Dental Implant Maintenance for the Dental Hygienist by Michelle Hendrickson A project submitted in partial fulfillment of the requirements for the degree of MASTER OF EDUCATION with emphasis in CURRICULUM AND INSTRUCTION WEBER STATE UNIVERSITY Ogden, Utah August 22, 2022 Approved Louise R. Moulding, PhD Shelley M. Costley, MEd, RDH J. Shane Perry, MEd, RDH Shelly M. Costley (Sep 13, 2022 12:38 MDT) Shelly M. Costley J. Shane Perry (Sep 13, 2022 19:01 MDT) J. Shane Perry Dental Implant Maintenance 2 Abstract Dental implant therapy has become a part of mainstream dental therapy (Krishnamoorthy et al., 2021). Unfortunately, despite the increase in dental implant and complete arch implant supported restorations being placed, scarce information is available about dental implant maintenance protocols (Krishnamoorthy et al., 2021). With the advancement of dental implantology, dental hygienists need to have current and comprehensive knowledge of current recommendations relating to implant maintenance (Zellmer et al., 2020). The purpose of this project was to create a dental hygiene protocol that dental hygienists can follow when treating their patients who have dental implants. Important focus was placed on maintaining complete implant supported fixed arch restorations. The scope of this project included three parts: a power point presentation, CE privileges, and decision tree visual aid. This project was created for licensed dental hygienists and other dental health professionals who care for patients with dental implants and implant supported fixed arch restorations. This project could also be useful in dental hygiene schools to educate dental hygiene students about dental implants and implant supported fixed arch restorations and the required treatment modalities for both. Dental Implant Maintenance 3 Acknowledgements I would like to thank Dr. Louise Moulding for her knowledge and time in helping to create this professional development as part of my master’s thesis. I would also like to thank Dr. Riley Clark for his time in helping me to organize my thoughts and helping me bring them to life. I want to acknowledge Susan S. Wingrove for her work regarding dental implant maintenance. Her book, Peri-implant Therapy for the Dental Hygienist, inspired me and gave me a “second wind” in my profession as a dental hygienist. Last, I would like to thank my husband, Matt Hendrickson. When we were dating, Matt got me my first job as a dental assistant working for his father. He has always been my biggest cheerleader. Matt encouraged me to become a dental hygienist and years later he encouraged me to get my Master of Education. I am very grateful for his and my family’s support! Dental Implant Maintenance 4 Table of Contents Nature of the Problem ..................................................................................................................... 5 Literature Review........................................................................................................................ 6 Peri-Implant Disease ............................................................................................................... 6 Medical and Dental History/Risk Assessment ........................................................................ 7 Assessment of the Dental Implant .......................................................................................... 8 Peri-implant Therapy Protocol .............................................................................................. 11 Homecare Recommendations ............................................................................................... 15 Recare Maintenance Schedule .............................................................................................. 18 Purpose .......................................................................................................................................... 19 Methods......................................................................................................................................... 19 Product Development and Review................................................................................................ 21 Dissemination of Products ........................................................................................................ 22 Conclusion .................................................................................................................................... 22 References ..................................................................................................................................... 24 Appendix A Permission to use Figure 1,2 & 3 ............................................................................. 28 Appendix B PowerPoint Presentation ........................................................................................... 29 Appendix C Decision Tree Handout ............................................................................................. 39 Appendix D CE Application and Correspondence with CERP .................................................... 40 Appendix E Quality Improvement Project-Intial IRB .................................................................. 41 Dental Implant Maintenance 5 Nature of the Problem Dental implant therapy has become a part of mainstream dental therapy (Krishnamoorthy et al., 2021). A dental implant is a surgical component that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, or denture. Dental implants are the solution for patients with high expectations for natural looking teeth that increase quality of life, improve esthetics, and can be delivered with fewer appointments (Wingrove, n.d.) The dental implant market value is expected to increase at a Compound Annual Growth Rate of 11% from 2021 to 2028 (Krishnamoorthy et al., 2021). What used to be considered uncommon in the United States is now customary standard care for supporting dental restorations and edentulous areas (Zellmer et al., 2020). Specifically, concepts such as the All-on-Four, which is a dental implant supported prosthesis replacing all of the missing teeth in a single arch, are becoming widely popular among clinicians and patients because it is the most natural looking option and can be placed the same day (Wingrove, 2013). Unfortunately, despite the increase in dental implant and complete arch implant supported restorations being placed, scarce information is available about dental implant maintenance protocols (Krishnamoorthy et al., 2021). In addition, conflicting information makes it hard to know the best management protocols to follow. With the advancement of dental implantology, dental hygienists need to have current and comprehensive knowledge of current recommendations relating to implant maintenance (Zellmer et al., 2020). The purpose of this proposal is to create a dental hygiene protocol that dental hygienists can follow when treating their patients who have dental implants. Important focus will be placed on maintaining complete implant supported fixed arch restorations. Dental Implant Maintenance 6 Literature Review This review will first define peri-implant disease and classify it into categories of severity in regard to the health of a dental implant. Following, it will describe the importance of reviewing the patient’s medical and dental history to place the patient in a risk category (risk assessment) which will help determine necessary implant therapy and maintenance. Next, it will describe a protocol of how to assess and monitor the health of the dental implant. Last, it will discuss necessary clinical peri-implant therapy for dental implants and complete implant supported fixed arch restorations, patient in-office recall maintenance schedules and necessary care to be done by the patient at home. Peri-Implant Disease Wingrove (2013) stated that peri-implant tissues cascade from peri-mucositis to peri-implantitis in a similar progression of gingivitis to periodontitis around natural teeth. Peri-implant mucositis is similar to gingivitis because it is caused by bacteria and is manifested by redness and inflammation in the soft tissue around the implant. With peri-mucositis, there is no bone-loss involved and it is generally reversible. Peri-implantitis is bone-loss around the implant which could be caused by stress, bacteria or both (Wingrove, 2013). The characteristics of peri-implantitis are probe depths of 5mm to 6mm or greater, bleeding upon probing and radiographic bone loss of 2 to 3mm (Froum, 2018). Below is a summary of three categories that can help the clinician determine the health and prognosis of their patient’s dental implants (Gibson & Wanless, 2020). Category 1: Healthy . Less than 4mm probe depth A. No bleeding or exudate upon probing Dental Implant Maintenance 7 B. Pink, firm, keratinized tissue C. No radiographic bone loss Category 2: Mucositis . Greater than 4mm probe depth at one implant site A. Possible bleeding upon probing, possible exudate B. Tender and inflamed tissue C. No radiographic bone loss Category 3: Peri-implantitis . Greater than 5-6 mm probe depth A. Bleeding upon probing with possible exudate B. Red, inflamed, tender C. Greater than 2-3 mm of radiographic bone loss Medical and Dental History/Risk Assessment Peri-implant disease is enhanced by several risk factors such as periodontal disease, smoking, diabetes, bruxism, residual cement, irregular periodontal maintenance visits, and poor plaque control skills (Zellmer et al., 2020). These risk factors can undermine the long-term success of dental implants which should be taken into consideration by the clinician and explained to the patient (Krishnamoorthy et al., 2021). Patient specific risk assessments that include the medical and dental history will help the clinician determine the pre- and post- operative risks with dental implant placement and will also help to determine recommended dental therapy and peri-implant maintenance (Krishnamoorthy et al., 2021). The Academy of American Periodontology developed a risk assessment that has questions on age, gender, oral health (such as bleeding gums and missing teeth), smoking and tobacco use, dental habits (such Dental Implant Maintenance 8 as frequency of dental visits and homecare), oral systemic diseases (such as periodontal disease), health conditions (such a diabetes, and osteoporosis) and etiological factors (such as dental caries and occlusion (Wingrove, 2013). Assessment of the Dental Implant Step One-Soft Tissue Assessment. The clinical methods to detect the presence of inflammation should include visual inspection, probing with a periodontal probe, and digital palpation (Berglundh et al., 2018). At every maintenance appointment, a soft tissue examination of the peri-mucosal seal should be done. The clinician should observe the color, texture and form of the tissue around the implant as well as watch for bleeding and inflammation (Wingrove, 2011). The clinician should probe and manually palpate the implant for signs of peri-implant disease. Wait 6 month to probe a newly placed implant, and then use gentle pressure with a titanium, metal or plastic probe (Wingrove, n.d.). To palpate, take a finger on both sides (buccal and lingual) of the alveolar bone starting at the apex of the implant and move toward the crown of the tooth. If there is suppuration, there is infection, and this should be noted in the patient’s chart (Gibson & Wanless, 2020). Wingrove (n.d.) stated that probing may be difficult in the presence of a prosthesis, such as with a patient who has a complete implant supported fixed prosthesis. In many cases it may not be possible at all. In this case, a clinician should look for keratinized verses non-keratinized tissue, inflammation and swelling around the implant and signs of infection. If probing is possible, an increase in clinical probing depth associated with bleeding on probing should be viewed as signs of peri-implant disease. Suppuration or exudate is a confirmatory indicator of disease activity (Krishnamoorthy et al., 2021). If the probe depths are greater than 5-6mm and Dental Implant Maintenance 9 there is bleeding or exudate, a radiograph should be taken to evaluate for bone loss around the implant (Wingrove, 2013). Wingrove’s (2013) recommendation for taking x-rays for patients with 1-4 dental implants is to take vertical bitewings or a periapical film at implant placement, 6 months, and 1year intervals. A panoramic film or full mouth series should be taken for 5 implants or more, at implant placement, 6 months, and 1year intervals. Horizontal bone loss of 0.5-1.5 mm or less in the first year is acceptable with 0.2mm vertical bone loss in years following Cone beam computed tomography (CBCT) is the standard of care when 3D imaging is necessary in dentistry. In an article published in the Journal of Periodontology (2017), it is stated the CBCT has been positioned as the modality of choice for cross-sectional imaging as an application that certainly has tangible implications for implant therapy especially if an implant is failing. This would be the x-ray of choice in this situation. In the case of complete implant supported restorations, a panoramic film might be the only option due to anatomical limitations. If systemic conditions or inflammation are present, continue to take x-rays as needed. However, if bone loss is evident, possible removal of the prosthesis may need to be considered (Wingrove, n.d.). John A. Hodges, DDS, runs a practice in Covington, Washington dedicated solely to dental implant services. Hodges (2018) wrote an article for Dentistry IQ where he stated that he only removes a fixed prosthesis when the patient and his dental hygienist can’t clean under it, or there are signs of peri-implantitis such as radiographic bone loss or suppuration or if the bridge or restoration is broken or damaged. He stated in his article, that frequent removal of the appliance has the potential of damaging the thread pattern on the implant which may necessitate the replacement of expensive dental implant screws. Dental Implant Maintenance 10 Step Two-Assessment for Calculus or Cement. The next step of assessment is to check for calculus and cement. Take dental tape or a woven floss and insert the floss into the mesial contact. Next, wrap the floss around the lingual surface of the implant and bring it through the distal contact. Then, criss-cross the floss in front of the implant and use a shoe-shine motion taking the floss up and down the implant. If there is calculus or cement present, the floss will shred (Gibson & Wanless, 2020). In order to floss the implant supported prosthesis, a floss threader will be needed to thread the floss under the prosthesis and around the implants. Step Three-Assess for Mobility. To check for mobility, take two mirror handles and place them on either side of the implant. Gently rock the implant back and forth. If mobility is present and bubbling of the saliva occurs along the gingival margin of the restoration, the internal screw may be loose. A radiograph can confirm this (Wingrove, 2013). If no bubbling occurs, it is likely the crown is loose and needs to be recemented. Mobility may be difficult to assess with an implant supported fixed prosthesis. The clinician will have to rely on the x-ray assessment as well as the soft tissue assessment to determine the health of these implants. In addition to a mobility assessment, an articulating medium such as articulation paper, should be provided for the dentist at every maintenance appointment to monitor occlusion (Wingrove, n.d.). If the patient is having any pain or discomfort around the implant, the dentist should determine if it is due to occlusal trauma. An occlusal adjustment may be all that is necessary. If the patient grinds or clenches their teeth, it can also be detrimental to the implant and can cause it to fail. This complication can be eliminated with a custom mouth guard that the patient can wear at night (Wingrove, 2013). Dental Implant Maintenance 11 Peri-implant Therapy Protocol Step One-Lavage. The first step in peri-implant therapy is to use a lavage to remove biofilm. Dental plaque is an example of both biofilm and a microbial community. Biofilm formation on oral implants can cause inflammation of peri-implant tissues, which endangers long-term success of the implant (Saini, 2011). Recent studies show that a lavage of cool water that cavitates around the implant can disrupt biofilm without modifying the implant surface (Tarquini, 2021). Biofilm removal can be done with an ultrasonic tip (magneto strictive or piezoelectric) that is compatible with titanium implants. Use the lowest setting on the unit or a lavage setting to flush any plaque or biofilm. Be careful not to touch the implant or the prosthesis (Wingrove, n.d.). Subgingival air polishers using low abrasive powders can also be used to remove stain and biofilm and have been proven safe (Gibson & Wanless, 2020). In 2016, The American Academy of Prosthodontists established new clinical guidelines for recall of healthy patients and maintenance of patients with dental implants. These guidelines recommend the use of powered instruments, such as a glycine powder air polishing system (Bidra et al., 2016). Wingrove (n.d.) suggested using subgingival air polishing (GPAP) with glycine powder, 25 microns specific power, using the perio implant tip to flush the oral debris and disrupt the biofilm prior to implant maintenance. In addition, recent literature shows that if a clinician starts with air powder polishing, they will remove the majority of the biofilm and have less instrumentation to do (Gibson & Wanless, 2020), Step Two-Calculus or Cement Removal. Calculus found on dental implants is easier to remove than that found on natural teeth because it is softer and usually found supragingival Dental Implant Maintenance 12 (Wingrove, 2013). If calculus or cement is found on the dental implant during the assessment phase, it must be removed with a titanium implant scaler (Wingrove, n.d.). Zellmar et al., (2020) reported that a systematic review evaluated the effects of different instruments on titanium implant surfaces and identified that non-metal instruments, rubber cup and air abrasives caused the least surface alteration to smooth and rough implant surfaces and maintained the implant surface integrity. Special attachments, like nylon sleeves and nonmetal ultrasonic inserts, can be used with metal sonic and ultrasonic instruments for scaling around dental implants. Short, horizontal working strokes with light pressure have been proven to cause the least damage (Bansal et al., 2019). Step Three-Repeat the Lavage. Repeat the lavage with the magneto strictive or piezoelectric to remove any excess debris. This can also be done with a GPAP. Polishing the implant is not necessary. However, if rubber cup polishing is done to smooth the prosthesis after scaling or to remove stain, a non-abrasive prophy paste (silica-based, no pumice) should be used (Wingrove, n.d.). Hempton et al., (2011) created an implant classification system to help guide the clinician in the selection of appropriate treatment modalities. Pattison and Sumi (2015) have made minor adjustments to those modalities which are summarized below. Class 1: Healthy. Figure 1 shows a healthy implant. Healthy tissue around well-maintained dental implants should not have titanium exposed and therefore does not require excessive subgingival instrumentation. Therefore, the clinician would treat this restoration like they would treat a natural tooth (Gibson & Wanless, 2020). Most likely the primary objective would be biofilm removal which can be done with GPAP, keeping in mind that it does not remove any calculus or cement. Another effective form of biofilm removal is rubber-cup Dental Implant Maintenance 13 polishing with a non-abrasive paste. However, the rubber cup may not extend into the sulcus like GPAP or a titanium scaler or an implant specific ultrasonic tip. Cleaning between the teeth with dental tape or woven floss will also help with biofilm removal during the maintenance appointment (Pattison & Sumi, 2015). Figure 1 Healthy Implant Note. Healthy Implant. From Post-Surgical Implant Care, by A. Pattison & J. Sumi, 2015, Dimensions of Dental Hygiene, 13(5), 24-29. Used with permission. See Appendix A Class II: Peri-Implant Mucositis. Figure 2 shows that some recession may be present in this phase which could expose the smooth titanium portion of the abutment (Gibson & Wanless, 2020). GPAP and rubber cup polishing are recommended for biofilm removal and will not scratch the smooth titanium surface of the abutment. If calculus or cement are present, the use of a titanium scaler or an implant specific ultrasonic tip are recommended causing the least amount of surface scratching compared to other implant instruments. In addition, titanium instruments are available with thinner, mini tips which allow for better insertion and adaptation. Pattison & Sumi (2015) stated in their report that despite years of research showing in vitro and in vivo scratching of implant surfaces, literature reviews have concluded that roughened implant abutment surfaces caused by different instruments do not increase implant complications. Current research also shows that any instrument that is used on a titanium surface can also be Dental Implant Maintenance 14 used on a zirconia surface, such as the zirconia that is used on the crowns of dental implants (Gibson & Wanless, 2020). In this phase, research also shows that the use of minocycline as an adjunct to non-surgical periodontal therapy can reduce the bacteria P. gingivalis, which can improve the clinical parameters of a dental implant at least 3 months after therapy (Faramarzi, 2015). Wingrove (2013), stated that the combination of minocycline microspheres (e.g., Arestin) after debridement and lavage has shown improved treatment outcomes for a period of 12 months. Figure 2 Peri-Implant Mucositis Note. Peri-Mucositis. From Post-Surgical Implant Care, by A. Pattison & J. Sumi, 2015, Dimensions of Dental Hygiene, 13(5), 24-29. Used with permission. See Appendix A Class III: Peri-Implantitis. Figure 3 is a diagram of Peri-implantitis. In this phase, recession of the gingival margin reveals exposed threads and a roughened titanium surface and referral to the dentist who placed the implant is very important. If the first or second thread are exposed by the gingival recession, horizontal strokes with a titanium instrument that follow the pitch of the threads is the most effective. (Gibson & Wanless 2020). However, according to current literature, non-surgical periodontal therapy for failing implants is not effective. In addition, if the patient is not referred to a specialist, progression to severe peri-implantitis and Dental Implant Maintenance 15 implant failure is very likely. Pattison and Sumi (2015) stated that when an ailing implant can be viewed directly by flap surgery, laser surgery, or endoscopy, cement and/or calculus can be removed with hand or ultrasonic instruments, burs, or lasers. The contaminated titanium implant surfaces can also be air polished and treated topically with antimicrobials or antibiotics; systemic antibiotics also may be prescribed. Before referring the patient back to the clinician who placed the failing implant, Gibson & Wanless (2020) and Wingrove (2017) recommend placing Cervitec Plus varnish by Ivoclar Vivadent, around the cervical area of the implant and as deep as the applicator will go. Cervitec Plus varnish is an antimicrobial, non-fluoride varnish (1% solution of Chlorhexidine Gluconate and 1% solution of Thymol) and has been proven to prevent the recolonization of bacteria for up to three months. Figure 3 Peri-implantitis Note. Peri-Mucositis. From Post-Surgical Implant Care, by A. Pattison & J. Sumi, 2015, Dimensions of Dental Hygiene, 13(5), 24-29. Used with permission. See Appendix A Homecare Recommendations Research confirms that the incidence of peri-implant disease can be minimized with routine dental plaque control. Therefore, brushing, and interproximal cleaning of the dental Dental Implant Maintenance 16 implants is essential. (Rösing et al., 2019). It is the clinician’s responsibility to educate the patient both verbally and visually about the different oral health care aids that can be used at home to achieve long term implant success (Krishnamoorthy et al., 2021). The homecare education agenda should cover three things: (1) directing the patient to control underlying medical conditions that could affect the health of the dental implant, (2) the importance of maintaining implant oral health and recall visits, and (3) educating the patient how to use at home hygiene products to maintain the health of the dental implants (Krishnamoorthy et al., 2021). It should be noted that some published articles state that dental floss causes peri-implantitis. However, in further research, this is only the case with exposed rough dental implant surfaces. Interproximal brushes, or toothpicks are recommended in these situations (van Velzen et al., 2016). Below is a summary of implant homecare protocols created by Wingrove (2019). The recommendations minus the brand names are listed below in Table 1. Regarding antimicrobial rinses, Kracher et al. (2010), stated that chlorhexidine gluconate (CHX) is a safe non-toxic adjunct to other hygiene procedures in the maintenance of dental implants. It is accepted mouth rinse by the American Dental Association due to its ability to bind to the tissue in the oral cavity and on titanium abutment surfaces. In a more recent study done by Menezes et al. (2016), it was found that mechanical therapy used with 0.12% chlorhexidine mouthwash reduced peri-implant mucositis. (Gibson & Wanless, 2020) state in their presentation at the American Dental Hygiene Association meeting, that recent studies recommend using the form of Chlorhexidine that does not contain alcohol because it can damage the peri mucosal seal around the implant. The only brand that does not contain alcohol at this time is Paroex by GUM. Dental Implant Maintenance 17 Table 1 Oral Health Care Summary Type of Dental Implants Homecare Protocol to Follow Healthy Implants ● Brush twice daily with a soft manual toothbrush or a powered toothbrush using a neutral PH toothpaste that will not corrode the titanium on the implant. Antimicrobial dentifrices containing stannous fluoride or triclosan provide antiplaque and antigingivitis benefits, unlike sodium fluoride products (Kracher et al., 2010). ● Floss using dental tape twice daily or use a water flosser on low or medium. Wrap the floss around the front of the implant in a criss-cross and move the floss in a shoe-shine motion. ● Use a rubber tipped stimulator around the implant once daily for keratinized tissue. ● Rinse twice daily with an antimicrobial rinse such as chlorhexidine gluconate or chlorine dioxide. Removable Overdenture Prosthesis Patient ● Remove dentures and soak in an approved cleaner or white household vinegar 1:1 water and follow the above protocol for healthy implants. ● Brush inside the overdenture twice daily with a powered toothbrush or a soft toothbrush but not a denture brush. ● Rinse off over denture with an antimicrobial rinse thoroughly but do not soak in rinse. ● Do a visual check of retention attachments in overdentures (O-rings, locator caps and clips). All attachments should be replaced yearly and replace clips when they are worn. ● Rinse mouth with an antimicrobial rinse such a chlorhexidine gluconate or chlorine dioxide. Full Arch Fixed Prosthesis Patient ● Brush implants and fixed prosthesis two times daily with a manual soft toothbrush or a powered toothbrush that adapts to the prosthesis and a neutral pH toothpaste. ● Use an interproximal brush on the powered toothbrush or a manual interdental brush to clean hard to reach areas (Wingrove, 2013). ● Floss with threaded implant specialty floss or use a water flosser on med or low 2x daily. ● Rinse 2x daily with an antimicrobial mouth rinse such as chlorhexidine gluconate or chlorine dioxide or put the rinse in the water flosser. Dental Implant Maintenance 18 Peri Mucositis Patient ● Brush twice daily for 3 minutes with a soft toothbrush or a powered toothbrush using a neutral pH toothpaste ● Floss twice daily or use a water flosser on med or low ● Rinse twice daily with an antimicrobial rinse such as chlorhexidine gluconate or chlorine dioxide for 1 minute ● Re-evaluate in 6 weeks to determine next step ● If improvement, place on 3month interval implant maintenance Kale et al., (2020), stated that chlorine dioxide (ClO2) formulation has shown to have antiplaque, antibacterial effect and is effective against oral malodor. Unlike CHX it does not cause teeth staining. Chlorine dioxide could be the possible alternative to CHX. Cervitec Plus is a varnish that contains chlorhexidine diacetate which is different that chlorohexidine gluconate. Diacetate is a slow release, targeted treatment meant to be used around the peri mucosal seal and on exposed threads of dental implants or exposed root surfaces. Wingrove (2020) stated for high-risk disease patients who present for 3-month recare visits such a diabetic, or patients with periodontal or peri-implant disease, this varnish can make the difference by protecting the teeth and implants with effective bacterial control until the next maintenance visit. Recare Maintenance Schedule After a dental implant is placed, follow up care should be scheduled on a 3–4-month interval for the first year. The maintenance appointments after that are based on the patient’s specific needs. Patients with poor oral hygiene and/or are medically compromised might require more periodic professional care. After one year, if the patient is clinically stable, they can be seen every 6 months (Bansal et al., 2019). This same recommendation goes for complete implant supported fixed restorations. Wingrove (n.d.) recommends 2-6 month in-office maintenance appointments based on the patient’s risk factors, previous periodontal disease, general health, and dexterity. Dental Implant Maintenance 19 Purpose With the advancement of dental implantology, dental hygienists need to have current and comprehensive knowledge of current recommendations relating to implant maintenance (Zellmer et al., 2020). The purpose of this project was to create a dental hygiene protocol that dental hygienists can follow when treating their patients who have dental implants. Important focus was placed on maintaining complete implant supported fixed arch restorations. The objectives of this project were: 1. Develop a PowerPoint presentation as a professional development for the dental hygiene industry. 2. Obtain CE privileges from the American Dental Association Continuing Education Recognition Program (ADA CERP) to award to participants who attend the professional development 3. Develop a decision tree visual aid that will serve as a guide for the clinician to determine treatment modalities for their patient depending on their medical/dental risk, classification regarding health of the implant, necessary clinical peri-implant therapy for dental implants and complete implant supported fixed arch restorations, patient in-office recall maintenance schedules and necessary homecare. Methods Dental implant maintenance is not a competency standard from the Committee on Dental Accreditation (CODA), which is the body that develops and implements education standards for Dental Implant Maintenance 20 dental hygiene programs (Zellmer et al., 2020). The purpose of this proposal was to create a dental hygiene protocol that dental hygienists can follow when treating their patients who have dental implants with an important focus placed on maintaining implant supported fixed arch restorations. Context and Intended Audience This project was created for licensed dental hygienists and other dental health professionals who care for patients with dental implants and implant supported fixed arch restorations. This project could also be useful in dental hygiene schools to educate dental hygiene students about dental implants and implant supported fixed arch restorations and the required treatment modalities for both. Professional Development The scope of this project included three parts: a PowerPoint presentation, CE privileges, and decision tree visual aid. PowerPoint Presentation As part of this professional development, the information from the literature review will be put into a PowerPoint presentation. Upon approval of CE privileges, this presentation will be delivered at the White Cap Institute in Heber City Utah under the direction of Dr. Riley Clark. Currently, Dr. Clark puts on seminars for dentists regarding dental implant placement. This professional development will be incorporated into the continuing education seminars offered at White Cap Institute for dental hygienists and dental professionals to help ensure that patients who have dental implants have long term success. CE Privileges Dental Implant Maintenance 21 To become a provider who has the ability to award continuing education credits to the dental professionals who attend this professional development, an application was sent into the ADA CERP. Only providers that can meet the ADA CERP recognition standards and procedures are granted recognition and are authorized to use the ADA CERP logo and recognition statement. Decision Tree Visual Aid As part of the professional development, a visual aid was developed to be given to the participants who attend the seminar. This visual aid is a condensed version of the PowerPoint presentation and is in the form of a flow chart. The flow chart serves as a guide for the clinician to quickly determine treatment modalities for their patient depending on their medical/dental risk, classification regarding health of the implant, necessary clinical peri-implant therapy for dental implants and complete implant supported fixed arch restorations, patient in-office recall maintenance schedules and necessary homecare. For example, if a patient is generally healthy, and has dental implants that are also healthy, the clinician will follow the flow chart from a healthy patient viewpoint to view the treatment modalities necessary for a healthy patient with healthy dental implants. If the patient presents with diabetes and has implant mucositis, then the clinician will follow the decision tree from the diabetic patient viewpoint to view the treatment modalities necessary for a diabetic patient with implant mucositis. Product Development and Review Over the course of the project the visual aid was changed from a flipchart to a decision tree. It was decided after asking 10 dental hygienists what they would prefer, that a decision tree printed on a small card as a quick reference would be the most useful.in private practice. The Dental Implant Maintenance 22 difficulty came when trying to condense a lot of information into a small, easy reference card. There were several drafts created before the final visual aid was created. An application was made to ADA CERP for continuing education privileges. The cost was $100.00 and took over two months to receive information regarding whether this project qualified. Once correspondence with the ADA CERP organization was received, a hold was put on the CE privileges until proof that at least one course is taught by the researcher in the next 12 months. Current efforts are being made with the faculty at WSU Dental Hygiene Department to set up a date and time to present this development. Dissemination of Products The decision tree created for this project will be given to registered dental hygienists and dentists who attend the professional development. The development itself, as well as the decision tree, will be reviewed by the ADA CERP organization in order to become eligible to award continuing education credits to the dental professionals who attend the development. This will be an ongoing process as long as ADA CERP continues to award CE privileges to those who attend the professional development. Conclusion In conclusion, a professional development was created to provide a protocol that dental hygienists and dental professionals can follow when treating their patients who have dental implants and implant supported fixed arch restorations. The development includes a PowerPoint presentation and a handout which is a condensed version of the PowerPoint presentation and is in the form of a flow chart. The flow chart serves as a guide for the clinician to quickly determine treatment modalities for their patients who have dental implants. In addition, an application was made to ADA CERP for continuing education privileges which can be awarded to the dental Dental Implant Maintenance 23 professionals who attend the professional development. Before these privileges can be awarded, the ADA CERP would like to see that at least one presentation of the development is completed. Current efforts are being made with the faculty at WSU Dental Hygiene Department to set up a date and time to present this development. With the rate that dental implants and implant supported restorations are being placed, further efforts to educate dental professionals on the maintenance of dental implants is necessary, especially in the dental hygiene and dental schools. Recently, Susan S. Wingrove published a revised edition to her book Peri-implant Therapy for the Dental Hygienist, which was published back in 2013. This might offer further education and research regarding dental implant maintenance. A follow-up study might also be useful to determine if the flow chart was valuable for the dental professionals who attended the professional development. This could be a survey which is sent out to the participants by email, 6 months after they attend the development. An incentive might be included for those who respond to the survey. Dental Implant Maintenance 24 References Bansal, P., Bansal, P., & Singh, H. (2019). Dental Implant Maintenance-" How to Do?" &" What to Do"-A Review. Journal of Advanced Medical and Dental Sciences Research, 7(3), 24-29. doi: http://dx.doi.org/10.21276/jamdsr Berglundh, T., Armitage, G., Araujo, M. G., Avila‐Ortiz, G., Blanco, J., Camargo, P. M., Chen, S., Cochran, D., Derks, J., Figuero, E., Hammerle, C.H.F., Heitz-Mayfield, L. J. A., Huynh-Ba, G., Iacono, V., Koo, K., Lambert, F., McCauley, L., Quirynen, M., Renvert, S., Salvi, G.E., ... & Zitzmann, N. (2018). Peri‐implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. Journal of Periodontology, 89, S313-S318. Bidra, A. S., Daubert, D. M., Garcia, L. T., Kosinski, T. F., Nenn, C. A., Olsen, J. A., Platt, J.A., Wingrove, S., DealChandler N., & Curtis, D. A. (2016). Clinical practice guidelines for recall and maintenance of patients with tooth-borne and implant-borne dental restorations. The Journal of the American Dental Association, 147(1), 67-74. Froum, S. 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Hygiene protocol for full-arch All-on-4 fixed bridges. DentistryIQ. Retrieved on March 1, 2022 from https://www.dentistryiq.com Kale, A. M., Mahale, S. A., Sethi, K. S., & Karde, P. A. (2020). Clinical and microbial comparative evaluation of 0.1% chlorine dioxide mouthwash versus 0.2% chlorhexidine mouthwash after periodontal surgery: A randomized clinical trial. International Journal of Innovative Science and Research Technology, 6, 935-39. Kracher, C. M., & Smith, W. S. (2010). Oral health maintenance of dental implants. Dental Assistant, 79(2), 27-35. https://www.proquest.com/docview/905173582?pq-origsite=gscholar&fromopenview=true Krishnamoorthy, G., Narayana, A. I., & Balakrishnan, D. (2021). The Dental Implant Maintenance. In L. Ardelean, & L. C. Rusu (Eds.), Oral Health Care [Working Title]. IntechOpen. https://doi.org/10.5772/intechopen.101187 Menezes, K. M., Fernandes‐Costa, A. N., Silva‐Neto, R. D., Calderon, P. S., & Gurgel, B. C. (2016). Efficacy of 0.12% chlorhexidine gluconate for non‐surgical treatment of peri‐implant mucositis. Journal of Periodontology, 87(11), 1305-1313. Pattison, A., & Sumi, J. (2015). Post-surgical implant care. Dimensions of Dental Hygiene, 13(5), 24-29. Dental Implant Maintenance 26 Rios, H. F., Borgnakke, W. S., & Benavides, E. (2017). The use of cone‐beam computed tomography in management of patients requiring dental implants: an American Academy of Periodontology best evidence review. Journal of periodontology, 88(10), 946-959. Rösing, C. K., Fiorini, T., Haas, A. N., Muniz, F. W. M. G., Oppermann, R. V., & Susin, C. (2019). The impact of maintenance on peri-implant health. Brazilian Oral Research, 33(1). https://doi.org/10.1590/1807-3107bor-2019.vol33.0074 Saini, R. (2011). Oral biofilm and dental implants: A brief. National Journal of Maxillofacial Surgery, 2(2), 228–229. https://doi.org/10.4103/0975-5950.94490 Tarquini, G. (2021). Ultrasonic cavitation and peri-implantitis. Retrieved February 16, 2022, from https://www.dentaltown.com/magazine/article/8475/ultrasonic-cavitation-and-peri-implantitis Wingrove, S. S. (2011). Dental implant maintenance: The role of the dental hygienist and therapist. Dental Health, 50(5). Wingrove, S. S. (2013). Peri-implant therapy for the dental hygienist: Clinical Guide to Maintenance and disease complications. Wiley-Blackwell. Wingrove Dynamics (2017). Peri-Implant Therapy. Retrieved March 1, 2022, from https://wingrovedynamics.com/articles Wingrove Dynamics. (2019). Implant Home-care Protocols all Implant-Borne Restorations. Retrieved March 1, 2022, from https://wingrovedynamics.com/articles Wingrove Dynamics. (n.d.). Maintenance and Homecare for the Edentulous Straumann ProArch Patient. Retrieved March 1, 2022, from https://wingrovedynamics.com/articles Wingrove Dynamics. (2020). Biofilm- focused care protocols for natural teeth, implants, and restorations. Retrieved May 1, 2022, from https://wingrovedynamics.com/articles Dental Implant Maintenance 27 van Velzen FJ, Lang NP, Schulten EA, Ten Bruggenkate CM. (2015). Dental floss as a possible risk for the development of peri-implant disease: an observational study of 10 cases. Clin Oral Implants Research, 27(5):618-621. doi: 10.1111/clr.12650 Zellmer, I. H., Couch, E. T., Berens, L., & Curtis, D. A. (2020). Dental hygienists’ knowledge regarding dental implant maintenance care: A national survey. American Dental Hygienists' Association, 94(6), 6-15. Dental Implant Maintenance 28 Appendix A Permission to Use Figure 1,2 & 3 Dental Implant Maintenance 29 Appendix B PowerPoint Presentation Dental Implant Maintenance 30 Dental Implant Maintenance 31 Dental Implant Maintenance 32 Dental Implant Maintenance 33 Dental Implant Maintenance 34 Dental Implant Maintenance 35 Dental Implant Maintenance 36 Dental Implant Maintenance 37 Dental Implant Maintenance 38 Dental Implant Maintenance 39 Appendix C Decision Tree Handout Dental Implant Maintenance 40 Appendix D CE Application Correspondence with ADA CERP Dental Implant Maintenance 41 Appendix E Quality Improvement Project-Initial IRB