Adroit Utilization of Dental Hygienist Key to Promoting Long-term Restorative Outcomes
Most restorative or cosmetic dentists spend significant time and money in continuing education courses, learning the proper clinical steps to achieve the most beautiful and longest-lasting restorative outcomes possible. What dentists may be overlooking, however, is a discussion and the pursuit of the proper care and maintenance of their restorations with their dental team, and, furthermore, their patients. The dental hygienist(s) plays an extremely important role in helping to promote long-term outcomes for dentists' restorative cases. By properly utilizing the dental hygienist to enhance maintenance of the health of restorative patients-as discussed in the following sections-dentists will not only improve their restorative outcomes but may also increase production within the dental hygiene department.
Provisional Restorations
Shorter Recall Schedules
Patients who undergo extensive treatment plans that require long-term provisionalization must maintain a frequent dental hygiene recall schedule. Depending on the patient's oral hygiene, caries and periodontal risk, and compliance tendencies, he or she may benefit from maintaining a recall schedule at shorter intervals during treatment. Dental hygienists can make these recall recommendations and reinforce to patients that they must employ proper oral hygiene practices around provisional restorations. Patients often can benefit from oral disinfection via subgingival air polishing with glycine powder as well as from removal of local irritants that can cause gingival inflammation. Maintenance of a healthy periodontium will contribute to enhanced ease of final impressions and stabilization of gingival margins.1 Moreover, improved long-term outcomes will be achieved when caries and periodontal risk factors are minimized during and after restorative treatment.
Bacterial Control
Both bis-acryl and polymethylmethacrylate materials are at risk for bacterial infiltration. Polishing provisional restorations will help to reduce bacterial infiltration, but, in general, provisional materials are significantly less resistant to the penetration of bacteria than definitive restorative materials.2 This can contribute to gingival inflammation or secondary caries development, especially in cases of long-term provisionalization. In addition to the mechanical removal of bacteria during a dental hygiene visit, the use of an antimicrobial varnish may be considered. A varnish containing chlorhexidine and thymol has been shown to reduce the prevalence of cariogenic bacteria and periodontal pathogens for 3 months after application.3 This can be especially useful when patients undergo lengthy restorative treatments that require long-term provisionalization and for tissue conditioning prior to final impressions. In addition, the application of a varnish containing chlorhexidine and thymol is useful after provisionalization (for single or multiple units) to promote tissue health for the delivery of indirect restorations, particularly in areas where bonding of the restoration is planned and proper isolation is required.
Implant Care
Dental implants are placed and restored with a very high success rate; however, maintenance regimens are often dictated by insurance reimbursement or periodontal status. Implants require special maintenance procedures, including biological and mechanical maintenance and observation. Peri-implant mucositis is reversible and characterized by bleeding when probing the area with gentle pressure. (Implants, indeed, should be probed periodically.) Peri-implant mucositis can lead to peri-implantitis, where inflammation around the implant is present, coupled with bone loss. Improper maintenance routines can be considered a risk factor for peri-implantitis and implant failure.4
Patients treated with implant-supported fixed and removable restorations should be put on a recall based on the type of restorations that have been placed, the patient's ability to provide at-home oral hygiene practices, and inherent oral or medical risk factors. Clinicians should provide individualized care, including the use of proper instruments and materials to facilitate mechanical plaque and calculus removal and biofilm disruption as well as topical therapeutic agents. In addition, it is recommended that dentists and hygienists evaluate the prosthesis for function and complications that would require the prosthesis or prosthetic components to be removed or replaced.5
Abrasives and Final Restorations
Dental restorative materials can be damaged when teeth are polished with coarse prophylaxis paste. Composite restorations are at a particularly high risk for damage, as coarse prophylaxis pastes can scratch the surface of direct composite restorations, reducing the surface luster, increasing bacterial adhesion, and over time, removing surface characterizations.6 In addition, coarse prophylaxis paste can damage the cavosurface margin of the restoration. Cumulative damage in this area may result in staining and ditching at the restorative margins, which can lead to a reduced lifespan for direct restorations.
Indirect restorations also are susceptible to damage by prophylaxis pastes; surface stains and glazes that are applied to indirect restorations (including CAD/CAM restorations) can be damaged or roughened by long-term use of coarse prophylaxis pastes.7 Dental hygienists typically are trained in selective polishing, and it is essential that dentists are supportive of this concept, as reduced longevity of dental restorations can negatively impact the bottom line of the dental practice and the reputation of the dentist. Non- or low-abrasive prophylaxis pastes can be used, and all restored teeth should be polished with care.8
Summary
The techniques to create beautiful restorations can be extensive, and it is critical that the dental team share the same ideals to promote favorable long-term outcomes of these restorations. Dental hygienists are valuable assets to the dental practice, as they can reinforce appropriate maintenance recommendations and utilize products that will contribute to the health of the supporting structures and oral environment without damaging the restored surfaces of teeth.
References
1. Bennani V, Ibrahim H, Al-Harthi, L, Lyons KM. The periodontal restorative interface: esthetic considerations. Periodontol 2000. 2017;74
(1):74-101.
2. Beurgers R, Rosentritt M, Handel G. Bacterial adhesion of Streptococcus mutans to provisional prosthodontic material. J Prosthet Dent. 2007;98(6):461-469.
3. Lipták L, Bársony N, Twetman S, Madléna M. The effect of a chlorhexidine-fluoride varnish on mutans streptococci counts and laser fluorescence readings in occlusal fissures of permanent teeth: a split-mouth study. Quintessence Int. 2016;47(9):767-773.
4. Curtis DA. A call for continuing dialogue on recall and maintenance of patients with tooth-borne and implant-borne restorations. J Prosthodont. 2016;25(2):97-98.
5. Bidra AS, Daubert DM, Garcia LT, et al. Clinical practice guidelines for recall and maintenance of patients with tooth-borne and implant-borne dental restorations. J Am Dent Assoc. 2016;147(1):67-74.
6. Truong K, Chen JW, Lee S, Riter H. Changes of surface properties of composite preveneered stainless steel crowns after prophy polishing to remove stains. Pediatr Dent. 2017;39(2):17-24.
7. Can Say E, Yurdagüven H, Malkondu Ö, et al. The effect of prophylactic polishing pastes on surface roughness of indirect restorative materials. ScientificWorldJournal. 2014;2014:962764. doi: 10.1155/2014/962764.
8. Monaco C, Arena A, Özcan M. Effect of prophylactic polishing pastes on roughness and translucency of lithium disilicate ceramic. Int J Periodontics Restorative Dent. 2014;34(1):e26-e29.
