Finding the ‘Gap’ in Your Implant Care

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Is Your Hygienist Ready for the Next Implant Patient? 

Dental implants are on the rise – are your clinicians ready to care for their next implant patient? It seems self-evident to say that hygienists learn about care of implants in school, so they are prepared. However, like most anything in dentistry, it’s never that simple. And in the case of dental support organizations (DSOs) who are scrutinized for compliance and often criticized (typically by those who have never worked for a DSO) for only caring about the money and not the patients, finding any gaps in patient care is always of utmost importance. Whether or not a dental practice offers implant services, here are some things you need to know.

The Rise of Dental Implants
Dental implants are now considered one of the preferred treatment options for replacing a missing tooth or teeth, as well as All-on-4 implants for edentulous patients. Although implants have long been a part of human history based on findings from ancient Egyptian and Mayan civilizations1, it wasn’t until the last 30 years that implants saw rapid innovation and widespread use.

Based on research published in 2014, the dental implant industry is a multi-billion-dollar global market and is forecast to grow over 7.7% in the coming years. It is reported that there are 5 million implants placed in the U.S. each year with over 15 million patients treated for missing teeth with crown and bridge. Today’s predominant material of choice is titanium due to its unique properties, and as a result over 92% of implants are made of titanium.2

Dental Implants and DSOs
Many DSOs are already capitalizing on this implant growth opportunity by including specialty offices or incorporating specialists on dedicated days, as well as growing their ranks of general dentists who are competent and confident in placing implants. As resources are increasingly allocated to paying specialists and training dentists, there is not, or at least not widespread corresponding emphasis and educational investment by DSOs for the ongoing care of implant patients. As a leader of a business, and a business owner myself, I’m familiar with the challenges of justifying investment. And along with rigorous ROI analysis and objective review to prioritize opportunities, I always use my guiding philosophy: if you take great care of your patients, the financial return will present itself.

Implant Care
Consistent care is key to low implant failure. Implants do not integrate into the gums like natural dentition does. If the tissue is not kept clean it can lead to a risk of peri-implant mucositis (inflammation without boneless), or worse, peri-implantitis (inflammation with boneless). It’s widely accepted that preventing peri-implant disease is fundamental to not just implant success, but also patient health. Ask most hygienists about implant care, and they will tell you that there are special cleaning challenges. However, there isn’t broad consensus in how to maintain implants.3 In a growing world of implants, and fast-paced DSOs, it’s incumbent upon all providers and their operational supporters to ensure they have the training and instruments needed to provide optimal care.

  • Care of titanium implants
    Titanium is the favored material for implants due to its properties suitable to oral healthcare: it’s strength, longevity, resistance to corrosion, nontoxicity, and biocompatibility. However, it does have the disadvantage of that it scratches easily. Thus, began inclusion of titanium instruments to avoid scratching implants during recare appointments. Having spent my career working as a dental hygienist and performing chairside coaching for DSOs, I have witnessed first-hand the use of stainless-steel curettes on titanium implants. And this is just one of the implant care gaps.

Top 4 DSO Implant Care ‘Gaps’
Beginning with the assumption that it is the goal to keep implant patients healthy and prevent failures, whether or not the implant was performed by your practice/DSO, it’s obligatory of clinical leaders to ensure the level of post-operative and ongoing care is as important as the initial implant placement. After all, implants are a very sizable investments for patients. Assessing if your organization has any gaps in care is an ongoing part of any dental business, and today is as good as any day to ensure your team is on the right path!

Implant care protocol
Most DSOs have a hygiene protocol for care. However, the emphasis of many hygiene protocols, which stands to reason, is on periodontal exam, classification, grading, extent and sequencing of procedures. Over the years I have helped several organizations develop hygiene protocols. In my current role as a head of Clinical Affairs for a DSO, we have a very detailed protocol for care. Additionally, more can and should be added to guide continuity of care for our hygiene team to ensure each implant patient receives the highest level of care by every hygienist.

Although even the most detailed protocol cannot define every patient type, providing guidelines that include implant considerations will help bridge confusion that may exist. Addressing misunderstandings regarding probing around implants, assessing disease, care frequency, instrumentation and more may all be relevant when updating your hygiene protocol. Substantiated with evidenced-based research and your organization’s philosophy and expectations will also help.

Implant training for hygienists
Having a protocol to address implant care alone won’t suffice. While some hygienists will devour hygiene protocol tomes, it is most likely that repeat training and ensuring understanding of the training is paramount to continuity of care.

Many DSOs have their own trainers and training programs the question is how many provide dedicated hygiene training that includes the understanding of implants and how best to care for them? In continuing education “future topic requests” surveys I have performed, I have seen few, if any requests for training on implant care – implant CE is seen as the domain of Dentists. Certainly, questions of care of implants and peri-implantitis arise during hygiene and periodontal disease training courses, however, informal knowledge sharing does not do much to build general consensus of how to care for nor guarantee continuity of care for all providers in the DSO setting.

Appropriate Instrumentation / Easy Access to Ordering
Considering the limitations, the average RDH faces today during a typical day in the DSO setting, many hygienists do not have the time or full autonomy to order preferred instruments. This is a major frustration of many practicing dental hygienists that complain of the lack of funding in their departments. Most DSOs have formulary/negotiated pricing, but many clinicians do not understand what that means exactly, or what products are included within that structure. It should not be assumed that hygienists will ask for, or order the instrumentation they need.

Additionally, it’s not uncommon in a DSO to have competing focus between the operations team seeking to control expenses and clinicians who need instrumentation for the patient in the chair regardless of the monthly supply budget that is based on the collections of the prior month – who is right, and who should win? Ultimately patient care should always win. Which means it is necessary for the DSO clinical team, procurement team and operational leadership to ensure clinicians have the proper instrumentation to treat every patient type.

A good practice, is to periodically review the current formulary and confirm that it contains the appropriate titanium instruments to perform ongoing care of titanium implants. While every DSO model, and individual hygienists vary, the minimum recommendation is to include at least one (1) titanium curette as part of every basic hygiene set-up. There should be at least two (2) full titanium implant care kits in every office.

Paradise Dental Technologies is one example of a company, with a great reputation that partners with DSO organizations, and has been paving the way with implant care. This was initiated by developing an implant kit named after Susan Wingrove, RDH BS, a well-known key opinion leader in the dental world, appropriately named the “R900 Wingrove™ Titanium Implant ‘Go-To’ Set.4

Figure 1 R900 Wingrove™ Go-To Set

Titanium instruments such as this are specifically designed to be safe and effective for use in all restorations including implants and the Hygienist can be certain it will not damage easy-to-scratch materials. As a Hygienist, it is meaningful to have a fellow clinician that was involved in the research and development of instruments suitable for every patient type.

Implant care metrics / accountability
As DSOs we rely on metrics to confirm that comprehensive care is taking place, a unique challenge is how to measure the recare an implant patient receives. In a single office, it is easy to measure care using patient charts and provider notes. However, some DSOs have teams of 20, 100, or even 900+ hygienists. The only possible scalable objective measurement is by reviewing the corresponding procedure codes. The ADA added D4346 and D6081 (the only code that can be used with D4346) to address treatment of inflammation and implants which can serve as a metric to monitor.5 However, determining the benchmark that should be used to serve as a parameter of treatment success remains in question. Do you know the exact number of patients in your DSO offices that have implants? And of those patients, how many may have peri-implant mucositis or worse still peri-implantitis? What percentage should we expect to see in a typical patient base? In a 2019 study at US Dental School which looked at the prevalence of peri-implantitis and common risk factors, it was determined that about 1/3 of the patients studied and 1/5 of all implant patients in general experienced peri-implantitis. The principle risk factors were poor fit or design of the restoration and history of periodontitis.6 If you are monitoring the implant patients in your office, this data can assist you in the development of benchmarks. If there has been no focus in this area, the initial step would be to start by tracking data. From there, set a baseline, then develop goals and track progress moving forward.

Seize the Opportunity
The opportunity for dental practices to grow their business with implants is significant and steadily increasing. As is the opportunity to improve the level of care that the dental team provides. To be truly successful in this regard, and ultimately winning the smiles and referrals from all patients requires the alignment and communication between clinical team members (specialty, general dentists, hygienists and assistants too!), as well as the operations team, procurement and an executive team willing to act. The most important thing is to take the first step to identify and close the implant care gap today!

Find out more about Implant Care and Maintenance 

About the Author
Mary Hughes, RDH, BS – is Vice President, Clinical Affairs for Dental Whale Practice Group and owns her own company Dental Education Partners where she is the CEO and Instructor. After 20 years as a clinical dental hygienist, Mary transitioned to corporate dentistry where she held training, sales, and executive roles in manufacturing prior to joining a DSO. Her passion for dental education led her to start her own consulting and education business, Dental Education Partners, based out of Fort Lauderdale Florida, focused on hygiene growth at general and group practice. She is a recognized dental lecturer, has been published in dental journals, and is a member of the ADHA.

References
1. The Open Dentistry Journal. (2014, May 16). A Brief Historical Perspective on Dental Implants, Their Surface Coatings and Treatments. Retrieved July 18, 2019 from https://opendentistryjournal.com/VOLUME/8/PAGE/50/
2. Grand View Research. (2014, April 28). Current trends in dental implants. Retrieved July 17, 2019 from https://www.grandviewresearch.com/industry-analysis/dental-implants-market
3. Perio Implant Advisory. (2017, November 8) Dental implant maintenance: So many recommendations, but which one is right? Retrieved July 18, 2019 from https://www.perioimplantadvisory.com/clinical-tips/hygiene-techniques/article/16412222/dental-implant-maintenance-so-many-recommendations-but-which-one-is-right
4. Paradise Dental Technologies Site. Retrieved July 18, 2019 from https://www.pdtdental.com/wingrove-implant-maintenance/
5. Dental Codeology. (2017, January 9) Do You Know the Insurance Codes for Peri-Implant Mucositis and Peri-Implantitis? Retrieved July 18, 2019 from https://dentalcodeology.com/blog/do-you-know-the-insurance-codes-for-peri-implant-mucositis-and-peri-implantitis/
6. Clinical Oral Implants Research. (2019, April 16) Peri‐implantitis prevalence, incidence rate, and risk factors: A study of electronic health records at a U.S. dental school. Retrieved July 18, 2019 https://onlinelibrary.wiley.com/toc/16000501/2019/30/4


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