Are Hygiene Programs Falling Behind on Teaching about Peri-implant Diseases?

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Background on Peri-implant Diseases and Conditions

Implant placement for adults has been increasing and is expected to reach 17% by 2026 for adults age 35 and older who have lost at least one permanent tooth due to periodontal disease or caries.1 Over the years, significant improvement with implant survival rate has been observed, which is predicted to be 95%.2,3

However, even with a high survival rate, peri-implant diseases and conditions such as peri-mucositis (50%) and peri-implantitis (12% to 43%) may occur, increasing the risk of implant failure.4-6

Peri-mucositis is the term used to describe inflammation, bleeding on probing (BOP), and no crestal bone loss at the implant site.7,8 Peri-mucositis has the same characteristics as gingivitis on a natural tooth. Peri-mucositis is reversible, is caused by biofilm, and often precedes peri-implantitis.7-9 Peri-implantitis will present with the same clinical characteristics of peri-mucositis with the addition of progressive crestal bone loss when compared to the baseline radiograph.7,9

To determine if there is bone loss around an implant, baseline radiographs are needed to compare crestal bone levels.7,9 Bone loss around an implant site causes increased concern as it generally is more accelerated compared to bone loss around natural teeth. Three main risk factors for peri-implant diseases have been concluded by the literature: 1) history of periodontitis, 2) inadequate biofilm control, and 3) lack of professional implant maintenance.10

Classifications and definitions for peri-implant disease did not occur until the 2017 World Workshop developed a new classification scheme of periodontal and peri-implant diseases and conditions. New standardized peri-implant case definitions and classifications, along with the dental hygienist’s role, are thought to aid in the assessment and management of implants during patient care.7-9

Arnett et al. Study Summary

Researchers at the University of Minnesota School of Dentistry investigated didactic and clinical curriculum at entry-level dental hygiene programs in the United States for content on conditions and diseases affecting implants. Faculty members throughout the U.S. responsible for didactic and clinical implant curriculum were surveyed. The majority of faculty reported that didactic courses taught the etiology of peri-mucositis and peri-implantitis, clinical characteristics, and risk factors contributing to disease.6 The most common treatment methods taught were subgingival irrigations or antimicrobial rinses and instrumentation with a plastic implant scaler.6

When it came to clinical instruction, 87% of surveyed faculty reported students were not required to provide care to a patient with a dental implant. The majority of the participants surveyed were aware that peri-mucositis and peri-implantitis were now part of the newest American Academy of Periodontology (AAP) classifications. About half of the participants reported they had a plan to implement the new AAP implant classifications and case definitions in their dental hygiene curriculum.6

Most dental hygiene programs taught evidence-based theory when it came to etiology, clinical characteristics, and risk factors of peri-implant diseases and conditions. However, the most common treatment methods (subgingival irrigation/antimicrobial rinses and plastic dental scalers) taught do not align with the most recent evidence-based research.6 These commonly taught treatment methods had been found in the literature to be ineffective with managing peri-implant diseases.6

The researchers identified discrepancies in what is known, taught, and practiced.6,11 The findings from this study align with the ongoing challenge of keeping up with current evidence and implementing it in clinical practice. Fewer dental hygiene programs taught subgingival air polishing for the management of peri-mucositis and peri-implantitis. Experts in the field found that there are significant improvements in BOP using subgingival air polishing compared to mechanical biofilm debridement.12 In addition to subgingival air polishers, the FDI World Dental Federation recommends Er: YAG lasers, titanium curettes, and ultrasonic scalers with plastic sleeves for biofilm removal for the treatment and management of peri-mucositis and peri-implantitis.13

Results from this study concluded that dental hygiene programs might not be able to keep up with the rapidly emerging evidence to include in the curriculum to assess and manage peri-implant diseases. This may result in dental hygienists entering the field upon graduation with limited experience in the management of peri-implant diseases.

The results from this study show the utmost importance of practicing dental hygienists’ responsibility to keep up with evidence-based literature. Further, dental hygienists need to be current with the recommendations for the assessment and management of peri-implant diseases and conditions. This study shows that new research and evidence in dentistry emerge quickly and is ever-evolving.

Gaining Knowledge and Moving Forward

Practicing dental hygienists can do several steps to stay current and provide the best evidence-based implant care to patients. Dental hygienists can take additional continuing education (CE) courses on the AAP classification scheme for periodontal and peri-implant disease and conditions, and peri-implant disease and conditions specific courses relating to the etiology, clinical characteristics, and risk factors.

Hands-on workshops can be highly beneficial for learning new clinical skills and advanced instrumentation to manage peri-implant disease and conditions such as subgingival air polishing, titanium implant scaler instrumentation, Er: YAG lasers, and ultrasonic scaling with plastic sleeves for implants. Workshops on these topics can be found at annual dental conferences, continuing education departments at dental schools, and sponsored by local American Dental Hygienists’ Association (ADHA) components.

The AAP has fantastic periodontal classification and peri-implant disease and condition information available. “The Proceedings from the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions” can be found here.14 Much of the AAP information is free to access and can be applied in dental hygienists’ clinical practice. This is a great resource for individual dental hygienists to learn more about the 2017 World Workshop classifications as well as dental offices to use to implement the new classification scheme for periodontal and peri-implant diseases.

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  2. Buser, D., Sennerby, L., DeBruyn, H. Modern Implant Dentistry Based on Osseointegration: 50 Years of Progress, Current Trends and Open Questions. Periodontol 2000. 2017; 73(1): 7-21.
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