Optimizing the Health of Soft Tissues to Ensure Success

Joseph J. Massad, DDS, Lily T. Garcia, DDS, MS, & Swati Ahuja, BDS, MDS
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Introduction

In treatment planning patient care, the initial focus is on disease control prior to definitive care. In edentulous patients, it is critical to improve the health of denture-bearing tissues prior to making impressions, especially in the clinical scenario when the patient is to have tissue-supported removable prostheses.1,2 Removable complete dentures, removable partial dentures, and tissue- and implant-supported overdentures fabricated on unhealthy tissues lead to further deterioration of tissue health and the compromise of prosthetic outcomes.1,3 Discrepancies in fit, tissue adaptation, stability, and occlusion can be attributed to the placement of a removable prosthesis on tissues that may have debris on them or have not been managed for proper intraoral hygiene. Patients who wear removable complete dentures are commonly affected by denture-associated pathologies such as stomatitis, Candida infection, traumatic sores, and/or denture-related hyperplasia.4 The capacity for healing and recovery of denture-bearing tissues is impacted by the presence of biofilm, plaque, calculus on the prosthesis, residual adhesive, irritation, and inflammation.5 To improve the potential for a successful patient outcome, thorough assessment and appropriate intervention are required for optimizing soft-tissue health.

The Importance of Overall Health

The improvement and maintenance of overall oral health is also important prior to the impression making, trial, and placement of a fixed prosthesis that may be tooth-supported or implant-supported.6-9 Increased bleeding and secretion of crevicular fluid (associated with inflamed tissues) makes it challenging to record the finish lines of the preparations/abutments, resulting in poor fit at the margins.9,10 It is not only the recording of the finish lines but also the trial and placement that are challenging in the presence of inflammation. Unhealthy gingival/peri-implant tissues are susceptible to recession,9-12 thereby affecting the aesthetics and oral hygiene maintenance of the definitive prosthesis.

Peri-implantitis

Peri-implantitis is one of the most frequent complications affecting the hard and soft tissues surrounding the implant, resulting in loss of implants.13-16 Poor plaque control is considered a key etiological factor in the development of periodontitis and peri-implantitis.17-20 Adequate plaque control is critical for the reduction of inflammation, limitation of pathogenic oral bacteria, and prevention of stains and odors.21 Unhealthy tissues affect the longevity and success of the teeth/implants and prostheses.22

Responsibility for Optimal Oral Hygiene Takes a Team Approach

Healthy and clean oral tissues are paramount during all phases of prosthesis fabrication.1 It is the responsibility of the entire dental team, including the assistants, hygienists, and the dentist, to educate, train and motivate the patient to improve and maintain oral health. The most efficient hygiene devices (manual and electric toothbrushes, brushing at least twice daily; interproximal brushes; flosses; antimicrobial rinses and gels; and subgingival irrigation systems) should be incorporated in the daily cleaning regimen of the patient.23-33 The practitioner can provide the cleaning aids to patients as soon as they accept their treatment plans. This is particularly advantageous because it ensures that the cleaning aids are immediately accessible to the patients and eliminates the possibility of getting the wrong products. The dental team should teach the use of the cleaning aids during the clinical appointment and not simply hand them over to the patient.

Toothbrushing (with a proper technique) aids in the mechanical removal of dental plaque, biofilm, calculus, food particles, and adhesive from the oral tissues34-36 and in massaging the oral tissues.37 An increase in blood flow, capillary permeability, and oxygenation; the promotion of keratinization of the gingival epithelium; a decrease in the gingival crevicular fluid volume, and an increase and enhancement of the proliferative activity of crevicular epithelial basal cells are the advantages associated with massaging/stimulation of the oral tissues.38-43 Electric toothbrushes/electric gum massagers aid in achieving the beneficial effects of tissue stimulation more quickly and efficiently compared to regular manual toothbrushes.44-46 A greater improvement in oral health and a reduction in plaque and gingivitis have been reported with powered (electric) toothbrushes when compared to manual toothbrushes.47-52 Electric toothbrushes are preferred by most patients because they are efficient, easy, and convenient to use.21

Recently, newer electric brushes (Genius [Oral-B]) with 3D cleaning action technology (oscillation, rotation, and pulsation), pressure sensors, position detection, and built-in timers have been introduced. The oscillating, rotating, and pulsating action of the electric toothbrush stimulates and massages the tissues, thereby increasing the velocity of red blood cells, which carry oxygen into the tissues. The use of electric toothbrushes for preventing peri-implantitis and maintaining peri-implant health has been discussed in several articles.34-36

Cleaning the Oral Cavity Before Clinical Procedures

All patients should be instructed to clean their oral cavities in the dental office prior to all clinical procedures. The technique for edentulous patients is a little different compared to others. They are asked to sip warm water, hold it in the mouth, and secure it by pursing their lips. Pursing of the lips prevents the water from dripping out of the oral cavity while inserting the dual-action brush head (in the Daily Clean mode) into the mouth. The massaging action while water is in the mouth aids in increasing tissue hydration and improving tissue health. Daily home care for edentulous patients, dentate patients, and patients with implant prostheses is described below.

Daily Home Care for Edentulous Patients

Edentulous patients are asked to place the brush in the mouth and gently move the brush head to contact all the tissue surfaces of the mouth (Figures 1a to 1c). They are instructed to use the electric toothbrush with the dual-action brush head (in Daily Clean mode) to clean and massage their oral tissues twice per day (Figure 1d) to maintain their oral health throughout their lives.

Figure 1a. The Genius (Oral-B) positioned on the buccal surface of the maxillary denture-bearing tissues. Figure 1b. The brush head positioned on the palatal surface of the maxillary denture-bearing tissues.
Figure 1c. The brush head positioned on the occlusal surface of the mandibular denture-bearing tissues. Figure 1d. Massaging the oral tissues aids in increasing blood flow, capillary permeability, and oxygenation.

Denture adhesive use is common among denture wearers. It is important to teach patients an effective method for adhesive removal from denture surfaces and oral tissues. Appropriate denture and oral hygiene should be accomplished by edentulous patients at least 2 times each day.

For removing biofilm, debris, and adhesive from the prosthesis, the patient is asked to submerge the prosthesis in a container filled with warm water. The patient is instructed to place the dual-action brush head (in Daily Clean mode) in the same container and slowly move it on the intaglio surface of the prosthesis (Figure 2a). Both the warm water and the oscillation-rotation-pulsation action of the brush aid in decoupling the biofilm, debris, and adhesive from the prosthesis (Figure 2b).

For removing biofilm, debris, and adhesive from the denture-bearing tissues, the patient is asked to sip warm water, hold it in the mouth, and secure it by pursing his or her lips (Figure 3a). Pursing of the lips prevents the water from dripping out of the oral cavity while inserting the toothbrush into the mouth. The patient is instructed to move the dual-action brush head slowly and gently on all the denture-bearing tissue surfaces. Both the warm water and the oscillation-rotation-pulsation action of the brush head aid in decoupling the biofilm, debris, and adhesive from the tissues (Figures 3b and 3c). Once all surfaces are clean, the patient is asked to expectorate.

Figure 2a. The patient moves the brush head slowly and gently on the intaglio surface of the maxillary denture. Figure 2b. Separation of biofilm, debris, and adhesive from the maxillary denture.
Figure 3a. The patient is asked to sip warm water, hold it in the mouth, and secure it by pursing their lips. Figure 3b. Separation of biofilm, debris, and adhesive from the maxillary tissues.

Daily Home Care for Dentate Patients, Patients With Fixed Dental Prostheses, and Patients With Implant-Retained Fixed Dental Prostheses

These patients are advised to place the cross-action brush head (in Daily Clean mode) in the mouth and gently move the brush head to contact all the surfaces of the teeth/prosthesis in the mouth (Figures 4a and 4b) and the gingival tissues (Figure 4c). This enables the cleaning of the lingual, labial/buccal, and incisal/occlusal surfaces of the teeth/prosthesis and massaging of the gingiva. For sensitive teeth and gums, it is recommended to use the sensitive brush head in the Sensitive mode. The oscillation-rotation-pulsation action of the brush aids in removing stubborn debris. The interproximal brush head in Daily Clean mode is recommended for interproximal cleaning (Figure 5a) and cleaning under the surfaces of pontics/prostheses(Figures 5b and 5c). This will permit the removal of biofilm, plaque, and food particles accumulated in these spaces.

Figure 3c. Separation of biofilm, debris, and adhesive from the mandibular tissues. Figure 4a. The Genius positioned on the palatal/lingual surfaces of the natural teeth.
Figure 4b. The brush head positioned on the occlusal/incisal surfaces of a fixed dental prosthesis. Figure 4c. The brush head positioned at the junction of the implant-supported fixed complete denture and the tissues.
Figure 5a. The Genius interproximal brush head positioned for use in interdental cleaning. Figure 5b. The interproximal brush head positioned between the pontic and the tissues.
Figure 5c. The interproximal brush head positioned between the prosthesis and the tissues. Figure 6a. The Genius cross-action brush head being used to clean all the surfaces of the bar.

Daily Home Care for Patients With Removable Implant Prostheses

Patients with removable implant prostheses supported by an implant bar attachment are asked to place the cross-action brush head in the mouth and rotate the brush to gently clean all tissue surfaces. The patient is instructed to position the bristles on the implant bar and gently move the brush head to contact all the surfaces of the bar. The oscillation-rotation-pulsation of the brush aids in removing stubborn debris from the buccal, lingual (Figure 6a), occlusal, and intaglio surfaces of the bar. The interproximal brush head in Daily Clean mode is recommended for cleaning the intaglio surface of the bar. The patient is instructed to gently guide the bristle head between the bar and the tissue with gentle pressure (Figure 6b). Move the brush head laterally to clean the entire area. This will permit the removal of biofilm, plaque, and food particles that have accumulated underneath the bar. For cleaning the stud attachment, the patient is instructed to position the bristles on the stud attachment and apply gentle pressure. Maintaining the vertical positioning not only aids in removing debris surrounding the stud abutments but also ensures that the bristles engage the apertures in the stud abutments and remove any impacted debris (Figure 7). Debris can accumulate in and around the retentive element of the stud attachment/bar in the prosthesis and affect the retention and stability of the prosthesis. The patient is asked to place the cross-action brush on the retentive elements of the stud attachment/bar and apply gentle pressure to remove debris within and around the retentive element (Figure 8).

Figure 6b. The interproximal brush head positioned between the bar and the tissues. Figure 7a. Debris being detached from the stud attachment.
Figure 7b. Clean stud attachment, Figure 8a. Debris being detached from the retentive element.
 
Figure 8b. Clean retentive element.  

Acknowledgment: All graphics in this article were created by Dr. Massad.

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ABOUT THE AUTHORS

Dr. Massad is an associate professor in the department of graduate prosthodontics at the University of Tennessee Health Science Center (UTHSC) College of Dentistry in Memphis; a clinical professor at the University of Oklahoma College of Dentistry in Oklahoma City; an associate faculty at the Tufts University School of Dental Medicine in Boston; an adjunct associate faculty in the department of comprehensive dentistry at the University of Texas Health Science Center at San Antonio (UT Health San Antonio) School of Dentistry; and an adjunct professor in the department of restorative dentistry at Loma Linda University in Loma Linda, Calif. He has a private practice in Tulsa, Okla. He can be reached at joe@joemassad.com.

Dr. Garcia is dean and a professor at the University of Nevada, Las Vegas School of Dental Medicine. She was in private practice in Denver early in her career, then served as faculty at the University of Colorado Health Sciences Center School of Dentistry, as the department chair of prosthodontics at UT Health San Antonio, and as professor and associate dean for education at the University of Iowa College of Dentistry. She can be reached at lily.t.garcia@unlv.edu.

Dr. Ahuja worked at UTHSC in Memphis as an assistant professor in the department of prosthodontics for 3 and a half years. She has lectured nationally and internationally on various prosthodontic topics at various dental conferences. She has more than 50 publications in peer-reviewed national and international journals and is also the co-author of the textbook Applications of the Neutral Zone in Prosthodontics. She is a consultant scientific writer and a consulting prosthodontist for several private dental clinics in Mumbai, India, and also for NYU Langone Medical Center in New York. She can be reached via email at swatiahuja@gmail.com.

DISCLOSURE: Dr. Massad consults with P&G. Drs. Garcia and Ahuja report no disclosures.

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