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The oral environment undergoes continuous changes, often leading to the progression of oral diseases. To halt the advancement of illnesses and provide the best treatment options, dental hygienists and dental technicians can draw on each other's knowledge and experiences to assist dental practitioners in generating the best treatment outcomes and preventative measures. Understanding oral health trends and sharing information about new developments in restorative materials and maintenance protocols become essential in projecting future needs and creating predictable and long-lasting results for dental patients.
Over the years, oral care protocols, restorative options, and dental materials have evolved quickly, contributing to longer-lasting dental prostheses, better esthetics, enhanced function, and a healthier oral environment. At the same time, dental professionals became overwhelmed with new information and faced hardships staying abreast of the ever-changing developments. Contemporary literature supports evidence that communication between dental professionals, especially dental hygienists and dental technicians, is lacking.1, 2 Thus, improved collaboration between the allied team members can have far-reaching benefits, alleviate many challenges, and deliver the optimum outcomes for dental practitioners and their patients.
Oral Health Trends
During the past 20 years, the impact of poor oral health expanded noticeably. According to the 2016 Global Burden of Disease Study, among the 328 health-related conditions affecting nearly 3.5 billion people worldwide, four out of the 30 most prevalent diseases are related to oral health and include untreated dental caries in adults and children, severe periodontitis, and severe tooth structure or complete tooth loss.3 In the United States, advances in prevention and expanded access to dental treatments improved oral health for children but not necessarily for adults. Nine in 10 children gained access to dental insurance. Unfortunately, adolescents ages 12 to 19 lose eligibility for dental coverage as they enter adulthood and are not covered by Medicaid, CHIP, or a family dental plan. More than one in four adults ages 20 to 64 have no dental insurance, and the segment of the US population that is age 65 years and older is growing rapidly. A decline in untreated tooth decay affecting those populations was noted: 8% in children, 3% in adolescents, and a 6% decline in older adults. Tooth loss affects all ages, but complete tooth loss (edentulism) continues to decline. Among working adults ages 50 to 64, an estimated 6% are edentulous, and 13% of adults ages 65 to 74 experience complete tooth loss compared to 50% in the 1960s.4 As more patients retain full dentition into their later years, they challenge their practitioners with higher demand for innovative treatments, including the latest fixed and removable options.5
The Importance of Teamwork
As essential team members contributing to successful treatment outcomes, dental hygienists and dental technicians should be familiar with the types of restorations and materials available on the market and what is involved in home care and professional maintenance of dental restorations. Since the dental practices' legal liability is linked to restorative cases, the allied team members should be capable of evaluating and contributing to treatment choices within the scope of their practices, sharing knowledge, consulting each other, and contacting manufacturers with relevant questions.
The longevity of dental devices depends on many factors, including the practitioner's knowledge and skills, techniques utilized during treatment, materials, patients' physical and cognitive conditions, overall health, financial standing, and compliance with oral maintenance.6 By staying on top of the latest trends and understanding the obstacles facing modern society, oral health professionals can open new communication channels and find creative ways to improve our nation's oral health.
Dental Restorations, Types, and Uses
Modern dental restorations can be classified as direct and indirect. Direct restorations are fillings created and placed directly in the patient's mouth by a dental practitioner. The most widely used filling materials include composite resin, amalgam, and gold. The tooth-colored resins retain a natural look, blend well with surrounding dentition, and last 7 to 10 years on average, while amalgams, the least esthetic of all fillings, last around 15 years. The gold fillings, which are the most expensive and longest lasting, can function for 15 to 30 years or longer before replacement is needed.7
Indirect dental restorations are made by dental technicians in compliance with the dental practitioner's prescription. They include fixed and removable restorations, which can be hybridized with dental implants. Fixed restorations are inlays, onlays, crowns, bridges, and full mouth reconstructions. Implants can be combined with crowns and bridges to create implant-supported fixed prostheses and can be cemented or screw-retained. Materials used for fixed restorations include metal alloys (high noble and noble alloys, base metal alloys, and titanium alloys), ceramics (powder-liquid, glass-based pressed or machinable, high-strength crystalline or metal-ceramic materials, and hybrid ceramics), composite resins, and polymers (PMMA, PEEK, and PEKK). Most widely used dental implants are made of titanium or zirconia, but other materials are also utilized.8
Removable dental prostheses are divided into partial dentures or full/complete dentures. Combined with implants, they become implant-supported removable prostheses and are used as part of the overdenture, hybrid, and telescopic structures. The materials most often used are polymers (PMMA, PEEK, and PEKK), composite resins, and metal alloys.
Orthodontic appliances utilized in various treatments are classified as active, passive, and functional. The most widely known orthodontic appliances include wire and invisible braces (aligners), night guards, sleep apnea appliances, and expanders. Orthodontic materials incorporate metal alloys, polymers, composites, and 3D printing materials like acrylonitrile-butadiene-styrene plastic, stereolithography materials (epoxy resins), polylactic acid, polyamide (nylon), glass-filled polyamide, silver, steel, titanium, photopolymers, wax, and polycarbonate.9
When advising patients on proper oral hygiene, the focus is on preventing oral diseases like dental decay and periodontal conditions. This is achieved by appropriately managing bacterial load and reducing pathogenic bacteria in the oral cavity through adequate brushing methods, interdental care (between teeth), and oral rinses. When providing oral hygiene instructions to patients with dental restorations, ranging from fillings to fixed or removable prostheses, and orthodontic appliances, routine oral care and its effects on restorative materials must be considered.
Most publicized post-restorative home care includes brushing teeth with a fluoridated dentifrice (toothpaste) at least twice a day, flossing once a day, using mouthwash recommended by the dentist, and, when indicated, wearing a night guard to protect restorations from parafunctional habits like bruxing. Quitting smoking or chewing tobacco and avoiding alcohol and high-sugar diets are also advocated.10
Dentifrice and fluoride treatments significantly influence restorative maintenance since they can jeopardize bonding abilities, color changes, and surface abrasion of dental restorations.
Abrasive wear caused by daily toothbrushing has been reported in multiple studies, which also noted that degrees of abrasion vary among restorative materials based on frequency, duration, stiffness of the toothbrush filaments, and properties of the restorative material. Abrasive wear can cause surface roughness, compromising esthetics and promoting bacterial retention. Polymers and composite resins are most affected by abrasive toothbrushing, resulting in increased surface roughness, diminished gloss, and color changes, while ceramic and zirconia restorations are the least affected.11, 12, 13 Additionally, fluoride products with acidic pH balance can alter dental restorations' color and surface roughness.14 Thus, dental professionals should regularly recommend gentle and safe dentifrice to their patients.
When used as intended, antiseptic mouthwashes positively reduce the number of pathogenic organisms in the oral cavity; however, they may still cause adverse effects on dental restorations. For example, continuous use of chlorhexidine mouthwash can contribute to discoloration of composite resin restorations, yet specific dentifrice can effectively remove such discolorations.15 Alcohol-based and low-pH mouth rinses can affect nano-filled composite resin restorations' surface hardness and color, and decrease the tension of orthodontic chains.16, 17Mouthwashes containing fluoride and acidic pH can react with Si, Na, and K ions on the surface of the ceramic restoration.14 Particular antiseptic oral rinses can also decrease color stability and translucency of zirconia and ceramic restorations.18 Thus, professional recommendations for oral rinses greatly benefit patients in the long run.
Thorough interdental care is essential to the longevity of dental restorations. Still, lack of education and decreased motivation were major obstacles to patients' compliance with recommended interdental care regimens.19
It is imperative to understand which interdental aid is best suitable for a specific type of restoration. Factors like the type of restoration (fixed or removable; single or multi-unit), size of the interdental space, gingival embrasure, and patient motivation/dexterity must be considered. Single-unit restorations are more commonly managed by using flossing techniques and devices. Depending on the patient's preferences and level of dexterity, floss (string, tape), floss picks, or power flossers are recommended to remove plaque from proximal surfaces of single-unit restorations. Multi-unit restorations require using a floss threader or super floss to assist in eliminating plaque and trapped food particles under artificial teeth (pontics). Interdental brushes are recommended in wide embrasure spaces, open contacts, and under fixed bridges. Using a waterjet flosser is considered safe for care around dental restorations and fixed bridges.20
Due to a common discrepancy in the size of the implant-supported crown in relationship with the implant, additional interdental care aids must be introduced. In a study surveying the efficacy of interdental biofilm removal from implant-supported crowns, five aids were evaluated: a waterjet flosser, a powered interdental brush, floss, super floss, and an interdental brush. Findings supported superior results for crowns cleaned with floss and super floss. However, none of the surveyed aids were able to eradicate biofilm completely.21 Therefore, regular dental visits are critical to monitor patients' compliance with maintenance protocols and prevent oral decline.
Home Care of Removable Appliances
Removable dental prostheses may negatively impact patient health, quality of life, nutrition, and communication. The lack of knowledge on proper denture care results in the poor condition of the appliance. Dental hygienists, as members of the dental team, are best positioned to educate patients on proper appliance care22; however, dental technicians should be aware and able to advise patients when asked. According to a 2020 survey, only 50.7% of respondents reported having sufficient knowledge of denture care, 12.7% did not clean their dentures, and 40% only cleaned once daily. The study found that the lack of knowledge and irregular cleansing habits contributed to these results, demonstrating the significance of proper care instructions and regular follow-up visits.23
Care should be taken in educating edentulous or partially edentulous patients on the importance of proper home care, as harmful microorganisms easily adhere to removable prostheses and have detrimental effects on oral and systemic health.24 Patients must know how to clean their removable prostheses and properly store them when outside of the mouth. It is recommended to clean the prosthesis with a soft denture toothbrush, remove any remaining adhesives, soak in commercially available denture cleaning solution or ultrasonic bath for 10 minutes, and rinse before storing. Further, removing dentures at night is necessary to avoid denture stomatitis.25 However, soaking prostheses in chemical solutions for more than 10 minutes could cause damage.24 In case of implant-supported dentures, adverse effects of cleaning solutions and water temperatures on the retention of locator attachments were observed.25 The best way to store removable appliances outside the mouth is by immersing them in water to prevent distortion.24 Yet, due to the lack of knowledge, 21.3% of the surveyed denture-wearers reported storing dentures in the open air or wrapped in a cloth or plastic bag.23 To avert miscommunication, patients should be provided with simple yet detailed instructions on how to care for their prostheses post-dental visits.
Professional Dental Hygiene Maintenance Protocols
Patients with a history of any restorative treatments are advised to follow up with regular dental hygiene visits ranging between two to four times per year (every 3 to 6 months). The frequency is determined based on the individual's risk factors and needs, the complexity of restorative treatments, the presence of periodontal conditions, and the effectiveness of the homecare routine.26 The goals of the visits are examination, removal of hard and soft deposits, and reinforcement of recommended home care protocols.27 Dental hygienists use specialized equipment and materials to remove soft and hard deposits from natural teeth and dental restorations without harming the patient. Dental technicians can contribute by promoting regular professional care of dental restorations when in contact with patients.
Hard and soft deposits are removed using hand and power instruments and coronal polishing using conventional and novel techniques.28 Studies showed that repeated use of power instrumentation on dental restorations could cause surface roughness, porcelain fractures in cervical areas, and scratches in the glaze, which could promote the accumulation of oral biofilm.27,28 The use of stainless-steel hand instruments is also consistent with reports of significant damage to the outer layers of dental restorations.28 Air polishing, an integral part of professional maintenance protocol, refers to using powder and water to remove harmful bacteria and biofilm and to polish natural teeth and dental restorations. It eliminates bacterial plaque and stains more effectively than polishing with a rubber cup and prophylaxis paste. Historically, early air-polishing devices used harsh powders that could cause abrasion and damage the natural teeth and dental restorations, resulting in stronger abrasion and increased adhesion of pathogenic bacteria. Erythritol and glycine are recommended over calcium carbonate and aluminum trihydroxide to minimize abrasion of restorative materials. The pressure, water flow, distance, and angulation of the air polishing nozzle also influence the extent of potential surface defects.29
Patients with complete dentures should seek professional maintenance and check-up visits annually. Those with partial or implant-supported prostheses should see a dental professional more frequently, every 3 to 6 months.25 During the visit, soft tissue lesions and bone loss will be assessed, and dentures will be evaluated for fit and professionally cleaned to prevent biofilm accumulation.24 Any remaining natural teeth will be cleaned using hand and power-driven periodontal instruments.
While focusing on materials and care of restored teeth, the longevity of natural teeth should be as crucial as the longevity of dental restorations.30 Patients must be carefully educated about their conditions and provided with comprehensive treatment options and detailed care instructions based on their needs, concerns, and abilities.31 Special recommendations should be given for patients' homecare regimens based on the type of restoration obtained.
Professional hygiene maintenance visits are equally important to preserving oral health and the longevity of restorations; thus, dental hygienists need to possess substantial knowledge about restorative materials. Dental technicians can significantly contribute by reiterating the importance of restorative home care when in contact with patients.
Continuous interdisciplinary communication between dental team members about new advancements in restorative materials, oral care products, and pre- and post-operative treatments is essential in projecting future needs and creating predictable and long-lasting results for dental patients.
About the Authors
Khrystyna Vyprynyuk, MS, RDH
Assistant Professor, Dental Hygiene
New York City College of Technology, City University of New York
Renata Budny, MBA, CDT, MDT, FNGS
Professor, Restorative Dentistry
New York City College of Technology, City University of New York
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