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The Magazine for all Canadian Hygienists and Therapists
Preventive
Dentistry Canada
Dental Implants: Oral Hygiene and Maintenance Smoking Prevention: The Team Approach
Vol. 1 No. 1
I May 2010
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Preventive
Vol. 1 No. 1
Dentistry Canada
in this issue
features 6
Palmeri Publishing Inc. Publisher: Ettore Palmeri, MBA, AGDM, B.Ed., BA
I May 2010
Dental Implants: Oral Hygiene and Maintenance
Editor-in-Chief: Dani Botbyl, RDH
Canadian Office: 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Tel: 905-489-1970 Fax: 905-489-1971 Email: ettore@palmeripublishing.com
Gregori M Kurtzman, DDS, MAGD, DICOI and Lee H Silverstein, DDS, MS
Preventive Dentistry Canada is committed to presenting cutting edge education in order to optimize patient care. A quality journal for hygienists and dental assistants who want to keep up-to-date on education and developments in preventive dentistry. Articles published express the viewpoints of the author(s) and do not necessarily reflect the views and opinions of the Editorial Board. All rights reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner. Publication Dates: May, September, December Design & Layout: Lindsay Hermsen B.Des.Hon. Printed in Canada Canadian Publications Mail Product Sale Agreement 40020046
12
Smoking Prevention: The Team Approach Graham Cope, Carole Bartley
editorial board
Dani Botbyl, RDH Murray Arlin, DDS Kathleen Bokrossy, RDH
Marilyn Goulding, Laura Iorio, RDH
Kim Ivan, RDH
RDH, BSc, MOS
May Diakoloukas, Stephanie Donnelly, CDA Level II RDh, BSc
Sylvie Martel,
Carolyn Rose,
RDH, HD
RDH, BA
departments 4 Editorial 15 Clinician's Corner 16 Q&A: Ask the Expert & 18 Products Announcements Dani Botbyl, RDH
Dani Botbyl, RDH
Murray Arlin, DDS, FRCD (C)
Beth Ryerse,
Lisa Shoemaker, Cheri Wu,
Jennifer Zurbrigg,
RDH
RRDH, BA
RDH
RDH, BDSc
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Editorial
Preventive Dentistry is Collaboration Dani Botbyl, RDH
W
elcome to Preventive Dentistry Canada! On behalf of the entire team, we are extremely proud to present this inaugural issue, the first of many, to those who dedicate their profession to preventive dentistry. For me, the opportunity to be part of this publication was a true honour as preventive dentistry and collaboration go hand in hand and have been passions of mine for as long as I can remember. I was first introduced to the concept of preventive dentistry over twenty years ago – I was a bright-eyed student ready to conquer the world and somewhat embarrassing to admit, I can remember vividly that preventive dentistry was simply one of many courses I needed to ‘pass’ on my road to graduation. I quickly learned, thanks to O’Harris and Christen (authors of the textbook I was required to purchase for the course), that preventive dentistry had many different meanings to different people and they broke it down into three levels for me (i) Primary Prevention (ii) Secondary Prevention and (iii) Tertiary Prevention. Yet still, just the tip of the iceberg. Little did I know at this point how much more comprehensive and meaningful the scope of preventive dentistry would become across the span of my career. After graduation the battles in my plight to conquer the world continued; I grew more experienced and wise and began to put into perspective the preventive dentistry concept, the same concept I naively approached in the beginning. Whether I focused my practice or teachings on halting the onset of disease, stopping the disease process in flight and
4 I Preventive Dentistry Canada - Vol.1 No.1 - May 2010
restoring tissue or the replacement of lost tissues and the rehabilitation of patients to the point where function is as near normal as possible, I could easily debate that from a to z each is captured under the preventive dentistry umbrella. Even more eye opening for me was my recognition of that fact that the scope of preventive dentistry was so comprehensive that I could not triumph within it alone. The picture became more clear day by day, all that preventive dentistry encompassed was woven among collaboration - ongoing collaboration with a team of inter and multidisciplinary professionals. From this moment forward I embraced my team, my knowledge and skill and my commitment and have become a better educator to my students and a better caregiver to my patients. A multidisciplinary collaborative focus on preventive dentistry is what you will find cover to cover inside each issue of Preventive Dentistry Canada. Our vision is to bring cutting edge information while at the same time offer readers a voice, an opportunity to participate and create a publication that is truly an interactive forum. So please enjoy the articles, join us in Clinician’s Corner, visit the future student forum site and peruse the product showcase but be sure not to miss the opportunity to ask the experts a question, share one of your cases with the nation, submit your own article for publication consideration or join our annual photo contest. We invite you to participate and welcome your feedback as the publication will evolve based on your needs. Preventive Dentistry Canada – you will like it today but you will love it tomorrow!
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Dental Implants: Oral Hygiene and Maintenance Gregori M Kurtzman, DDS, MAGD, DICOI and Lee H Silverstein, DDS, MS
D
entistry has become so exciting and challenging since predictability has been recognized for long-term dental implant and restoration success. 1-3 As the number of patients selecting dental implants as a treatment option continues to grow, the dental team must accept the challenges of maintaining these sometimes complex restorations. Proper monitoring and maintenance is essential to ensure the longevity of the dental implant and its associated restoration through a combination of appropriate professional care and effective patient oral hygiene.4,5 The value of using conventional periodontal parameters to determine peri-implant health is not clearly evident in the literature. 4 Therefore, it is paramount that the dental implant team understands the similarities and distinctions between the dental implant and the natural tooth. Subsequently, by examining the similarities and differences between a natural tooth and a dental implant, basic guidelines can be provided for maintaining the long-term health of the dental implant. Direct anchorage of the alveolar bone to a dental implant body provides a foundation to support a prosthesis and transmits occlusal forces to the alveolar bone. This is the definition of osseointegration. 6 With the increased acceptance of dental implants as a viable treatment option for the restoration of a partially edentulous or edentulous mouth, the dental team is faced with maintaining and educating those patients. Recently, the focus of implant dentistry has changed from obtaining osseointegration, which is highly predictable, to the long-term 6 I Preventive Dentistry Canada - Vol.1 No.1 - May 2010
maintenance health of the peri-implant hard and soft tissues. This can be achieved through appropriate professional care, patient cooperation, and effective home care. 7 Patients must accept the responsibility for being co-therapists in maintenance therapy, so the dental team essentially must screen the potential implant patient. Diagnosis and treatment planning based on a risk-benefit analysis should be performed subsequent to a thorough medical, dental, head-and-neck, psychological, tempromandibular disorder and radiographic examination.8 There is convincing evidence that bacterial plaque not only leads to gingivitis and periodontitis 9 , but also can induce the development of peri-implantitis. 10 Thus, personal oral hygiene must begin at the time of dental implant placement and should be modified using various adjuctive aids for oral hygiene to effectively clean the altered morphology of the peri-implant region before, during, and after implant placement. For instance, interproximal brushes can penetrate up to 3mm into a gingival sulcus or pocket and may effectively clean the peri-implant sulcus.11 In addition to mechanical plaque control, daily rinses using 0.1% chlorhexidine gluconate or Listerine12 provide a welcome adjunct. Hygiene with dental implants is so tedious and critical to their long-term success that the patient and dental professional must exercise considerable effort. During the maintenance visit, the dental professional should concentrate on the peri-implant tissue margin, implant body, prosthetic abutment to implant collar connection, and the prosthesis.13
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Clinical inspection for signs of inflammation, ie. bleeding on probing, exudate, mobility, probe-able pockets, and a radiographic evaluation of the peri-implant bony housing still remains the standard mode for evaluating the long-term status of endosseous dental implants. For instance, successful and stable endosseous dental implants exhibit no mobility. But, if there is clinically perceptible mobility, then subsequent to radiographic evaluation of the implant and its surrounding bony housing, the abutment retaining screw14, and/or prosthetic abutment collar interface should be examined for looseness or breakage. All these modes of clinical assessment are used routinely, except for periodontal probing around peri-implant tissues that appear to be in a state of good health. The baseline data and data from subsequent recare visits should be recorded in the daily progress notes to properly assess the peri-implant status logitudinally. Subsequent to a thorough intraoral examination, unless there is visual evidence of soft tissue changes, ie. inflammation of peri-implant tissue with even slight attachment loss or mucositis, routine probing of the periimplant tissue should not be performed. Usually during the first year subsequent to restoring dental implants, a 3-month recare schedule should be implemented, especially if the patient lost teeth because of periodontal disease. But if after 12 months, the patient's implants are stable and peri-implant tissues are healthy, then a 4-6 month recare regimen can be implemented.15 However, be cognizant of each patient's level of home care effectiveness, systemic health, and periodontal status of the peri-implant tissue when determining these recare intervals. With dental implant patients, the dental professional must evaluate the prosthetic components for plaque, calculus, and the stability of the implant abutment. Radiographs of dental implants should be taken every 12 to 18 months during these maintenance visits. 16 For dental implant restorations that are screw retained, the dental professional needs to remove the prosthesis at least once a year to more easily assess the status of the peri-implant's hard and soft tissues, the existence of acceptable mobility of the prosthetic components or the implant fixture itself, and the patient's level of home care effectiveness. 17 Remember that the presence of any symptoms of infection, radiographic evidence of periimplant bone loss, and/or neuropathies may be indicative of an ailing or failing implant.18
Fig. 1
Fig. 2
Implants vs. Natural Teeth It is essential to understand the periodontal relationship between the gingiva and the structure it attaches to be it a natural tooth or an implant (Figs. 1 and 2). The fiber orientation of the gingival cuff around a natural tooth attaches perpendicular to the long axis of the tooth (Fig. 3). This acts as a barrier when a periodontal probe is inserted within the sulcus. The probe tip advances apically till the tip contacts the perpendicular fibers and is halted. This orientation is not seen around implants. With an implant the gingival fiber orientation is parallel to the
Fig. 3
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Fig. 4
implants long axis (Fig. 4). When a periodontal probe is inserted into the sulcus around an implant, the probe tip advances passing between the fibers of the gingival cuff till the crestal bone prevents it from further advancement. The peri-implant mucosal seal may be less effective barrier to bacterial plaque than the periodontium around a natural tooth, tissue attachment.19 There is less vasculature in the gingival tissue surrounding dental implants compared to natural teeth. This reduced vascularity concomitant with parallel-oriented collagen fibers adjecent to the body of any dental implant make dental implants more vulnerable to bacterial insult.20 During recare appointments, peri-implant periodontal probing should be performed only where signs of infection are present, ie. exudate, swelling, bleeding on probing, inflamed peri-implant soft tissue, and/or radiographic evidence of peri-implant alveolar bone loss. Lastly, routine periodontal probing of dental implants should not be performed, because this procedure could damage the weak epithelial attachment around dental implants, possibly creating a pathway for the ingress of periodontal pathogens.21 Commercially available plastic probes should be used when investigating the crevicular depth around dental implants. The probing depth around dental implants may be related closely to the thickness and type of mucosa surrounding the implant. A healthy peri-implant sulcus has been reported to range from 1.3 to 3.8mm, which is greater than those depths reported for natural teeth.22 In essence, the best indicator for evaluating an unhealthy site would be probing data gathered longitudinally.23 For all of these reasons, personal home care and consistent professional maintenance have proven to be critical to the success and longevity of endosseous dental implants. This is especially true in an environment with adjacent natural teeth, which if affected by periodontal disease, could act as a reservoir for pathogenic bacteria, ie. gram-negative anaerobic rods, and seed the peri-implant sulcus.24 The physical characteristics of the peri-implant soft tissue are the focus of all oral hygiene instruction. The presence or absence of keratinized tissue in this critical area has not been unequivocally documented to state that peri-implant tissues are more vulnerable to the ingress of pathogenic bacteria with or without keratinized tissue being present around dental implants. However, the ability of the patient to maintain good 8 I Preventive Dentistry Canada - Vol.1 No.1 - May 2010
home care around dental implants is facilitated by the presence of keratinized tissue surrounding implants. Thus, if a patient has no keratinized tissue around an implant, and a pull from a frenum or a chronic peri-implant mucositis exists, then placement of a soft tissue autogenous or alloplastic connective tissue graft is recommended to facilitate proper mechanical oral hygiene maintenance.25 Specific criteria for obtaining clinical data around dental implants that would allow proper monitoring and detect early possible failure of osseointegrated dental implants has not been clearly defined. Presently, the presence of mobility is the best indicator for diagnosis of implant failure. As opposed to natural teeth, dental implants exhibit minimal clinically undetectable movement because of the absence of a periodontal ligament. Therefore, healthy implants should appear nonmobile, even in the presence of periimplant bone loss, if an adequate amount of supporting alveolar bone still exists.26 When monitoring the health of the peri-implant soft tissues, the practitioner should be cognizant of changes in soft tissue color, contour, and consistency. The presence of a fistulous tract could indicate the presence of a pathologic process or implant fracture.
Bleeding There is controversy in the literature as to the accuracy and significance of bleeding upon probing around dental implants. Presently, the literature advocates the use of bleeding on probing as an indicator of peri-implant disease, because it can occur prior to histologic signs of inflammation or concurrently with other signs of implant failure, ie. bone loss. However, as previously mentioned, routine probing is not recommended.
Radiographic Evaluation Radiographic interpretation is one of the most useful clinical parameters for evaluating the status of an endosseous dental implant. Invasion of biologic width, predictable remodeling, or so-called saucerization, is an average marginal bone loss of 1.5 during the first year following prosthetic rehabilitation followed by an average of 0.2mm of vertical bone loss every subsequent year. Thus, progressive bone loss around a dental implant that exceeds these averages may be indicative of an ailing or failing implant. Lastly, during radiographic evaluation, no evidence of a peri-implant radiolucency should be found, because such a rarefaction usually indicates infection or failure to osseointegration.27
Professional Cleaning Instrumentation Instruments made of metal, such as stainless steel, should be limited to natural teeth and not to be used to probe or scale dental implants. The rationale for this welldocumented and spoken conclusion is that this metal is so hard it can scratch, contaminate, or cause a galvanic reaction at the implant-abutment interface.28
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Fig. 5
Fig. 8
Fig. 9
Fig. 6
Fig. 7
Ideally, hand periodontal scalers for cleaning dental implants can be plastic, Teflon, gold-plated, or made of wood (Figs. 5 and 6).29 When using gold-plated curettes, the manufacturer recommends not sharpening these hygiene instruments, as the gold surface could be chipped exposing the hand metal underneath this coating. Stainless steel scaling instruments may abraid the implant surface, stripping off any surface treatment such as hydroxyapatite (HA) as the instruments hardness is greater than the titanium alloy the implant is fabricated from (Fig. 7). Other cleaning armamentarium contraindicated for use with dental implants are air powder abrasive units, flour or pumice for polishing, and sonic and ultrasonic scaling units.30 Ultrasonic, piezio or sonic scaler tips may mar the implants surface leading to microroughness and plaque accumulation. The stainless steel tip may also lead to gouging of the implants polished collar (Fig. 8). However, some clinicians advocate using a sonic instrument with a plastic sleeve over the tip for scaling dental implants. Air powder polishing units may also damage the implant surface and should be avoided during hygiene appointments (Fig. 9). Even the use of baking 10 I Preventive Dentistry Canada - Vol.1 No.1 - May 2010
Fig. 10
soda powder in these units may strip off any surface coating on the implant. Additionally, the air pressure may detach the soft tissue connection with the coronal of the implant leading to emphysema. Titanium or titanium alloy surfaces of dental implants can be polished using a rubber cup along with a non-abrasive polishing paste or a gauze strip with tin oxide. Not only is the hygiene armamentarium important, but so are the home care techniques used to maintain endosseous dental implants. Patients should be taught the modified bass technique of brushing using a medium-sized head, softbristled toothbrush. The use of intradental brushes should be used by implant patients after being shown their proper use. The plastic-coated wire brush is the only type to be used with dental implants to clean and not scratch the implant surface (Fig. 10). Recently, automated mechanical toothbrushes have been advocated as a daily mode of tooth cleansing. These devices may be a rotary, circular, or sonic type. With these home care instruments, the key to their effectiveness is proper instruction on their use and then diligent daily use by the implant patient.
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As with natural dentition, adjunctive cleaning aids such as flossing are still valuable. As with dentated patients, an implant patient's home care requirements should be individually tailored according to each patient's needs. Individual needs are based on the location and angulation of the dental implants, the position and length of transmucosal abutments, the type of prosthesis, and the dexterity of each patient. The other popularized type of cleansing device is the use of oral irrigators with or without the addition of antimicrobial solutions. Also, oral rinses with antimicrobial properties such as Listerine or chlorhexidine have been widely advocated throughout the literature.31-33
18. Meffert RM.: How to treat ailing and failing implants. Implant Dent. 1992 Spring;1(1):25-33.
Summary
25. Artzi Z, Tal H, Moses O, Kozlovsky A.: Mucosal considerations for osseointegrated implants. J Prosthet Dent. 1993 Nov;70(5):427-32.
During the infancy years of dental implantology, the emphasis for long-term success of osseointegrated implants was the surgical phase of dental implantology. In the years that followed, the emphasis for success had switched from a purely surgical influence to focusing more on the proper fixture placement which would be dictated by the prosthetic and aesthetic needs of each particular case. In more recent years, the dental professional has recognized professional implant maintenance and diligent patient home care as two critical factors for the long-term success of dental implants. The microbiota and clinical presentation of peri-implantitis is the same as periodontitis around a natural tooth.
References 1. Adell R, Lekholm U, Rockler B, et al. A 15 year study of osseoinegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10:387-416. 2. Cox JF, Zarb GA. The logitudinal clinical efficacy of osseointegrated dental implants: a 3 year report.Int J oral Maxillofac Implants. 1987;2:91-100. 3. Albrektsson T, Branemark P,Hansson HA, et al. Osseointegrated titanium implants. Acta Orthop Scand. 1981;52:155. 4. Orton GS, Steele DL, Wolinsky LE. The dental professional's role in monitoring and maintenance of tissue-integrated prostheses. Int J Oral axillofac Implants. 1989;4(4):305-310. 5. Bauman GR, Mills M, Rapley JW, et al. Clinical parameters of evaluation during implant maintenance. Int J Oral Maxillofac Implants. 1992;7(2);220-227. 6. Rateischak KH, Wolf HF, eds Color Atlas of Dental Medicine; Implantology. Stuttgart, NY: Thieme Medical Publishers; 1995:305-316. 7. Meffert RM, Langer4 B, Fritz ME. Dental Implants: a review. J Periodontol. 1992;63(11):859-870. 8. Meffert RM. Contemporary Implant Dentistry. Carl E. Misch, ed. st Louis, Mo: Mosby Year Book; 1993:chap33. 9. Warrer K, Buser D, Lang NP, et al. Plaque-induced peri-implantitis in the presence or absence of keratinized mucosa: an experimental study in monkeys. Clin Oral implant Res. 1995;6:131-138. 10. Lang NP, Karring T. Proceedings of the 1st European Workshop on Periodontology. Chicago, IL: Quintessence; 1994. 11. Balshi TJ. Hygiene maintenance procedures for patients treated with the tissueintegrated prothesis (osseointegration). Quintessence 1986;17(2):95-102. 12. Ciancio SG, Lauciello C, Shibley O. et al. The effect of an antiseptic mouthrinse on implant maintenance: plaque and peri-implant gingival tissues. J. Periodontol. 1995;66(11):962-965. 13. Garg AK. Practical Implant Dentistry. Dallas, TX: Taylor Publishing Co: 1995:111-115. 14. Lekholm U, Ericsson I, Adell R, et al.: The condition of the soft tissues at tooth and fixture abutments supporting fixed bridges: a microbiological and histological study. J Clin Periodontol 1986;13:558-562. 15. American Academy of Periodontology. Annals of Periodontology. 1996 World Workshop in Periodontics. 1996:1(1):816-820. 16. Baumgarten HS, Chiche GJ.: Diagnosis and evaluation of complications and failures associated with osseointegrated implants. Compend Contin Educ Dent. 1995 Aug;16(8):814-822.
19. Weyant RJ.: Characteristics associated with the loss and peri-implant tissue health of endosseous dental implants. Int J Oral Maxillofac Implants. 1994 Jan-Feb;9(1):95-102. 20. Nevins M, Langer B.: The successful use of osseointegrated implants for the treatment of the recalcitrant periodontal patient. J Periodontol. 1995 Feb;66(2):150-7. 21. Lang NP, Wetzel AC, Stich H, Caffesse RG.: Histologic probe penetration in healthy and inflamed peri-implant tissues. Clin Oral Implants Res. 1994 Dec;5(4):191-201. 22. van Steenberghe D, Klinge B, Linden U, Quirynen M, Herrmann I, Garpland C.: Periodontal indices around natural and titanium abutments: a longitudinal multicenter study. J Periodontol. 1993 Jun;64(6):538-41. 23. Quirynen M, van Steenberghe D, Jacobs R, Schotte A, Darius P.: The reliability of pocket probing around screw-type implants. Clin Oral Implants Res. 1991 OctDec;2(4):186-92. 24. Mombelli A, Marxer M, Gaberthuel T, Grunder U, Lang NP.: The microbiota of osseointegrated implants in patients with a history of periodontal disease. J Clin Periodontol. 1995 Feb;22(2):124-30.
26. Papaioannou W, Quirynen M, Nys M, van Steenberghe D.: The effect of periodontal parameters on the subgingival microbiota around implants. Clin Oral Implants Res. 1995 Dec;6(4):197-204. 27. Apse P, Ellen RP, Overall CM, Zarb GA.: Microbiota and crevicular fluid collagenase activity in the osseointegrated dental implant sulcus: a comparison of sites in edentulous and partially edentulous patients. J Periodontal Res. 1989 Mar;24(2):96-105. 28. Speelman JA, Collaert B, Klinge B.: Evaluation of different methods to clean titanium abutments. A scanning electron microscopic study. Clin Oral Implants Res. 1992 Sep;3(3):120-7. 29. Gantes BG, Nilveus R.: The effects of different hygiene instruments on titanium surfaces: SEM observations. Int J Periodontics Restorative Dent. 1991;11(3):225-39. 30. Rapley JW, Swan RH, Hallmon WW, et al. The oral hygiene instruments and materials on titanium implant abutments. Int J oral Maxillofac Implants. 1990;5:47-52. 31. Mombelli A, Lang NP.: Antimicrobial treatment of peri-implant infections. Clin Oral Implants Res. 1992 Dec;3(4):162-8. 32. Ciancio S.: Expanded and future uses of mouthrinses. J Am Dent Assoc. 1994 Aug;125 Suppl 2:29S-32S. 33. Garg AK, Duarte F, Funari K.: Hygienic maintenance of dental implants: the key to success. J Pract Hygiene. 1997;6(2):13-20.
About the Authors
Dr. Kurtzman is in private general practice in Silver Spring, Maryland and is a former Assistant Clinical Professor at the University of Maryland, Department of Endodontics, Prosthetics and Operative Dentistry. He has lectured both nationally and internationally on the topics of Restorative dentistry, Endodontics and Implant surgery and prosthetics, removable and fixed prosthetics, Periodontics and has over 160 published articles. He is privileged to be on the editorial board of numerous dental publications, a consultant for multiple dental companies, a former Assistant Program Director for a University based implant maxi-course he has earned Fellowship in the AGD, ACD, ICOI, Pierre Fauchard, Mastership in the AGD and ICOI and Diplomat status in the ICOI. He can be contacted at dr_kurtzman@maryland-implants.com. Dr. Silverstein is an Associate Clinical Professor of Periodontics at the Medical College of Georgia in Augusta, Georgia. He has lectured both nationally and internationally on the topics of periodontics, dental implantology, bone grafting and suturing. He has been granted Fellowships in the Pierre Fauchard Academy, American College of Dentists, International College of Dentists, and the American Academy of Implant Dentistry. Dr. Silverstein is the author of the textbook "Principles of Dental Suturing: A Complete Guide to Surgical Closure." and "Principles of Soft Tissue Surgery: A Complete Step-by-Step Procedural Guide". He maintains a private practice at Kennestone Periodontics in Marietta, Georgia and can be reached at kenperio@bellsouth.net.
17. Meffert RM. In the spotlight: Implantology and the dental hygienist’s role. J Prac Hygiene. 1995; September:12-14.
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Smoking Prevention: The Team Approach Graham Cope, Carole Bartley
T
he smoking public are generally antagonistic against cessation advice. They are weary of the constant message to quit smoking, but never really being told why they should and as a result, largely switch off. What they require is a better understanding of the need to quit, support and practical advice on how to stop smoking.
Understanding, Appreciation The basic level of understanding by the public about smoking is that smoke goes into their lungs and is puffed out, which makes them feel ‘less stressed’. They do not appreciate the harmful chemicals that enter the blood stream, interact with the blood and circulate around the body and entering every cell, with nicotine actually measurable in toe nails. As far as the mouth is concerned smokers understand it will stain the teeth and cause bad breath, but damaging the gums, reducing the underlying bone, loosening their teeth, and affecting the cells which fight off infection is hard for them to comprehend. But information like this has been shown to increase awareness among receptive smokers and help them interact with literature and other information given to them. Another way to interact is to provide biofeedback – information relating directly to a person’s medical condition. This could take the form of sequential photographs showing the increase in staining or changes such as leukoplakias. Another approach shown to be successful is salivary cotinine measurements1. Cotinine is the major metabolite of nicotine and 12 I Preventive Dentistry Canada - Vol.1 No.1 - May 2010
it can be measured by chair-side, point-of-care tests, such as SmokeScreen2. The speed and visual impact of the test’s colour change allows the oral health professional to assess the extent of a person’s smoking habit, rather than relying on self-reported cigarette consumption. The test’s colour change can be shown to the patient and this has a powerful impact on many smokers, helping them to appreciate more about their smoking and realizing nicotine is in their blood stream. This can be directly related to their oral health. This helps to personalize the information and it can be used to tailor the advice given to an individual.
Desire, Willpower Yet achieving change in smoking behaviour largely depends on a smoker’s ‘readiness to quit’. The ‘Stages of Change’ model3 divides the process of quitting smoking into five stages (Table 1), through which each smoker must pass to achieve abstinence. Recent research has shown that patient’s attitudes and desire to quit is important and nearly half current smokers who wanted to quit requested cessation advice to be provided by the dental team alongside periodontal treatment4. One simple step that can be taken to focus a patient’s thought towards an attempt at stopping is to set a ‘quit date’. This allows them to prepare psychologically, recruit support from family and friends, dispose of smoking materials and time to read around the subject. This also gives an excuse for the members of the dental team to ask later how the quit attempt went. If they didn’t adhere to it then
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another date should be set. If it went well, then encouragement should be given and perhaps retesting to reinforce the message. Variations of this approach have been reported5 and condensed to the 5As: Ask, Advise, Assess, Assist and Arrange (Table 2). Estimates put this type of intervention at about 10 minutes and it should be revisited at each of the patient’s visits. The amount of counseling given to the smoker will obviously depend on the amount of time available, but it has shown the longer it is, the better the outcome. But just a brief, three minutes of counseling has been shown to have a significant impact by encouraging more quit attempts6.
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BOX 1 STAGES OF CHANGE MODEL (3) PRECONTEMPLATION
Does not acknowledge that there is a problem with smoking and does not see the need to stop
CONTEMPLATION
Acknowledges that there is a problem but not yet ready or sure of wanting to stop – still thinking about it
PREPARATION
Making preparations to quit – reading about the subject, talking to others, looking into what help is available
ACTION
Making positive steps to stop smoking – buying patches, seeking advice, getting help
MAINTENANCE
Changing their behaviour – still learning a new way of living without smoking, struggling with the urge to smoke again
RELAPSE
Smoking again after a period of abstinence – may try again later but may not
Cold Turkey? An important question is, “Should the smoker be advised to quit outright or cut-down?” Clearly abstinence from tobacco is the ultimate goal, but many smokers feel incapable of quitting immediately. Fading is the term given to cutting down, and this has been shown to be useful in some individuals on future cessation attempts 7, but much depends upon the individual smoker and their belief in their ability to quit. However, cutting down often results in ‘compensation’, the process by which the fewer cigarettes are smoked more effectively to maintain the usual circulating nicotine level. Again, cotinine testing can establish if this is the case. Smoking cessation intervention should come from the whole dental team. The practitioner should be the first to address the issue of smoking and its effects on oral health and give brief general advice and then pass on the responsibility of testing and counseling to the hygienist, therapist or oral health promoter who have undergone specialist training to plan the cessation programme8. This will involve practical advice on how to avoid the stimulus to smoke, how to cut out specific cigarettes in the day and avoid being with others who smoke, particularly partners. Advice on the use of nicotine replacement therapy and other pharmaceutical aids, such as Zyban (Bupropion) and Varenicline (Champix) is also helpful. However, it should be borne in mind that many smokers quit without these aids and an initial quit attempt could be made without. The dental team should also be aware of the national and local facilities for smoking cessation, such as the national telephone helpline or the local stop smoking service. Referrals to these services help many people to quit, but they do not suit all.
Table 1
BOX 2 PROGRAMME OF 5As FOR SMOKING CESSATION (5) ASK
Ask “Do you smoke?” Some will answer truthfully, others will admit to it but under report their tobacco use and some will deny smoking, especially if they their treatment may be compromised if they smoke. Biochemical testing could be used to get accurate information.
ADVISE
Advise all to stop smoking or at least cut down with a plan to quit later. Counsel about the effects of tobacco smoke on the oral tissues and recommend a better diet and more exercise.
ASSESS
Assess the heaviness of smoking. Could be done by asking about daily cigarette consumption, but this is flawed. This is best done with chair side cotinine testing. Check at each visit to determine if cotinine levels are falling or are zero. Best if this is relayed back both verbally and written down.
ASSIST
Assist the patient by setting a quit date and giving verbal information and printed literature about smoking. Also give out the details of telephone helpline or local cessation services.
ARRANGE
Arrange a follow up. This could be their next appointment or better still a special session to reiterate information, retest and lend ongoing support. Also offer telephone support if available.
Table 2
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Measured Hope Finally, the expectation of success by the dental team with regards to smoking cessation should recognize that the addictive nature of nicotine is very powerful and the circumstances and attitudes of many do not lend themselves to stopping; but there are individuals who want to stop and seek advice and support to do so. Quit attempts are essential, but it has to be remembered that it takes on average six quit attempts before an individual is successful – it may take less, but in others it might never happen. The point is it is worth trying.
References 1. Barnfather K, Cope G, Chapple I. Effect of incorporating a 10 minute point of care test for salivary nicotine metabolites into a general practice based smoking cessation programme: randomized controlled trial. Br Med J 2005; 331: 999-1001. 2. Cope G, Nayyar P, Brock G, Chapple I. Nearpatient test for nicotine and its metabolites in saliva to assess smoking habit. Ann Clin Biochem 2000; 37: 666-673. 3. Prochaska J, Di Clemente C. Stages and processes of self-change of smoking: toward an integrative model of change. J Consulting Clin Psychol 1983; 51: 390-395. 4. Martinelli E, Palmer R, Wilson R, Newton J. Smoking behaviour and attitudes to periodontal health and quit smoking in patients with periodontal disease. J Clin Periodontology 2008; 35: 944-954. 5. Binnie V. Addressing the topic of smoking cessation in a dental setting. Periodontology 2000; 48: 170-178. 6.
Gordon J, Andrews J, Lichtenstein E, Severson H. The impact of a brief tobacco-use cessation intervention in public health dental clinics. J Am Dent Assoc 2005; 136: 179-186.
7. Falba T, Jofre-Bonet M, Busch S, Duchovny N, Sindelar J. Reduction of quantity smoked predicts future cessation among older smokers. Addiction 2004; 99: 93-102 8. Rosseel J, Jacobs J, Hilberink S, Maassen R, Allard R, Plasschaert A, Grol R. What determines the provision of smoking cessation advice and counseling by dental care teams? B Dent J 2009; 206: E13.
Fig. 1: The positive and negative readings from Graham’s smoking detection instrument
About the Authors
Dr. Graham Cope is an Honorary Senior Research Fellow at the University of Birmingham and is a clinical chemist by training and has worked on smoking-related research topics, specifically cotinine testing, most of his career. He is now the director of a medical diagnostics company specializing in point-of-care cotinine testing. Contact: grahamcope@gfcdiagnostics.co.uk. Carole Bartley is a dental hygienist in Cardiff, South Wales. She is the smoking cessation coordinator for the Dental Postgraduate Department and provides smoking cessation training for General Dental Practice teams and Dental Undergraduates at Cardiff University Dental School. She has worked for several years on smoking cessation methods in general dental practice. Contact: cbartley23@aol.com
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14 I Preventive Dentistry Canada - Vol.1 No.1 - May 2010
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Clinician’s Corner
Your Practical Resource
Needle Free Local Anesthesia Dani Botbyl, RDH
A
s a professional educator, I travel across Canada lecturing and facilitating hands on education courses to hundreds of dental professionals a year. I particularly enjoy the questions that course participants ask as they lead to great discussions within the group where everyone (including myself) has a chance to learn. Most recently, many of these great questions and discussions have been about Oraqix®, a product new to the Canadian market, launched by DENTSPLY Canada in February 2010. Oraqix® is a needle free local
Fig. 2a Fig. 1: Apply Oraqix® to the gingival margin around the treatment area using the blunt tip applicator. Wait 30 seconds.
Fig. 3a
anesthetic containing 2.5% Lidocaine and 2.5% Prilocaine and is indicated for adults who require localized anesthesia in periodontal pockets during scaling and/or rootplaning. Clinically, I have had success with Oraqix® on a variety of patients including those with mild, moderate and severe periodontal disease. I have also experienced successful anesthesia in patients who exhibit root surface sensitivity. Successful effects are based on proper application. The manufacturer recommends the following directions for use for Oraqix®.
Fig. 2b
Figs. 2a and 2b: Insert blunt tip applicator to base of periodontal pocket.
Fig. 3b
Figs. 3a and 3b: Fill the periodontal pocket with Oraqix® and wait 30 seconds.
Fig. 4: Rinse prior to instrumentation. The duration of anesthesia lasts for approximately 20 minutes.
About the Author
Dani Botbyl is an RDH with eighteen years of experience in the dental industry. She is a recognized national speaker and an expert in the area of ultrasonic instrumentation. A clinical educator for nine years with DENTSPLY Canada, she lends much of her expertise to incorporating ultrasonics into the curriculums of dental and dental hygiene programs across Canada. Dani also holds a faculty position at Niagara College of Applied Arts and Technology in Welland, Ontario where she teaches tomorrow’s dental hygienists. Preventive Dentistry Canada - Vol.1 No.1 - May 2010 I 15
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Q&A
Ask the Expert
What are the benefits and limitations of Antimicrobials for my Periodontal patients? Murray Arlin, DDS, FRCD (C)
A
ntimicrobials can be divided into 2 broad categories namely Topical Antimicrobials and Systemic Antimicrobials. In this issue we will address the benefits and limitations of topical antimicrobial therapy. Periodontal Diseases are bacterial induced infections of the periodontium and are characterized by plaque and calculus formation. More recently plaque has been described as existing in "Biofilms" which are complex and may be resistant to eradication with topical and systemic antimicrobials. Extensive research and clinical experience has demonstrated that mechanical debridement can be an effective treatment of Periodontal Diseases. Antimicrobial therapy alone without mechanical therapy has not been shown to achieve long-term beneficial results. This should not be surprising when one considers that without mechanotherapy, the calculus and even probably the pathogenic Biofilm, will not be removed. There is limited research that has shown that antimicrobial therapy may enhance the results that can be achieved with adequate mechanical therapy alone. If one Fig. 1: Pre SRP
does want to consider Topical Antimicrobials, specific ones could be considered and utilized in certain situations, but as an adjunct to the gold standard of mechanical debridement. Topical delivery systems are generally categorized as "sustained" or long acting and "non-sustained". Sustained delivery achieves better "substantivity" (better lingering power) and are more likely able to achieve a sufficient concentration and contact time to be effective against the resistant plaque biofilm. An example of a sustained product would be "Arestin" from Johnson and Johnson. Some recent studies have shown an adjunctive benefit to Arestin when used as an adjunct along with scaling and root planing. From a clinical point of view it would be reasonable to consider adjunctive use of a product like "Arestin" when one cannot achieve adequate mechanical removal of the subgingival biofilm. It is important however to recognize that treatment may control but not cure disease and thus the patient must be monitored and treatment modulated if the therapy does not achieve the desired outcome. Fig. 3: Residual Calculus
Fig. 2: 9 months Post SRP
About the Author
Fig. 4: Calculus Removed
Dr. Arlin received his DDS at McGill University and his Diploma in Periodontics at the University of Toronto. He received his Fellowship in the Royal College of Dentists of Canada in 1983. Dr. Arlin has taught at the University of Toronto at the undergraduate and postgraduate levels. He has presented numerous seminar lectures internationally and has authored many articles in leading dental journals. Dr. Arlin is a co-founder of the Toronto Implant Study Club and the founder of the Dental Hygienist Periodontal Study Club of Toronto.
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Products VOCO - Profluorid Varnish VOCO launched with Profluoride Varnish, a 5% Sodium fluoride varnish with xylitol, its first fluoride product to the US market. Taking only seconds, the new patented single dose delivery system, which includes the brush and the material, makes the application very easy, The Varnish sets quickly in the presence of saliva providing immediate and longlasting results. It is available in adult’s dose (0.4ml) and children’s dose (0.2ml). Patients like the natural melon flavor without the aftertaste of some other brands. The material is free of saccharin, aspartame and gluten. The white transparent color makes the material invisible on the teeth and leads to a high patient acceptance. A high immediate fluoride release makes the material perfect for treating sensitivities after scaling and root planning. Profluorid has enhanced flow characteristics reaching areas traditional varnishes may miss and adheres well to moist surface. For more information, call 888-658-2584, email info@voco.com, or visit www.vocoamerica.com.
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Announcements Basic Periodontics Hands-on Course - November 12, 2010 Register today for the information that you need to enable your office to immediately incorporate a rewarding periodontal program! Dr. Murray Arlin presents this course on Friday, November 12, 2010 from 8:00am to 4:00pm at the Meridian Banquet Hall in Toronto, Ontario. The course fee is $145.00 + GST and includes breakfast, breaks, lunch and the course manual. Earn 6 continuing education points. This course is ideal for dentists, dental hygenists and staff. For more information or to register, call 416-243-0655 or visit www.MurrayArlin.com.
Advanced Periodontics Hands-on Course - November 13, 2010 Build on your existing skills in periodontal care and enhance your office periodontal program! Dr. Murray Arlin presents this course on Friday, November 13, 2010 from 8:00am to 4:00pm at the Meridian Banquet Hall in Toronto, Ontario. The course fee is $145.00 + GST and includes breakfast, breaks, lunch and the course manual. Earn 6 continuing education points. This course is ideal for dentists, dental hygenists and staff. For more information or to register, call 416-243-0655 or visit www.MurrayArlin.com.
Implant Placement Hands-on Course - November 26 & 27, 2010 Register today for this two-day surgical skills workshop featuring live surgical demonstration! Dr. Murray Arlin presents this course on Friday, November 26th and Saturday, November 27th from 9:00am to 5:00pm at the Nobel Biocare Training Centre in Richmond Hill, Ontario. The tuition fee is $1195.00 + GST plus a $350.00 material fee, which includes implant materials and Powerpoint notes. 12 continuing education credits will be provided. This course is intended for surgically oriented restorative dentists looking for a basic handson experience or refresher program for implant placement and the uncovering process. For more information or to register, call 416-243-0655 or visit www.MurrayArlin.com.
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