Use of a Powered Toothbrush for Hygiene of Edentulous Implant-Supported Prostheses

he rates of full and partial edentulism have declined in the past 20 years.^1-5 However, the number of older adults in the population will increase,⁶ a trend that is expected to persist through at least 2050.⁷ The prevalence of adults in the United States requiring removable prosthodontic therapy has grown dramatically in the past 20 years^8-10and is projected to continue to rise during the next 20 years.¹¹ Given the cumulative impact of these population characteristics (ie, declining edentulism, increasing older adult population, and growing demand for removable prosthodontic therapy), the dental profession must continue to optimize existing therapies to manage edentulism and develop more efficient and effective treatment approaches for the future.

One of the most effective methods for the management of edentulism and the prosthodontic replacement of missing teeth is implant dentistry.^12,13 Since its historic introduction,¹⁴ the strategic application of osseointegrated dental implant therapy in the management of edentulism has revolutionized the profession's ability to satisfy the psychological, functional, and esthetic demands of this patient population. As with all forms of prosthodontic intervention, providers are confronted with numerous challenges, including diagnosis and treatment planning, surgical and restorative implementation, and long-term maintenance of the treatment result.

Similar to conventional prosthodontic restorations that do not involve dental implants,¹⁵the patient's ability to implement a regular and effective personal oral hygiene regimen impacts the comfort, function, esthetics, and success of treatment results in the long term.¹⁶ Accumulation of bacterial plaque and formation of organized biofilms¹⁷ have been shown to cause reversible inflammatory changes in the peri-implant soft tissues,¹⁸ which is commonly designated as "peri-implant mucositis."¹⁹ Long-term prevalence of peri-implant mucositis has been reported to be 76.6%.²⁰ If untreated and in the absence of effective oral hygiene practices, peri-implant mucositis may cause deterioration of the osseous tissue supporting the implant, known as "peri-implantitis."^21,22 This may lead to the loss of osseointegration and failure of the implant.^23,24 Although therapeutic interventions for peri-implant mucositis and peri-implantitis have been described,^25-27preventing the damaging effects of these pathologic conditions is highly desirable.

In general, toothbrushes function by the bristles contacting accessible oral surfaces.²⁸ Manual toothbrushing requires the user to appropriately orientate bristles and impart efficient brushing motions for a sufficiently long duration. When patients are provided professional-level, oral hygiene instructions and subsequently implement regular manual oral hygiene, clinical indicators of periodontal health may be maintained or improved.^29-31

An advantage of powered toothbrushes may relate to their unique mechanical interaction with debris-contaminated surfaces.^32,33Improved patient hygiene compliance may result from a psychological "high-tech" effect patients feel while using powered toothbrushes, as well as from patients feeling more motivated to brush. Compliance may also improve because powered toothbrushes are often professionally recommended. From a practical perspective, use of a powered toothbrush allows the patient to concentrate on the appropriate orientation of the bristles against oral surfaces and the duration of cleaning, without having to consider a manually induced brushing motion.

Existing literature supports the oral hygiene benefits of powered toothbrushing.^34-37 Recent systematic reviews compared the effectiveness of manual and powered toothbrushes. Conclusions indicated that powered brushes removed more plaque and reduced gingivitis more effectively than manual brushing.^33,38

An effective personal oral hygiene regimen for edentulism depends, in part, on the design of prosthodontic aspects of the rehabilitation, the patient's desire and commitment, and the instruments and materials available for cleaning access-challenged oral conditions. Various means of plaque removal from implant components and associated prostheses have been suggested, including manual and powered toothbrushes, interproximal brushes, flosses, antimicrobial rinses and gels, and subgingival irrigation systems.^39-49 Powered toothbrushes, which include a wide variety of brush attachments, may prove beneficial for those seeking manageable methods to maintain the cleanliness of implant-supported prostheses, ensuring the health of the peri-implant-supporting hard and soft tissues. This article describes a personal oral hygiene regimen that incorporates a powered toothbrush and demonstrates its application in several edentulous situations restored with implant-supported prostheses.

Recent investigations suggest that a powered toothbrush with controlled rotational oscillation movement may remove more plaque than a manual toothbrush.^37,50-52 This rotational oscillating powered toothbrush (Oral-B^® Professional Care SmartSeries 5000 powered toothbrush with Wireless Smart Guide, Procter & Gamble, www.pg.com) also offers various brush-head attachments (Oral-B FlossAction^™ and Oral-B Power Tip, Procter & Gamble). One of these attachments is a cone-shaped brush head 6 mm in diameter at the base of the brush and tapering to approximately 4 mm at the apex (Figure 1). A second attachment is an oval, multi-tufted brush head approximately 15 mm x 13 mm in diameter (Figure 2). By combining the use of these brush-head attachments, adequate access to most surfaces of hygienically designed edentulous implant-supported prostheses is possible. Patients often elect to use small amounts of toothpaste during their oral hygiene routines to provide both fresh taste and improved cleaning.

To effectively clean individual implant-supported overdenture abutments (Figure 3), the use of the oval, multi-tufted brush head has proven beneficial. With the bristles directed toward the abutment and denture-supporting tissues, the patient applies enough pressure to force bristles into and around the abutment (Figure 4). Because the bristles engage internal aspects of the abutment, entrapped debris is readily removed. Use of a gentle rocking motion of the brush will allow all abutment surfaces and peri-implant soft tissues to be cleaned. Then to clean and stimulate these tissues, the patient can gently move the brush across all denture-supporting soft tissues covering the alveolar process and palate.

Facial, lingual, and occlusal aspects of most overdenture bar attachment systems are readily accessible to routine hygiene efforts. The key is gaining access beneath the bar. Depending on the available space and bar design, the small cone-shaped brush head and/or the larger oval brush head may be used (Figure 5 and Figure 6). Patients are instructed to position the bristles perpendicular to the facial and lingual surfaces of the bar and apply sufficient pressure to facilitate bristle access beneath the bar. By allowing the brush to do the cleansing and providing a gentle rocking motion, the patient can access all the prosthetics for cleaning.

In most circumstances, the intaglio surfaces of implant-supported overdentures can be effectively cleaned using the oval-shaped, multi-tufted brush head of the powered toothbrush (Figure 7). Occasionally, bristle access into the overdenture attachments is restricted by the facial-lingual dimensions of the prosthesis. This occurs primarily with mandibular overdentures that have been closely approximated to the facial and lingual flanges. In these situations, the smaller cone-shaped brush head can be used.

Hard and soft debris accumulation in internal aspects of overdenture attachment components can interfere with the retentive mechanics of the attachment system. Patients must maintain these surfaces free of debris. Patients should place the bristles directly on the denture's intaglio surface. By applying light pressure, bristles are forced into the attachments, thereby contacting all internal attachment surfaces. This bristle approximation will efficiently eliminate plaque and debris.

Much like overdenture bar systems, the key to cleaning implant-supported fixed complete dentures involves gaining access to all surfaces between the prosthesis and associated oral tissues. Depending on space availability and prosthetic design, either the small cone-shaped brush attachment or the larger multi-tufted oval brush head may be used. The small cone-shaped powered brush head is particularly effective in accessing difficult-to-reach surfaces beneath the prosthesis (Figure 8 and Figure 9), while the relatively large multi-tufted head is more suited for general external surface cleaning. Patients should position the bristles perpendicular to facial and lingual surfaces, applying sufficient pressure to promote bristle access beneath the restoration. By allowing the brush to do the cleansing and providing a gentle rocking motion, all prosthetic surfaces may be accessed for effective oral hygiene. Patients should be advised to finish their cleaning routines by using the larger multi-tufted brush head to gently massage and clean all soft tissues in close proximity to the restoration.

These restorations present hygiene challenges similar to implant-supported fixed complete dentures. Therefore, similar instructions are provided to patients. In addition, consideration must be directed to the proximal apposition of the prosthesis with natural dentition. The small cone-shaped powered brush head usually provides good oral hygiene access when used to supplement a normal cleaning routine involving conventional dental flossing.

Much of the success of dental implant therapy depends on well-planned and skillfully accomplished surgical and prosthodontic procedures. However, the patient's ability to perform regular and effective personal oral hygiene impacts the long-term therapeutic success. All too often, implant prostheses present contours and spaces challenging to even the most enthusiastic personal oral hygiene efforts. The availability of hygiene devices that are easily manipulated by patients and capable of accessing difficult-to-reach areas associated with complex dental implant restorations will help maintain the cleanliness of critical prosthodontic surfaces and the health of associated oral tissues in the long term.

David R. Cagna, DMD, MS
Professor, Department of Prosthodontics, Director, Advanced Prosthodontics Program, University of Tennessee Health Science Center College of Dentistry, Memphis, Tennessee

Joseph J. Massad, DDS
Director, Removable Prosthodontics, Scottsdale Center for Dentistry, Scottsdale, Arizona; Associate Faculty, Tufts University School of Dental Medicine, Boston, Massachusetts; Adjunct Associate Faculty, Department of Prosthodontics, University of Texas Health Science Center Dental School, San Antonio, Texas

Tony Daher, DDS, MSEd
Associate Professor, Department of Restorative Dentistry, Loma Linda University School of Dentistry, Loma Linda, California