Hello and welcome to another episode of Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. Today we are honored to have Erica with us, and Dr. Hauer. Welcome, guys; I appreciate you being here.
This is going to be part two of a series on the maintenance of a hybrid restoration, covering both day-to-day care and long-term residual care in terms of routine scheduled maintenance. We are going to cover what we look for and the different aspects that go into our position, as well as the industry's position, on how often things should be cleaned.
Today’s episode revolves around frequently asked questions. Erica has compiled a list, and we are going to go through different questions she is exposed to. We will have conversations in between, but we’re going to keep it mostly to how maintenance works. We’ll likely touch on warranties and how we see the system and why we’ve set things up that way. They go hand-in-hand; you really can't separate the two. Warranty, how long things last, and how well we take care of them through both daily and scheduled maintenance are intricately connected pieces.
Basically, we want to give everyone a general idea of what to expect when they come in for hygiene. These are common questions we get asked on a daily basis during consultations: what is hygiene going to look like, how long will the appointment take, how long do I have to stay in town, etc. So, the first thing I want to ask you guys is: what does regular routine maintenance look like in our office? What is the timeframe, what exactly is done, and are any parts or pieces replaced?
Our philosophy is that patients are always going to be with us. We’re not just placing these implants and sending patients on their way. Patients come in at a year, and that’s when we first remove the prosthetic. There are many reasons for that. Once the zirconia goes in, we shouldn't remove it for a minimum of about three months because the implants are still integrating at a higher level into the bone. We prefer to wait about a year.
At the hygiene appointment, we take X-rays once a year and evaluate the teeth, the gums, the implants, and the screws. You can't really get the whole story just looking at an X-ray. You want to be able to see things clinically to understand what is going on so you can best diagnose health or disease and provide the right maintenance protocols.
What would you say you look for in the tissue levels? Do you remove the arch?
Yes, once a year we actually remove the arch. All we have to do is access the screw holes—it could be more, but usually we place four implants. We want to see healthy, almost coral-pink tissue. We don't want to see red, angry tissue, or anything that is separating. Sometimes we can't tell what the tissue looks like without removing the teeth, which is why we need to see underneath. Sometimes the tissues are healthy, but other times they can have problems because screws are loose or a component is not in the right place. Whatever it is, we have to be able to see it to diagnose it, and that’s critical.
In addition to that, once we have the teeth in hand, we realize there are parts of the teeth you can clean well at home and parts you can't. That’s the reality of a full arch. If we can provide that deep cleaning for you, then it’s a true cooperative relationship: we do our part, you do yours at home, and we give you the best hygienic set of teeth to maintain everything.
One of the reasons we do it once a year is that many people who lose their teeth didn't necessarily do so from over-care. To say it without being dismissive or rude: if you exhaust a patient by saying they need to be seen every three months—which would actually be bad for the teeth—that interval is too frequent and exhausting for their schedule. Once a year provides a nice balance. It doesn't overload their system or schedule, but it allows us the safety of knowing things are being handled well, and that nothing is broken, warping, or experiencing negative biological changes in the gum tissue. It gives us a physical checkpoint. The key is not to exhaust the patient with a ton of visits, but to maintain that interval.
As the industry as a whole develops in hybrid dentistry, a big change I've seen over the last 10 to 15 years is that when we first started, the offices I was exposed to never even talked about post-care. Many patients would show—
Many patients would show up two or three years later after not being seen, perhaps with an issue, and would be shocked that we even needed to see them. I think that is a big step the industry is taking forward. Perhaps it is through competition and people bringing it to light, but these do need to be maintained. Implants still function in the human body in a way that requires them to be looked at and taken care of. Providing that message and getting it out there is something we discuss with every patient and something I am proud of regarding the way our system works.
As an industry as a whole, I think people are coming out of their consultations—regardless of where they go—with a better knowledge of how frequently they need to be evaluated and an understanding that these are not failproof. We make it very apparent during the consultation. We definitely discuss coming back once a year for cleanings, but it does seem like some past patients, or those who didn't pay attention in their consultation, are still shocked they have to return for actual cleanings. They thought this was the "end-all, be-all" place where you get your dental implant work done and then you leave or go out of town.
However, as you mentioned, regular daily brushing and water picking are sometimes not enough because those are surface-level. There is more going on underneath than you can even see. One of the things misunderstood by the dental community is that implants are quite different from teeth.
The cornerstone of maintaining natural teeth is maintenance; people with periodontal disease are maintained at a minimum of every three months. Implants are different for many reasons, but they are actually harder to clean. They are a foreign object and they have a different tissue attachment that is not as firm as a natural tooth's ligament. The cornerstone of keeping teeth is maintenance, and the same applies to implants—even at a higher level. When you have a prosthetic that is inherently difficult to clean, that is just the reality of full arch. We have to be on the same team, and it is of utmost importance.
There is a touch and a communication aspect to it that is a little bit intangible as well. That is why we highly recommend our patients, even if they are from out of state, come in to see us. You get that touchpoint and continued relationship building, because this is a long-term relationship and a friendship in many ways. One of those aspects involves the decision of adding gum tissue and realigning the zirconia prosthesis. That is part of the relationship.
Some patients are insistent that the prosthetic gum tissue must push really hard into their existing gum tissue because they want absolutely no gap. That is fine, but they need to know the risks involved and what they are putting their system at risk for. Finding and striking that balance is key. As periodontists, we often want that space to be as accessible as possible because it allows for more effective cleaning. When you hide those areas away, it is harder to reach them. Finding the appropriate amount of gum tissue contact is a very personal experience. Regardless of whether it is three months after surgery or on an accelerated protocol, it is very important that you work together with your professional to strike that balance.
That was actually going to be my next question: do you have a preference for where the zirconia prosthesis meets the natural gums? That sometimes seems to be in the patient’s hands and sometimes in ours. We usually come to an agreement, but some patients just can't get over that feeling.
The reality is we don't want this procedure and expense to be an encumbrance on a patient’s life. We don't want it to be something they constantly obsess about. Even if it is just a minor bite issue, that is another reason why maintenance is great. If they have a nuance they want adjusted that might not have been worth a special trip, the maintenance visit gives them the opportunity to sit down so we can adjust the bite in ways they may have discovered after going home.
As I mentioned, we generally want that gap to be as accessible as possible. In the past, there was a prosthetic design known as a Montreal Bridge (or Montreal High Water). It was a type of hybrid bridge that featured a "belly" on the underside. In the lower arch, they would intentionally leave a significant space between the prosthetic and the gums—about three to five millimeters—so that nothing touched the tissue. This made hygiene incredibly easy because food couldn't really get trapped.
While we want to strike a balance for aesthetics and speech, we also have to inform patients of the risks. If we push the prosthetic too hard against the gums, it causes inflammation. It’s like your fingernails: if you rest your finger on top of the nail, it’s fine. But if you push up into the cuticle for hours, it gets red and angry. The tissue around an implant is essentially a "cuticle" that we cannot invade for too long without causing irritation.
Evaluation of how the pink area of the teeth lines up with your actual gums is a key part of maintenance. We are on the same team; if we see an area that needs a reline, we’ll do it. It is always a balance between cleanliness, feeling, and function. If a gap is affecting your speech, we will definitely change it.
It is interesting to see how the surgical and restorative teams work together. During the first week after surgery, a patient is often still swollen. It’s tricky to find that "happy medium" until the tissue has fully settled. Often, the true assessment happens at the one-year hygiene appointment. That is when we see if the zirconia needs to be adjusted back or if we need to perform a reline by adding material.
When we used to place acrylic temporaries on the day of surgery, we would see drastic tissue changes over three months. Acrylic is porous and holds bacteria, which hinders smooth healing. Back then, there was often a massive difference—sometimes nearly a centimeter of change—between the temporary and the final.
By comparison, our digital design protocol allows us to incorporate our experience directly into the design. We are manipulating the healing process, almost like a cast, so the gum tissue heals in a healthier, more predictable position. Because of this, when we talk about striking a balance today, we are usually only looking at minor tweaks—perhaps a difference of 2 mm—rather than the sweeping changes of the past.
Long-term, we have to look at how things truly finish healing. How did the gum tissue settle into its ideal position versus where it started? Working through those nuances is exactly what we address during that one-year visit, and that’s where the relationship between the clinical team and the patient helps strike the right balance.
To add to that, when we used to work with older materials, stacking material on top of an existing bridge wasn't a chemical bond; it was a mechanical retention. You essentially had to cut grooves into the prosthetic to get the new material to stick. Most of the time, it didn't stay long-term. If you had an acrylic-on-metal bar from 10 or 12 years ago, relining was a nightmare because any flex in the bar would break that mechanical bond and cause the layers to separate.
Now, when we adjust gum tissue on a zirconia arch, we are adding pink porcelain using a process similar to the original manufacturing. It doesn't compromise the integrity, strength, or look of the arch. We are literally filling in the space, and the material becomes an integrated, chemical part of the prosthesis. There is no compromise to the strength.
A reline is actually one of my favorite things to offer because it is so routine and simple, yet it makes a massive difference in how the patient feels. It typically takes about two to three days in the lab. The patient wears their temporary during that time so they are never "toothless." They get their teeth back looking exactly the same, but the fit is perfect.
Is there a limit to how many times you can reline a prosthesis?
Generally, you can do it once or twice. Beyond that, it's better to scan the new tissue levels, incorporate that data into the digital file, and remake the prosthesis entirely. If you're on your second reline, you're usually splitting hairs. Most of the time, the patient is satisfied after one. We really only see the need for multiple relines in severe cases, such as patients with medical conditions that cause significant bone loss. In those cases, we work with the patient as part of our warranty relationship to ensure they are taken care of.
Regarding the tools for daily cleaning, do you prefer an electric toothbrush or manual? Water flosser or super floss?
For natural teeth, electric always trumps manual. However, for a hybrid, I am somewhat indifferent as long as the cleaning is effective. When you brush natural teeth, you are cleaning the "cuticle"—the junction between the hard tooth and the soft tissue. You are mechanically debriding that connection to keep it healthy.
With a hybrid, a toothbrush is mostly for surface cleaning to prevent staining and to help disinfect the area. It is very difficult for a toothbrush—even a soft-bristled one—to reach where the implants are actually located. Therefore, while I recommend electric if asked, a manual brush is sufficient. The real work is done by the water flosser.
totally fine. If a patient goes on a vacation to Europe for two weeks and they end up using a manual toothbrush, it's not going to put anything at compromise. The one thing that you can have an issue with is long, long, long-term; this surface is like glass. The zirconia, we'll say, is like glass. You can scratch it if you use, say, a wire brush. You don't use a hard toothbrush. You can scratch it and cause an area that will be more prone to staining. So, it's important that you still use a softer toothbrush, but it's not as terribly important as it is for brushing regular teeth, electric versus manual, as it is for a hybrid. So, with that being said too, do you also have a preference on toothpaste? Because during the consultation, we do sometimes speak about the abrasiveness, kind of the "test the toothpaste between your finger" test. See if you feel any little grit and try to stay away. Is that the same kind of example?
Yeah, I would say on teeth, toothpaste is actually meant to promote remineralization of teeth and has fluoride components. Really, for full arch, none of that exists. So I would say if you want to use toothpaste to have that fresh minty feel and to have something that tastes like you're brushing your teeth, a very, very small amount is okay. But you don't want to be grinding it very hard because the reality is any toothpaste can be abrasive whereas the brush isn't. So I think the key there is just like Dan said: keeping everything clean, avoiding staining, and for me, I think the number one is using any type of water irrigator to clean the intaglio, which is the undersurface of the teeth to the gum tissue.
The we used to talk a lot about abrasiveness, which I'm glad you brought up because I've kind of gotten away from it. The surface of the zirconia is such that abrasiveness really isn't going to come into play. But there are toothpastes that are unnecessarily abrasive. When you get a whitening toothpaste, as a general rule, what they've done is taken their toothpaste formula and they've essentially added different particles of sand. And that pumice that's in there is abrasive enough to take the surface stain off of your teeth. Well, in zirconia, we're not going to have that issue. So, staying away from getting anything that's 3D White, Super Oxide White, etc., is going to have that pumice and is going to cause more abrasiveness for absolutely no reason. So, to Blake's point, if you're in the toothpaste aisle selecting, you want something, as a general rule, being more of a sensitivity toothpaste. A sensitivity toothpaste isn't going to necessarily have that abrasiveness to it. So, in an ideal perfect world, we don't need that abrasiveness to make it white. You already chose your color. You just need to keep it from being stained. And so, we want to use something that's really slimy in the hand. So, if you were to test two different peas of toothpaste in your fingers, and you would be able to feel one is going to be more abrasive than the other, right? We would ideally want you to use something that's more slimy because the practice of using a toothbrush is just to kind of disinfect and clean the mouth, but it's not to scrub really anything off of the surface in a hardcore way. We want to just keep it clean. You're not adding any sort of abrasiveness to make it more white. It's already that white. You just need to keep it clean.
Is there anything that patients can potentially put inside of their waterpick tank to help with any of the underneath kind of buildup, anything that helps on that end? Some patients like to put some peroxide. I've also heard some like non-alcoholic mouth rinse. What is your perspective on that?
As it comes to waterpicks and superfloss—to touch on the superfloss thing—superfloss works fine and it's a great way to get underneath any sort of bridge. If you have a regular bridge, it's a great way to get underneath it and a great way to get it sort of mechanically debrided. Get the stuff away that's loose and kind of in the way. It certainly is an effective way to loosen things in a hybrid. I don't necessarily push superfloss as a daily because at some level it's going to become so inconvenient that the person's going to give up more than we want them to give up in terms of cleaning.
That's what I was going to ask if you had a preference, because some patients do say it's kind of just one other extra step that you have to do that they probably did not do at all before the procedure. It can tend to be kind of a pain because sometimes the prosthesis is really tight. So it is difficult to kind of get that superfloss through it. So I know we typically don't touch on it too much in our office. We do like it, it's not that we don't, but I think we prefer waterpicking.
Right. If I'm asked what the absolute preference is—and obviously that's the point of this conversation—but if I'm asked what the absolute preference is: sure, use it. But it's not something that I'm going to push on you to add to your routine because I don't want to push anything that's going to encumber you and cause you to do something else that I consider to be of more value less often or less thoroughly. So, that's kind of how I see superfloss: use it for big stuff, maybe have it on hand, try it. If you want to include that in your daily routine, that's totally fine. I would certainly not dissuade it. But some people are going to have some tough spots. It might be a little bit touchy to do it. It might be even difficult dexterity-wise to get it done. So, it's not anything that I really heavily push on patients. But then as a substitute, we will use a water pick. And a water pick is really, in my opinion, your number one go-to tool to keep things clean.
Why? Because it's going to be able to irrigate and get into places that you can't get to. And you want to prevent, we call it biofilm, you want to prevent bacteria and food from collecting on the underside of this area that you can't really brush and get into. And so a water pick is going to gently irrigate and rid yourself of all of that stuff. Is there something that goes into a water pick? Not necessarily. Other than the recommendation is add whatever you would like. You could add a mouth rinse into it. You can add salt water into it if you're feeling like your gums are sort of irritated and swollen. You can add as an additional step anything that you want into the reservoir.
And while I'm on the topic of reservoirs and water picks, I like my patients to always be on a sort of desktop version of the water pick, or something that is in line with the sHauer, because you're going to get the volume of water, the volume of lavage, through that space versus the more portable ones. I don't really like those. I know it's a big popular thing with Facebook because you can take it with you, etc. I'm okay with that as an add-on as well, but I don't want that to be the number one quarterback of what you're using to keep that irrigated because it's smaller amounts of water. It's smaller bursts. It's not as strong. And you can use it when you travel. That's fine. That's great. But I don't want that to be the number one water pick. That's always your convertible, if you will. I want your daily driver to be something that sits on the desktop that has a relatively big reservoir that has the difference in the pressure that you can change, etc., versus being relied on for short little bursts that may not get to where we want.
And we're not pressure washing with a water pick. We're not cleaning the side of a house, like I always say. We're just irrigating it. You're just trying to flush that area of soft particles. When it gets to a point that you've left it long enough that it becomes hard, that's where the maintenance comes in. That's where we have to come in and get that off and fix your habits and make it so that you're getting it better. We want to be able to attack this when it's still soft and when it's still there. So, daily cleaning with a water pick is very important.
In terms of an additive, we're working actually on something to be an additive to a water pick, but it's one of my projects. Long term, what we're going to have is essentially a pack that they can add to the water pick as an additional thing that's specifically formulated for a hybrid. What that will exactly be and what that will exactly look like—it'll probably be some sort of subscription as a tack-on to the lifetime warranty. Very cool. But that's something that's actively being worked on, but not quite ready to discuss any further.
I'm excited. It's something that will help peace of mind. And this is such an—we always talk about it—but this is such an intimate, personal journey for everyone. The expense, the travel, who is going to do it and the selection, how am I going to take care of this long term, who's going to be there for me, and what am I going to do and where do I get this? All of those answers you want to try to bundle up and be as comprehensive as a system as you can. Let's just take the water pick additive as an example. It's not about the water pick additive doing anything other than making it so that we have fewer problems. Fewer problems means that my employees are less encumbered and we can treat more people and people will be happier with it. And so that's really the focus of everything here.
Absolutely. With that being said, on the contrary, have you ever seen where patients over-water pick or over-brush or anything of that sort? Has anybody come in stating my tissues are kind of getting raw? I'm kind of bleeding. Am I doing something wrong?
Not to the frequency you may expect. There are patients that will get obsessive about it. One big thing that can happen is I've seen it quite often in patients that have early onset dementia or some sort of dementia. They start to get very obsessive about cleaning something that doesn't exist. Maybe it's that they're feeling their implant connection in a certain point and there is no cleaning that because it is a hard fixed structure. They can get very obsessive about it and start to use instruments and tools that we wouldn't recommend. And so the main take-home is that there isn't a lot to worry about in terms of a patient hurting something so long as they're using the right tools. And the right tools are some super floss, a water pick, not at too high of a pressure, and a toothbrush with softish or I would say maybe even medium bristles are kind of okay. They're not in your own teeth, but they're kind of okay on a hybrid. The main thing is that there isn't a
lot that they can hurt with those instruments. What we normally see as a fallout from a patient being too aggressive with something is they're using something they shouldn't. They're getting in there with a toothpick, or their sister-in-law had a pick that they got when they had a random bridge from another person in Costa Rica, or whatever it is that they may be using. If you go outside of the toolbox that we've given you, that's when we see issues.
I will say I've definitely heard a few patients complain about some discomfort from the water picking, but usually it does end up coming from the level of the pressure, which is obviously where our favorite quote came from: "do not pressure wash your gums." I do think sometimes it happens. We see it. It's not super common, and typically it doesn't cause any bleeding—just some tender areas. Most of the time, if they just back off, it will resolve itself.
If you're going to turn up your water pick, it's for that one particular thing. If you can't get to it and it still is an issue, call us or call your provider. If you do get it, great. Turn that sucker back down because you don't need it like that all the time.
Have you guys ever seen any crazy cases where patients didn't think they needed their teeth cleaned, had their procedure done, left out of town or out of state, and we haven't seen them for the last two to three years? They come back into our office, haven't had a local cleaning done—what would that patient's mouth look like?
If you want to look at anecdotally or look at literature, it's very obvious that with better maintenance, you're going to have better results. We have to be able to recall our patients. The patients that are more likely to have problems, prosthetically or implant-related, are going to be the ones that we haven't touched base with. Diagnosis is everything, and you just have to be on board for maintenance. Those patients that are erratic, non-compliant, and don't come back are typically the ones that may have issues.
You even mentioned earlier, Dr. Hauer, that sometimes the X-ray isn't the end-all, be-all tell-all to the story. So if a patient does go somewhere, sends us a local X-ray to check everything out, and it looks like it's okay from there—sometimes it's not. What are some things that you would find physically going on inside rather than being able to tell it from the X-ray?
To rewind a little bit, I think it's a good segue. We're in an interesting spot in full arch where no one has a true consensus on when to remove these things. I'm going to quote the 2016 consensus statement made by the ACP, which is the American College of Prosthodontists. What they say is that the removal of a fixed screw-retained implant prosthetic for evaluation is not needed, and they only recommend it for signs of peri-implantitis, if the patient can't clean, or if there are mechanical complications.
The problem is that peri-implantitis—which means you have an issue with the implant that affects the bone and the soft tissues—sometimes cannot be diagnosed on an X-ray. Patients may have symptoms, but the X-ray is a 2D image. Even with a 3D image from a CT scan, there's a lot of scatter and artifacts because of the abutments and the restorations. For us to be able to see what's going on, it's critical to take these off once a year and look "under the hood."
As for what we are looking at once it's off, we want to make sure from an implant level that there's no active separation, no bone loss, and no excessive gray showing through the implant. From a prosthetic level, we want to look at the abutments, which are basically the connectors from the implants to the teeth. We make sure those are healthy, not loose, and screwed down. Then, as we talked about before, we want to catch any prosthetic problems with the actual teeth and make sure the contours are okay—maybe a reline is needed, or maybe there's too much material. All these things come into play. We're going to re-torque screws, clean, take X-rays, and another important thing about this is we're going to talk about oral hygiene at the visit. What are you doing to clean? How can we be on the same team to guide you to maintain things better? Also, if you're in the office, there's an opportunity to talk about medical history. What has changed? Are you taking new medications? Do you have a new diagnosis like diabetes? That's important for us to know so we can look at you through a different lens.
A way I think about it is that I was a lifeguard when I was really young, so we went through basic life support and CPR. Then we went through it all in dental school, and we have to keep doing it. In theory, I could perform CPR from when I was 14 until now and probably could have retained that information the whole time. Maybe based on the research, I didn't need to go to that class. But because of the bulk of everyone, and because we know that things fly out of the window in terms of memory and just like truly being on top of it, there's an interval that we're supposed to go get recertification from. Regardless of whether or not we know why, is it because you or the bulk of the public will lose that information? No, it's a refresher. When we talk about maintenance at the one-year interval, I think it's important to understand that while I may be able to perform CPR at two years out and five years out from the last time I took the class, it's still important to get that refresher and that little touch point because it just makes things better.
We don't want to touch it too much. We don't want to alter the schedule, and we don't want to alter the materials. We don't want to put too much pressure in and out on the screws. We don't want to overly financially burden the patient, but we want to find a happy medium that allows for that refresher course—refresh the CPR knowledge, refresh the oral hygiene, and the things like Blake was talking about. For us, that one-year interval is important because it's very easy and reliable to look at. It's an easy interval to be able to tell if something is going south.
To touch on your point: have you ever seen patients that come in after not being seen? I'll tell you that when I first started doing these hybrids, the attitude was that once you put somebody in a hybrid, they will fail eventually. When they fail, they're going to fail so catastrophically that they won't have very good options for replacement. As a whole, hybrids weren't really pushed in my education. It wasn't anything that we really learned. This was just 10 years ago—well, a little bit more, but around 10.
What I've seen throughout the process is that this has become a bigger part of the conversation. Because it is a bigger part of the conversation and part of the responsibilities of the patient, they are more responsible and therefore take care of them. We also have better materials that can last longer. When we have a problem, we're able to jump on it, fix it better, fix it more efficiently for them, and keep them in something long-term.
When I used to see bigger catastrophic issues, it came from the group of patients that were getting treated—maybe spending $100,000 on it—but were in two or three different offices. There really wasn't a consensus on how often they should get cleaned. When that dentist, good or bad intentioned, was explaining or telling them about the procedure, there was no responsibility put on them for cleaning. It was just pitched as the most ideal, amazing thing ever. Then they were using materials that had a tendency to pick bacteria up. Where I've seen really big issues is when a patient disappears forever and the material isn't great for guarding against bacteria. There used to be a lot of acrylics on top of a bar, and that's when you see whole prostheses coming out and smelling like a dead person. To be honest, it's horrific when you see it.
Things have improved to such a level that if you can impart on the patient the responsibility and what their role is—lay that out in the very beginning—and then in tangent use a great material that will perform and be resistant, it works. If you can get those two things to hum and go in line, that's why I've committed my career to this. I don't see it as a big handcuff; I can always pretty much get us out of it in a very black-and-white way.
Even when we see patients who go local for a cleaning—which is something that we encourage if you're not able to get back down to Boca—you can go anywhere nearby your house to get it done. We do still recommend that the arch gets removed. We prefer that rather than it being hand-scaled inside of your mouth. Just like Dr. Hauer explained earlier, we can check under all those gum tissues and check all the abutments to make sure they're nice and tight and doing what they're supposed to be doing. Do you ever think it makes our job a little bit more difficult going in after someone goes to get a local cleaning? Would you see any problems when people go get a local cleaning with a general dentist office who's doing this patient a favor because they've been going there for 20 years, but now they've had a full arch procedure and they go there just because it's convenient?
Excellent question. For those watching or listening, generally I don't put anyone that I have on this podcast up to a big schedule and list of things that I want them to say. Erica was on her own to come up with this list of questions, and that is an amazing question.
When it comes to—let me think of how to put this. Just let it out. Let me tell you what made me think of asking you that question. The other day we saw a patient; she did not have her zirconia done by our office, and she did not have her full arch procedure done by our office at all. She had uppers and lowers completely done. I don't know if it was four implants; I want to say it was six on the bottom and six on the top. She's coming to us for something that we call a refresh, which is actually where we go ahead and remake the zirconia, kind of freshen everything up, and check on her implants. This is something we'll probably talk about in another episode as well, but she is coming to seek treatment with us. She let me know that while she was in the office, she wanted to have one of her access holes filled. If you don't know, an access hole is one of the screw channels where we access the implants and screw in the zirconia or screw in the temporaries to make sure they're nice and secure.
Well, she actually stuck a piece of orthodontic wax into her access hole, and it just about made it impossible for the team. I almost felt bad for the clinical team that I grabbed to help this patient out temporarily while she was in the office for a few minutes. I was like, "Hey, she lost one of her hole fillings." If you have a full arch, you know how frustrating and annoying that is because it's a little circular hole with sharp edges that your tongue finds and bothers. She stuck a piece of orthodontic wax into that little hole, and I thought, "Oh my goodness gracious, someone's going to spend the next 30 minutes trying to get that out of there."
The part that I was struggling with addressing to begin with was that I can understand the preference of major centers saying you have to come back here for me to ensure the work I put in. I understand wanting to be the one that has the touchpoint. Where we've diverged from that—allowing other offices to touch it if a patient can find an office to address it—is due to the change in materials and the switch over into zirconia.
Zirconia is really, really, really resistant to abuse. As such, when you're accessing those screw channels with a bur in any other material, the hole can open and widen before you even blink. That can hurt the prosthesis and its longevity, and it can really make it intolerable for the patient to wear. This applies to any sort of plastic or nanoceramic. Since we've switched over to zirconia, we think it's unfair for a patient to be locked into one location. 90% of what we see in Boca is from out of state. While we want them to come back, we realize there needs to be a release valve so they can go to someone in Washington state or elsewhere in a pinch.
The switch in material gives us that confidence because a person can touch it without really ruining it. If they're even somewhat competent, they're not going to ruin our prosthesis. They're going to get that look and that check. The whole point of taking it out is to make sure it's intact; you don't want to ruin it in the process of opening it up. With a nanoceramic or an acrylic, you almost risk that prosthesis every single time.
Any dentist listening will understand what I'm saying: when you had a hole in acrylic—let’s say it was a bar with denture teeth and acrylic—the filling material or resin that goes in there is almost harder than the surrounding acrylic. When you go in with a bur, it would almost accidentally hit a trough because it would run to wherever it was softest. Right at minute one, you'd make this hole larger and hurt the teeth. Zirconia is not that way, so we can get into it and clean it out.
The other negative that came from those soft materials was that we wanted an easy way to retrieve the screw without hurting the bridge. There were a lot of different methods we used to use. We used temporary endodontic root canal filling or impression material here and there. Those trends fell out because they didn't really keep the area clean, and you want it sealed so it stays hygienic.
The reason why we don't mind if somebody else sees it is that they are plenty competent to check if the implant is okay—perhaps they’ll be even more critical than we would be because they're looking for something we did wrong. They're going to be more than capable of not hurting our prosthesis or putting things at long-term risk. We are okay with it, whereas another office might not be because they haven't taken that leap of faith. In general, it's very hard to hurt those access fillings or the holes in zirconia, and that's why we're okay with other people seeing it.
I'm fascinated by your answer because I never thought it had anything to do with the zirconia itself. I always thought it had to do with the implants.
I wouldn't blame you. That's why I said it was a really good question because it's a very nitty-gritty reason why we're okay with other places touching it. That's just very accidentally or intentionally insightful. I never would have thought about it in that direction because the focus is usually just on what kind of implants I have and if that office has the proper tools. Nine out of ten times, they do.
In most offices that are okay with seeing a patient from another location, they are going to have the necessary instruments. If they overtighten a screw, those screws are designed to function somewhat like a shear pin—a safety factor to prevent hurting the implants once they are fully healed. Even in a worst-case scenario where they break a screw, the problem they’ve created isn't irreversible. I don't want to hand a patient over to someone if the risk is irreversible. In a high-finesse procedure, like orthopedic surgery for a knee replacement, a surgeon wouldn't want you seen by a general practitioner who could cause you to lose your leg. It is all about retrievability and reversibility. With our materials and the way the screws and implants are built, you generally aren't going to cause an implant problem; you would cause a prosthesis problem. Since zirconia is so resistant, we don't feel a big need to be overly particular.
It used to be scary soft. A long time ago, a dentist had his assistants remove all the access fillings before he would come in. A brand-new assistant told me she couldn't find the screw hole, and when I looked, the area was obliterated with about 18 different holes. Those are the reasons you want to prevent damage, but the materials we use now mitigate that.
To summarize what real maintenance looks like in the office: it involves coming in once a year, having your prosthetic removed, having an updated X-ray, examining the gum tissue and abutments, ensuring everything is torqued and screwed down properly, and cleaning the prosthetic. This is a great opportunity for the doctor to diagnose any biological implant-related or prosthetic complications.
On the staff's end, the process is usually simple. The appointment is about 90 minutes. We unscrew the zirconia and place it into an ultrasonic bath to shake off any calculus that has built up over the year. We check the gum health to ensure it looks nice and pink. When the teeth are put back in, the screws—specifically the prosthetic screws, the shear pins we discussed—are assessed and replaced on an as-needed basis. We close everything back up, and you are good for another year.
We advise on oral hygiene but don't provide a water flosser. We suggest looking at options on Amazon to find what you like. We prefer desktop water flossers for daily use, but for the initial learning curve, a travel version you can take into the sHauer is helpful since it can be messy the first time. There are even versions that plumb directly in line with the sHauerhead. We also recommend a specific water flosser tip that is curved like a hook to help get around the corners and clean from the inside out.
Regarding fees, our lifetime warranty covers the maintenance, but there is a fair and reasonable fee involved for the appointment. We have intentionally made it accessible so it isn't an encumbering expense. A big sign of whether an office wants you around is their cleaning fee and their recommended interval. If an office tells you to come in every six months, you should be wary. The consensus is that we don't even strictly need to take these out; we do it for touchpoints. Anything more frequent than once a year is often a cash grab, a misunderstanding of the protocol, or creates too much pressure and fatigue on the screws and materials. Some locations charge $700 to $1,300 per arch, not because they provide a better cleaning, but because they don't want you to come back. They’ve made their money on the procedure and want any future problems to be someone else's responsibility. We position ourselves with a reasonable price to send a clear message: we still want you to come here.
Take care of your arch and we will take care of you. Done In One doesn't end when you leave the chair. We appreciate your attention for part two of our maintenance series.
