aesthetic and functional expectations have a direct correlation to the number of implants necessary, type of restoration to be used, time to heal, and how much the final cost of treatment will be. All of these factor into patient selection and need to be discussed with the patient prior to treatment.

      A complex or larger treatment case will require a separate treatment conference and possible models or other diagnostics prior to the conference. Schedule the conference with the doctor and/or implant coordinator to walk the patient through the treatment options, time involved, and fees associated with the case. The doctor may also need to collaborate with the patient’s physician prior to proceeding with implant therapy due to the systemic health factor.

      Implant treatment planning is interdisciplinary and the hygienist needs to have an understanding of oral‐systemic health, medical history, and risk factors to assist with the necessary diagnostics and questions/answers for the dentist to complete the best treatment plan for the patient.

Oral‐systemic health link to overall health

      It is now widely accepted and confirmed through research that there is an oral systemic connection. A link established between bacterial infections, oral bacterial biofilm, and cytokine release in periodontal tissues. The link between oral infection and certain systemic diseases has taken center stage, and inflammation is the key!

      Who better to identify inflammation than hygienists who evaluate for potential periodontal disease on a daily basis? Periodontal disease is one of the major inflammatory diseases in the body. Dental professionals, therefore, hold a key role now, not only in the treatment of periodontal disease and peri‐implant disease but also in comprehensive disease management.

      Periodontal medicine is now the coined term that looks at the risk for certain systemic diseases that is increased by an oral infection (i.e., periodontal and peri‐implant disease) from patients’ inflammatory response to infection. To fully understand the severity of the problem, a basic knowledge of how bacteria from the periodontal or peri‐implant sulcus gains access to the systemic circulation (i.e., blood stream) is important.

The bacterial biofilm comes in contact with ulcerated epithelium, which creates a pathway directly to the systemic circulation. Gram‐negative bacteria, which are always present in the oral cavity, have access to the blood vessels, which allows the infection to reach other tissues and organs throughout the body. Periodontal and/or peri‐implant disease act as a reservoir of pro‐inflammatory mediators or modules that enhance the inflammatory response. They enter the systemic circulation and can induce and/or perpetuate systemic effects that can ultimately affect the overall health of the patient (see Figure 2.1).

There are four major diseases with proven links to periodontal disease and are by association considered risk factors for peri‐implant disease: cardiovascular/cerebrovascular disease, preterm birth/low birth weight, diabetes , and respiratory disease ; see Box 2.1.

Figure 2.1 Inflammation process.

Box 2.1 Four major diseases linked with periodontal disease/risk factors for peri‐implant disease.

      Cardiovascular/Cerebrovascular (CV/CV) disease: A link between periodontal/peri‐implant disease and cardiovascular disease/stroke has been established. Changes caused by infection and/or inflammation responses affect the build‐up of plaque on the inner lining of the blood vessels supplying the heart (coronary arteries) or brain (carotid arteries) and atherosclerosis can occur (4, 5).

      Preterm birth/low birth weight: Studies have proven a link between periodontal/peri‐implant disease/infection and the risk of adverse pregnancy outcomes, including preterm birth and low‐weight babies (6, 7). This is caused by the action of blood‐borne oral bacteria or an increase in the blood levels on the inflammatory mediators that can cause early delivery.

      Diabetes: Periodontitis/periimplantitis is a proven complication and all patients with diabetes should be evaluated for periodontal disease and monitored for signs of infections in the periodontium of implants. Good news, controlled diabetics show the same dental implant survival rate as patients without diabetes and it is now considered a predictable dental rehabilitation procedure for diabetics. (8)

      Respiratory disease: Lung diseases, especially hospital‐acquired pneumonia, are linked to poor dental health. Pulmonary pathogens in plaque are aspirated into the lungs increasing the risk of pneumonia and chronic obstructive pulmonary disease (COPD). This includes implant patients with implant supported removable overdentures, often the implants are overlooked in institutional care facilities without the necessary information on care of dental implants. Treatment for good oral health care can reduce the patient’s risk of fever and fatal aspiration pneumonia (9–12).

Cardiovascular/cerebrovascular (CV/CV) disease

      There is a documented association between inflammation, periodontal/peri‐implant disease, infection, and the risk of cardiovascular/cerebrovascular (CV/CV) disease. The national survey of health conditions of the US population collected between 1988 and 1994 (NHANES III database) states; “the relationship between periodontal attachment loss and the risk of myocardial infarction was demonstrated.” This data suggest a real and important influence of periodontitis on the risk of CV/CV disease. According to the American Academy of Periodontology (AAP) Mouth Body Connection, “Researchers have found that people, especially diabetics with periodontal disease are almost twice as likely to suffer from coronary artery disease” (4).

      As dental professionals, we can provide treatment for periodontitis/implantitis that may help prevent the onset of and delay in the progression