What is the best way to take care of our patients following treatment? How can we encourage our patients to return for evaluation? What does the research say to back up our recommendations?
In a group effort, the American College of Prosthodontics (ACP), the Academy of General Dentistry (AGD), the American Dental Hygienists Association (ADHA), and the American Dental Association (ADA) gathered to create a systematic review focused on parameters related to the maintenance of complex dental restorations.
Clinical Practice Guidelines (CPG) were published in an effort to provide recommendations for tooth supported and dental implant supported restorations for the recall interval, the professional maintenance regimen, and the recommendations for home care.1, 2, 3 The goal of the CPGs relate to improved clinical outcomes for our patients.
Patients who have elected to proceed with complex restorative dental treatment often present with a multi-factorial etiology that may include biological considerations or structural breakdown to instigate a dental reconstruction. Certainly, the recall and maintenance requirements for a healthy adult with little to no dental work will be very different than a patient who has been restored with the goal to restore form and function in areas of missing teeth. Specifically, guidelines for the maintenance of dental implant-supported restorations are at best not clear.
The scientific review was completed to evaluate articles published during a 15-year period between 1999 and 2014. The committee comprised of members of the professional organizations focused on 16 studies related to tooth-supported restorations and 20 studies related to implant-supported restorations. The randomized controlled clinical trials (RCTs) were prioritized; however, observational studies were included due to the clinical relevance and lack of RCTs in the area of consideration. Certainly, this is a document that can be modified as more information becomes available.
Summary of the Clinical Practice Guidelines
Recall interval: The baseline continues to be a six-month lifelong recall interval with additional considerations for patients at higher risk to have a shorter recall interval. Higher risk includes the ability to perform oral or potential biological of mechanical complications identified through clinical examination. This recommendation is the same for tooth-supported or implant-supported restorations. What is interesting with the recommendation that seems familiar is that it is based on “expert committee reports or opinions or respected authorities” and only extrapolated from clinical research.
Professional maintenance: Includes an intra-oral and extra-oral examination, a professional cleaning, oral hygiene instructions related to the teeth and implant supported restorations as well as the care and maintenance of removable prostheses including partial dentures and occlusal appliances. Topical agents are recommended for use as determined to be appropriate. The CPG provides additional recommendations for dental implant-supported restorations where chlorhexidine gluconate is recommended as a topical agent as well as cleaning instruments compatible with the implants, abutments and restorations. Specifically mentioned is the use of glycine powder air polishing system for use with dental implant-related restorations. The use of glycine powder and the chlorhexidine gluconate has generated a high level of support in the literature.
Home maintenance: The recommendation includes a twice daily regimen using “dental floss, water flossers, air flossers, inderdental cleaners and electric toothbrushes.” Soft brushes are specifically discussed for use with removable prostheses. The CPG includes a specific recommendation for patients who have experienced more advanced dental treatment to use toothpaste containing 5,000 ppm fluoride. Toothpaste with 0.3 percent triclosan with the addition of chlorhexidine gluconate on a short-term basis is recommended for both tooth-supported as well as dental implant-supported restorations. The use of 5,000 ppm fluoride, 0.3 percent triclosan, and chlorhexidine gluconate all have a strong recommendation based on the literature support.
Potential Changes to Recommendations: Areas of Interest
The committee spent a considerable amount of time to evaluate the recommendations available with an intentional focus on high-level randomized controlled clinical trials (RCTs). It is interesting to see that with all of the dental work we are prescribing and completing for our patients at a high level, there are still a few areas where we could improve our basic understanding. In this case the focus relates to the care and maintenance related to our patients’ oral health.
Chlorhexidine glucontate is a recommendation that is strongly supported in the literature. In the CPGs, chlorhexidine gluconate is recommended in the form of a mouthwash/rinse as well as a gel for localized use as an antimicrobial agent. The rinse (Peridex) contains 12 percent alcohol, which may be a problem for our patients with xerostomia. Will diluting the solution provide the same impact for a patient with dry-mouth symptoms who truly needs the desired antimicrobial effect?
Also, concerns related to increased staining and potentially calculus formation are the reason behind the “short-term” use recommendation … are we able to monitor the follow-through with our patients? Dr. Bob Winter’s series on antioxidants include the use or PerioSciences AO products before, during and after restorative dental treatment. The idea of working with anti-oxidants is to create an environment conducive to healing with an anti-plaque and an anti-gingivitis effect on the surrounding tissues. The information presented with the links below provide a window into future recommendations for our patients.
The recommendations related to toothpaste, specifically toothpaste containing 5,000 ppm fluoride or 0.3 percent triclosan, is another recommendation strongly supported in the literature. One of the topics of interest includes the rating of the toothpaste using a scale of Relative Dentin Abrasiveness (RDA). While this scale itself may be improved in the future, it is interesting to compare the recommendations. A relatively common “high fluoride” toothpaste is Prevident 5000 Booster, which has been rated at 110 on the RDA scale. This means it is a highly abrasive toothpaste. ClinPro 5000 on the other hand has been rated at 62 and is considered a low abrasive alternative. This information might come in handy when working with removable prostheses with denture teeth or potentially patients with a combination of tooth-supported restorations and a dental implant-supported fixed hybrid restoration.
Along the same line of thinking … what about toothpaste that contains 0.3 percent triclosan, e.g. Colgate Total. This toothpaste has been rated at 70 on the RDA scale, which puts it in the low abrasiveness category. There may be some concern as a result of a study released in 2014 connecting triclosan with cancer in mice. The ADA has issued a statement stating that they continue to monitor all products they recommend and "at this time there is no clinically relevant scientific evidence indicating that the Seal should be removed from the Colgate Total product."
One area that is lacking in the CPG would fit under the professional maintenance category to include recommendations related to probing around dental implants. Certainly, there is an opinion that probing can only cause damage to the hemidesmosomal attachment between the tissue and the supracrestal structures associated with the implant and implant supported restoration. Dr. Gregg Kinzer addresses the topic focusing on what can be gained by probing around the dental implant. Specifically, the goal is to evaluate for early signs of biologic complications that can benefit from early clinical management. The signs include bleeding on probing, suppuration, radiographic bone loss, probing depth and implant mobility.
(Click this link to read the article “Should You Probe Dental Implants?”)
Changing prosthetic screws is a recommended component of the CPGs as presented. Certainly there is fair amount of discussion in terms of how often the screws should be changed after a restoration is removed. While there is an obvious comfort factor related to replacing previously used screws in order to avoid the time-consuming process of removing a fractured abutment screw, it is interesting to note that the recommendation falls in the category of recommendation based on “expert committee reports or opinions or respected authorities” and only extrapolated from clinical research.
One of the interesting pieces of information is that what we would consider the baseline six-month recall interval. Certainly, this is based more on opinion than research. This recall interval allows dental care providers to be on the front line in evaluating our patients and recommending continued evaluation beneficial to our patients’ overall healthcare. While hypertension is a condition that does not attract our patients’ attention until a measurement is made, what about a more dramatic scenario where hypertension might be connected to a sleep disorder where we have the potential to be influential in our patients quality of life or even lifespan?
The recommendations presented are based on the information available at this time. As we all know, the variety of complex restorations that have been designed and implemented as a plan to achieve goals related to improved appearance, oral health, and chewing function speaks to the idea that the CPGs provide a baseline to provide recommendations for our patients. The idea is that the information can then be used to customize the regimen based on the specific patient and their maintenance needs.
The goal of creating Clinical Practice Guidelines is to improve the outcome of our patient's restorative dental treatment. Clinical outcomes and collecting data to record clinical outcome has already become important in the hospital patient care setting and will only become a more important component in the treatment of our dental patients as well.
(Click this link to read more articles by Dr. Douglas Benting.)
Dr. Douglas G. Benting, DDS, MS, FACP
1. Bidra, AS, et. al. Clincial Practice Guidelines for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental Restroations. Journal of Prosthodontics 2016;25(S1):S32-S40.
2. Bidra, AS, et. al. A Systematic Review of Recall Regimen and Maintenance Regimen of Patients with Dental Restorations. Part 1: Tooth-Borne Restorations. Journal of Prosthodontics 2016;25(S1):S2-S15.
3. Bidra, AS, et. al. A Systematic Review of Recall Regimen and Maintenance Regimen of Patients with Dental Restorations. Part 2: Implant-Borne Restorations. Journal of Prosthodontics 2016;25(S1):S16-S31.