Expert Helps Teams Understand and Provide Proper Implant Care

Right out of high school I went into dental hygiene school at Broome County Community College. My mom encouraged me to do a secondary degree beyond my dental hygiene license, which I received as a baccalaureate degree from Thomas Jefferson University. My program director, Joanne Guerlain, encouraged me to go for a master’s degree and hired me as part-time faculty.

I received my master’s from the University of Maryland. This program focused on ergonomics as part of preclinical instruction. I realized how important ergonomics is and became one of the first hygienists to speak and write about ergonomics. I published the first article about hygienists using loupes in 1997. This led me to Orascoptic, where I worked for over 25 years.

It’s rare for a rep to start with a company with a single owner and watch the company grow into a Fortune 200. Orascoptic is part of ENVISTA and I worked many events with the Nobel Biocare team.

Employees’ needs change, and I could no longer manage the travel demands of my position with Orascoptic, so I took an opportunity with a smaller territory for Nobel Biocare.

As an implant rep I had a lot of questions about maintenance protocols. Jake Thomason with Nobel’s training and education team picked up on my education background and I helped contribute to the maintenance training module.

In 2022, I was taking care of an elder in my family and became distracted. After my aunt passed, I became her executor, and was missing sales goals. Nobel reworked territories and offered me a severance package. Having my territory eliminated was the best possible thing to happen to me. It gave me time to sit down and focus on my family’s estate work and figure out this next chapter of my life.

I wanted to move from sales and do something creative. I started networking and soul searching to decide what to do next. Theresa Groody of Harmen College asked me to teach a continuing education class on Dental Implant Basics and Maintenance for Hygienists and Assistants. The class was well received! The Greater Delaware Valley Dental Health Conference booked my class for three dates. A few of my Nobel and once Nobel/now Keystone Dental Technology contacts asked me to present to their study groups. Most of my bookings are obtained by word of mouth by simply networking with people I know and asking for their input.

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DSOPro: Tell us about the courses you have developed.

Surgeons present surgical cases at hygiene meetings and it’s confusing for hygienists. I took every question the dental hygienist in me had while working as an implant rep and researched it. My class is historical, explaining popular trends and innovations and how what was popular at one time is no longer appropriate. I share changing protocols and focus on basics—assessment, homecare, biocompatibility, and treatment protocols.

My goal is to help hygienists who don’t see a lot of implant patients be more comfortable and make confident decisions for their implant patients.

DSOPro: What is different about your approach?

I’m a trifecta: I have clinical, education, and sales experience. I learned big implant companies such as Nobel/ENVISTA have their sales team versed on the process of data acquisition to case planning, to case acceptance, surgery, placing the restoration, and the laboratory work for the final restoration. Once the implant is completed, so is the program, because the program was related to the company’s product line.

I am a conduit between industry and clinical. As a clinician I can explain what in our offices may or may not be the best option to use on our patients depending on our assessment.

I feel as dental hygienists we sometimes work in fishbowls. Each office, private practice or DSO environment can be very different. When DSOs or group practices make an acquisition, there is no control over what implant maintenance equipment is acquired. Each office can have a different variety of implant instruments and the team members may have different levels of knowledge for implant patients depending on the time of their education and past experience. If you have high-functioning hygienists in an office reduced to using plastic instruments, the hygienists will be frustrated knowing they do not have the right tools to be effective.

When working with a DSO, I want to survey the offices and ask, “What instruments are you using? What type of equipment are you using? How are you using it? What more would you like to see for patient care?” Then sit down with the clinic care manager and explain the findings.

DSOPro: What would your general advice be? Do you recommend air polishers?

According to the Wingrove textbook Peri-Implant Therapy for the Dental Hygienist, air polishers are standard of care for implants. If it’s a franchise practice focused on implant placement, it makes sense to invest in them.

Guided biofilm therapy is the new standard of care. It’s atraumatic, effective, and gives a better patient experience.

DSOPro: How many DSOs are treating implant patients?

I assume all restore implants. Some offices have a full-time or part-time specialist who surgically places implants.

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DSOPro: Given that hygienists are charged with providing patient education on homecare, what information do they need to help their patients?

Recently, I temped in an office and saw a patient with an overdenture she had received 3 months before. It was her first maintenance appointment post-placement. When the overdenture was removed, the tissue underneath was horribly infected.

I asked the patient, “Are you brushing?” and she said, “No, I was told not to.” It seems there was a miscommunication. Somewhere between the implants being placed and the overdenture delivery, there was a missing appointment where homecare should have been reviewed. The way I see it, that appointment should be with the hygienist on the same day as the post-op evaluation.

An appointment should be scheduled for the patient to be disclosed and educated on plaque then given homecare instructions. The hygienist should go over tools the patient needs, such as the Waterpik, soft-end tuft brushes, interproximal brushes, an Autoflosser if there is a bridge, etc. Instead of telling the patient to buy a Waterpik, offices should incorporate a Waterpik, electric brush, and specialty brushes specific for the patients’ individual needs as part of the follow-up appointment. All homecare aids should be included in the quoted fee.

DSOs works with systems; the post-op homecare appointment should be part of the scheduling system. I see greater success when the front desk knows how to schedule and when that time should be with the doctor or the hygienist. If it’s a system, the whole team is in on the plan.

In the example above, the patient missed or wasn’t offered a patient education homecare appointment.

DSOPro: What tools do you consider essential for hygienists treating implant patients?

Depending on assessment, plastic probes, stainless-steel probes, and titanium probes are all fine. Digital x-rays should be taken annually, including periapical, to assess the implant threading and see if there is consistency or bone loss year after year.

Photos should be taken to demonstrate what the tissue looks like. A visual assessment determines if the tissue is red or inflamed. Palpating is done to see if there is any type of exudate, whether the patient has any pain, and if there is any movement of the crown.

After the assessment, you review homecare and demonstrate with disclosing solution. The Waterpik is essential, especially if the patient has screw-retained full arches, because it has a curved dental tip that fits under the arch just beautifully.

The Autoflosser is a little palm-sized device you can place under bridges to advance floss underneath them. It is so much easier than the traditional floss threaders we’ve all worked with. Implant patients also need specialty brushes and interdental brushes. TePe has a fantastic kit containing all their different brushes for patients to try and see what works best for them. Patients need to understand what the tools are and determine what is most comfortable for them.

If the patient has an electric toothbrush, be sure the brush tip fits underneath the restoration. The patient needs to understand brushing implant crowns is different from brushing around the abutments. A pointy, small, round, or kind of tapered-shape tip on an electric toothbrush can get into these axis areas so much better. They should also be using an antimicrobial mouthrinse. And you want to ensure that all the products they use have the appropriate pH. Some products have very high or low pH, and that can cause corrosion of the titanium.

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If the office has an air polisher, it should be used with glycine or erythritol. They are both antimicrobial and won’t cause any scratching or damage to the abutment. This is where that “old school” education comes in. If a hygienist graduated in the 1990s, the earlier air polishers used baking soda, but the pH can cause damage and implant failure. And if they’re using an ultrasonic, the tip must be made of titanium or PEEK (polyether ether ketone) to be safe.

I’ve been helping a company called PDT (Paradise Dental Technology), which has fantastic Pineyro scalers designed to fit underneath full-arch implant restorations for implant debridement.

Teams need to assess whether they have the right instruments and how they must be used. There is often a lack of education plus a disconnect because usually someone else is buying the instruments and they don’t know these details.

My goal is to spread the word. I offer a 3-hour lecture on the basics of implants where we break into small groups and have hands-on experience. I bring in manufacturers’ reps to do hands-on demonstrations, such as Waterpik, PDT with titanium instruments, and TePe with specialty brushes.

I share various models of various implant restorative concepts to practice instrumentation. We discuss the differences between working on abutments and the threading of implants. Attendees leave the class much more confident.

I also do an hour-long webinar as a teaser, and then a hands-on class in a 5-hour format. I’ve been booked by surgeons for their study groups and their referring offices and will be lecturing at three upcoming state hygiene meetings.

DSOPro: Any final comments?

There is so much more to talk about on this subject! But the points about chemistry and compatibility and the fact that “Implants are not teeth” and should not be treated like natural teeth are so important. There are products on the market that are not biocompatible with implants that can cause corrosion or decrease fibroblastic production.

We want to make sure what we’re using is safe. At one time, the theory was the less you did with implants, the better. Another theory is that we don’t completely understand how to best treat peri-implantitis and just throw as much as we can at it to see what the response will be.

I guess that is why we call it “implant practice”!