Hello and welcome to Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. With me today, I have Erica and Dr. Hauer from our Boca team. Welcome, folks.

Today we have an exciting topic: full arch maintenance. We’ll be discussing interval professional cleanings, how to care for your restoration at home, and the nitty-gritty of the industry. We’re going to break down what the research says and what we believe, including recommendations on how we approach maintenance and what items are addressed in regularly scheduled professional visits versus what a patient needs to do in their day-to-day life. It is about breaking up reponsibilities and understanding why each part is important.

The theme of today is that this is not just "set it and forget it." When I first started performing these procedures, the common attitude in the industry was exactly that. It wasn't pushed as a long-term relationship. Instead, it was pitched as a "fail-safe, ironclad, bulletproof Cadillac" solution that you’d never have to think about again. While that doesn't apply to everyone, that was the general pitch to justify the expense of the procedure. Part of this podcast is to get the data out there and push the industry to tell people the truth: this needs to be cleaned, it needs to be monitored, and the patient has a vital role to play. That is a protocol we have been pushing from a corporate and clinical standpoint.

Let's talk about daily maintenance, as that is what patients deal with every day. Erica, how do we talk to a patient about their cleaning routine? What should they expect?

If I were a patient, I would expect my routine to consist primarily of brushing and water picking. Thankfully, it’s nothing too crazy or out of this world. You’re brushing once in the morning and once at night with a soft-bristled toothbrush and regular toothpaste—nothing fancy or expensive. We advise water picking at least twice daily, though some patients like to do it after every meal to feel fresh and keep that minty flavor.

If a patient is in an awkward scenario, like a restaurant, and they feel something stuck, a simple rinse with water and spitting into a sink works well when a water flosser isn't available. I’ve even had a patient tell me that you can create a surprising amount of suction just with a sip of water to clear things out. It's all about keeping the surface clean from both the underside and the outside.

Regarding toothbrushes, for regular teeth, electric is far superior to manual because you are cleaning the junction between the tooth and the gumline (the "cuticle"). With a hybrid restoration, you don't have those same connections, as they are mostly hidden under the prosthetic gums. In my opinion, manual versus electric doesn't matter as much for a hybrid. What is important is thoroughly cleaning the surface to prevent staining and remove bacteria.

The rest of the work is mechanical debridement through water picking. You aren't trying to pressure wash the side of a house; you don't want to overwork the system. It’s about good, clean, thorough massage and lavage through daily habits. I have friends and family who have had this done over the years, and I’ve asked them for the "nitty-gritty" on what it's like to clean so I can be sure that what I’m telling patients is accurate.

I’ve asked them: what is the cleaning process like compared to original teeth?

The best way it was described to me was by Jamie. She told me that it’s the exact same amount of work, just a completely different order of operations. It’s not easier and it’s not harder; it’s just a different way to clean and a different physical experience. Effort-wise, it's the same. There are no added steps or increased difficulty; it's the same amount of inconvenience you're already used to with natural teeth.

Actually, for some, it might be effort that was potentially never there before.

I agree on the maintenance. Regarding toothpaste, you should use it in a very moderate amount. Unlike natural teeth, there is no enamel to protect and no remineralization of a tooth structure occurring. You just need a consistent strategy to keep plaque and food away from the implants.

Ideally, you should use something non-abrasive. The easiest ones to point toward are sensitivity toothpastes. Whitening toothpastes essentially contain "sand" or pumice. That abrasiveness brightens and removes stains from natural enamel, but it isn't needed for zirconia. Zirconia is already the color it needs to be. While I don't "shove it down someone's throat," my preference is for a toothpaste that feels "slimier" in the hands and lacks that pumice.

When you clean natural teeth, you are removing food material and sugars. Bacteria take those sugars to help them attach to the tooth and create acid, which breaks down the enamel. This acid causes cavities and bacterial infections that can eventually reach the root and necessitate a root canal. Normal cleaning prevents these cavities. With fluoride, you are trying to build up the tooth structure to prevent further acid attack. Additionally, you are cleaning the area underneath the gums where debris collects and creates irritation that, over time, causes bone loss—known as periodontitis.

With an implant—whether it’s a single unit or a full arch—your intention is to remove the irritant before it reaches the connection between the implant and the bone. You want to avoid the implant version of periodontitis, which is called peri-implantitis. (The implant version of gingivitis is called peri-implant mucositis).

These are just fancy terms for essentially the same thing happening around implants. Since we don't have to worry about cavities, remineralization is less of a factor. If you were a person who historically got a lot of cavities, you are now largely protected. However, if you lost your teeth to periodontal disease, you have a higher risk factor for peri-implantitis. Other risks include bruxism (teeth grinding) and diabetes.

The bacteria that colonize your mouth are established early on and generally stay there forever; it isn't necessarily a genetic thing, but an environmental one. If you have periodontal disease and I don't, your bacteria are simply "angrier" than mine. If we both get hybrids, you may still have a tendency toward bone loss because those aggressive bacteria are still present. This is why professional cleanings are so vital—we have to ensure that history doesn't repeat itself. If you are prone to cavities, you're usually in better—

If you have a tendency toward bone loss and periodontitis, you still retain that tendency after getting implants. This is why we need to stay in close contact; those bacteria are still "angry," and there is no simple way to calm them down.

Is that a fair way to explain it?

Yes. I think it’s also important to note that a seasoned surgeon will be open about the complications and limitations of implants. Just as natural teeth can have periodontitis or gingivitis, implants can suffer from peri-implantitis or peri-implant mucositis. Understanding the biological process is vital because disease around an implant can progress much more rapidly than it does around a natural tooth. It is critical for us to catch it early, before bone loss occurs. This is why we remove the prosthetic—to "see under the hood" and prevent catastrophic problems.

That is an excellent point. The interface between the implant and the bone doesn't have as much protection, blood supply, or "life" as your own teeth do, making it less resistant to infection. We want to ensure longevity. When we remove teeth affected by bone loss and cavities, you essentially win a "World War" against infection and enter a quiet, peaceful stage. However, over time, bacteria can build back up. It’s a reset button—a second chance—and we want to capitalize on that so you don't lose the battle again.

So, the cleaning serves two purposes: keeping the zirconia arches free of debris and buildup, and more importantly, managing the periodontal side to prevent infections and diagnose risk factors.

Exactly. When you are in the chair for a maintenance appointment, we can diagnose whether an issue is mechanical (like a chip in the teeth or a problem between the zirconia and the gum tissue) or biological (like peri-implantitis at the implant level).

Think of daily cleaning as holding your ground in biological warfare. When you come in for your annual checkup, we are evaluating both the biological and the mechanical warfare. We look at the bacterial load and the gum tissue health, but we also check for mechanical stress factors: loosened or broken screws, chips in the prosthesis, or stress fractures. We don't intend for these to happen, and they don't happen often, but we need to put our eyes on them to maintain the peace.

Protocols for maintenance vary widely across different centers. Blake, what is the current consensus on frequency—what is considered too much or too little?

The industry standard has shifted back and forth, but the most recent consensus comes from the American College of Prosthodontists (ACP). As a specialty group, they recently stated that the routine removal of a screw-retained implant prosthetic is not actually required. They only recommend removal when there are signs of bone loss, an inability of the patient to clean properly, or a mechanical complication.

Taking that into account, we have to decide if we agree or disagree. This is a good segue into why we do what we do at our practice.

We want to be on the patient's team. The reality is that when we take a yearly X-ray, we can't see everything. While we firmly believe that removing the prosthetic every three or six months is excessive, we believe once a year is the ideal frequency. It allows us to remove and clean the prosthetic, clean the gums, and properly evaluate the health of the implants and the surrounding tissue.

X-rays provide a two-dimensional or three-dimensional view, but metal components in abutments and prosthetics cause "scatter" that can obscure the image. To provide a proper diagnosis, we must evaluate the bone via X-rays while simultaneously examining the gum tissues. This gives us the opportunity to intervene early. If the tissues are a healthy coral pink, that’s great; if there is inflammation, such as peri-implant mucositis, we can provide adjunctive care. We simply cannot make these recommendations without seeing "under the hood."

Some might wonder why we use X-rays at all if they aren't a perfect "gold standard." I thought of a comparison while roasting pumpkin seeds with my family. When you bake seeds, it’s hard to tell exactly when they are done just by looking through the oven window. The window tells me they aren't burning and they aren't raw, but it doesn't reveal the exact crispness or moisture content. An X-ray is like that oven window: it can tell us if something is disastrous or clearly perfect, but it doesn't provide the full story of exactly where we stand. Physically examining the site with our instruments is the only way to get the full picture.

What about the "sound test" or tapping when patients come in?

The simplest method is a percussion test. While there are high-tech devices that use resonance frequencies to measure how well an implant has integrated with the bone, a percussion test provides similar information. Implants are generally "on or off"—they are either fully integrated or they aren't.

When you tap an implant and it feels "dead" or produces no sound, it suggests the surface isn't properly adhered to the bone and may be held only by soft tissue. However, when you hear a crisp, sharp "ting," you know the connection is solid—much like tapping a screw driven into a solid piece of wood versus one sitting in loose soil. It’s an "off and on" scenario that tells us if the implant or a screw is loose or if it is rock solid.

It really comes down to the fact that there isn't just one way to evaluate health. We use X-rays, percussion tests, and "torque tests" (where we manually feel the stability of the implant with an instrument). X-rays are a great window, but they don't tell us everything. Combining these methods is a provider-based skill rooted in experience and research to ensure the best quality of life for the patient.

We don’t want to over-evaluate to the point that a cleaning becomes a four-hour ordeal. We don't want it to be a painful experience, but we do need to gather enough information to feel good about the long-term results.

Every-six-month cleanings are too excessive. It puts too much mechanical pressure on the screws through constant removal and reinsertion, and it’s an unnecessary financial and scheduling burden on the patient. We found that once a year is the ideal steady point to ensure things aren't "going south" biologically or mechanically. To Blake’s point, these things can deteriorate faster than a natural tooth, so we need to see them. We don’t feel comfortable letting patients go forever without a checkup.

Our pricing reflects this. It isn't a $1,500-per-arch cleaning designed to tell the patient "we don't want you here." It is a bit more expensive than a standard cleaning and occurs less frequently, but it is vital for protecting the patient's investment and our own clinical peace of mind. If we don’t address issues in a timely manner, they can escalate quickly for no reason at all. We could have intervened early and made it a non-issue.

When it comes to longevity and warranties, the healing process for these implants is very reliable and straightforward. However, we wanted to reward patients who are responsible with their maintenance. This is why we created our warranty program. It isn't just a cleaning program; it’s a warranty program that includes a cleaning. We want to see the patient once a year so we can fix things quickly. This shared relationship renews annually because we believe in addressing issues efficiently to keep the patient healthy. This provides peace of mind; if we see a problem, it gets addressed quickly and without a significant financial burden on the patient. If they stay responsible to us, we stay responsible to them.

So, what does a maintenance visit actually look like in the office?

It involves speaking with the doctors and working with our restorative team. At the most basic level, we diagnose the health of your implants and review any changes in your medical history. We are on your team; we need to know if you have new medications, a diagnosis like diabetes, or anything that might alter your bone metabolism.

From there, we remove the prosthetic to:

• Inspect the health of the abutments and screws.
• Evaluate X-ray health.
• Check the gum tissue.
• Inspect the integrity of the zirconia (looking for chips or the need for a reline).

Having the patient in the chair is critical. While the majority of patients could likely go two years between visits, using an inconsistent timeline allows too many people to fall through the cracks. If 10% of people are going to have an issue over 10 years, we want to catch that one person per year at the right time.

What is the big reason why we are okay with patients going to other centers to get cleaned? What has changed over time with hybrid dentistry?

We are comfortable with patients seeing a local provider for cleaning because modern zirconia is incredibly strong. One of the biggest problems someone unfamiliar with hybrids might have is actually disengaging the prosthesis from the mouth. However, due to the rigidity of the zirconia and the design of the screw channels, providers can navigate the access holes and remove the bridge easily without damaging it.

Older materials used to be very soft—sometimes even softer than the composite filling material in the access holes. Back then, it took a very steady hand to remove the prosthesis because you didn't want someone causing serious damage to the bridge or the implant interface. Additionally, in materials like acrylic or nanoceramic, those access holes would widen over time with every cleaning. As the "pothole" got bigger, it compromised the integrity of the prosthesis and the patient's daily comfort. It also made finding the screw head much more difficult because the hole would eventually blend in with the teeth.

With zirconia, because it is so resistant to abrasion, a provider can go in with a bur and clean out the access channel without causing that widening or damage. This makes us much more comfortable letting an outside provider handle the maintenance.

One thing we haven't mentioned much is that keeping things clean actually starts with the selection of the implant brand and the restorative design. We are very intentional about the brands we use. For example, our current implant system uses a cone-shaped abutment with a solid platform or "disc" that supports the base of the teeth. This circle does not have any screws passing through it, which creates a tight seal all the way around. Other brands have screws going through that connection point, which creates nooks and crannies where plaque and bacteria can build up.

Even if you have the best periodontist performing your surgery, if the brand selection is poor, you are theoretically going to have more issues. It isn’t just about daily or yearly cleaning; it’s an end-to-end selection process.

Another factor is sealing the access holes. While you shouldn't freak out if an access hole has been open for a while—since you can still irrigate and clean it—it is important to seal it off to protect the screw underneath. We need a "safety zone" material that is easily removable but doesn't collect bacteria.

If you were to watch us assemble a case, the accepted standard is to fill the hole first with Teflon tape. It’s clean, easy to work with, and doesn't harbor bacteria. We used to use cotton pellets, but those would get very foul-smelling over time. On top of the Teflon, we use a standard composite filling material to create the best possible bond against the walls of the zirconia channel. All of this is why having a strict protocol in place is so important.

How well does an implant hold the bone long-term? Does a professional look at it often enough? Is there real thought going into where bacteria could collect? There is a lot that goes into this: the design of the underside of the prosthesis, whether it is easily flushable, and how that selection impacts daily care. If these restorations are not created correctly, they can create significant problems. We aren't fail-safe; we’re human. We want to cross all the "t's" and dot the "i's," which is why we’ve set a once-a-year maintenance standard. It isn't too encumbering, but it allows us to ensure the design is functioning exactly as intended.

I think of it this way: our patients have the job of selecting a center, paying for the procedure, sticking to a soft diet during healing, and maintaining daily hygiene. Our responsibility is using high-quality materials, selecting the right team to identify issues, and utilizing the best machinery to accomplish the result. Finally, our job is to double-check and certify that the restoration remains healthy long-term. It is a shared relationship with major categories of responsibility on each side.

It is a cooperative responsibility. We have a duty as surgeons to place the best implants in the best bone for the best surgical results. Our restorative team provides the best contours to facilitate cleaning. But without the patient’s interest in daily maintenance, we can’t have total success. We are all in this together.

Blake compiled a list for us, and there is a note here regarding a systematic review and meta-analysis on the "impact of maintenance therapy in the prevention of peri-implant diseases." The take-home bullet point is:

"Implant therapy must not be limited to the placement and restoration of dental implants, but to the implementation of preventative maintenance therapy of implants (PIM) to potentially prevent biologic complications and hence to heighten the long-term success rate."

To summarize, it’s not that it has to be looked at every day because there is a problem every day; it's that, long-term, you are better off having a professional eye on it. That awareness is vital. One of the main reasons we are here is to bring to light the fact that dental hybrids are not completely maintenance-free. There are aspects that need to be considered throughout the life of the restoration.

I’m excited for this niche of dentistry. Ten years ago, I saw many cases—even in my own offices—being sold as a "golden arrow" without covering maintenance. Now, we see a public campaign to educate people on what they are actually getting. If our practice isn't your cup of tea or you aren't in our location, I hope this information helps you understand that this is a two-way street. This isn't "set it and forget it." Implants are not free of potential complications and they need to be monitored by a professional. The frequency and cost are up to you, but these aspects are incredibly important.

Full arch maintenance isn't hard; it’s just important. It’s simple and straightforward, but it needs to be done.