Table 3.

Main themes, sub-themes, and summary of experiences and attitudes

1. Bruxism and implant treatment outcomes

1. General attitude about impact of bruxism on oral health

•Bruxism is damaging (wear, endodontic treatments, tooth loss, fractures, pain, or limitation of movement) •Without pain function is not impaired •Occlusion/articulation are important mediators for damaging effects

2. Feasibility of implant dentistry in bruxers

•Positive attitude: implants are possible, bruxism is not a contraindication (unless there is pain, some precautions needed, it can even help distribute forces better, better than conventional porcelain) •Negative attitude: clenching can be dangerous, possible, but with uncomfortable feeling for dentist

3. Encounters with complications

Variation in attitudes: •Occurrence of complications: never, there is always something, real bruxers will break everything, no control over when it goes well/sometimes miraculously well, no complications until occlusion changes over time due to wear of all teeth except the implant-borne restoration •Type of complications: usually chipping of porcelain, wear or fracture of FP, wear or fracture of mesostructure, wear of antagonists or problems with antagonistic porcelain, fractures of screws, fractures of implants, bone loss •Bone loss: not possible, only after infection, independent of infection •Loss of osseointegration: possible, impossible

4. Mechanism of complications

Bone loss/loss of osseointegration: •Excessive loading can lead to bone loss, which can be followed by bacterial invasion, ultimately leading to peri-implantitis •Inflammation pre-exists and subsequent overload can lead to more profound bone loss •Load can cause micro-movements of the implant in the bone, which can lead to loss of osseointegration •Load can cause loss of osseointegration, only if this was poor already •Peri-implantitis occurs mainly due to other reasons (e.g., wrong placement of implant, cement remnants) •Uncertainty about form of relation Other complications: inattentiveness of dentist (tightening of screws, occlusion, etc.), materials, wear and subsequent change of occlusion over time, bad starting point (e.g., after peri-implantitis treatment), technician

5. Consequences and treatment of complications

•Chippings: usually not very troublesome, investigate cause •Finances: reparation under warranty, pain less with cheaper materials, burden for practice is low •Emotional: irritation for patients, blame on dentist, burden not high for dentist •Practical issues: immediately new implant after removal of fractured one, harder suprastructure materials may lead to other, deeper problems, time investment

2. Treatment aspects of implantological interventions

1. Assessment of patients

•Thorough investigation of signs of function in every patient from the start of therapeutic trajectory •Understand why fractures occurred in the past •History/knowing the patient/intuition helps •Make intraoral pictures and discuss them with patient

2. Treatment features

•Occlusion, various views: only when biting hard in maximal occlusion, out of occlusion, can make contact, may be out of contact, check at preventive check-ups •Articulation: no contact if lateral forces are anticipated, strive for front and canine guidance, may be out of articulation, check at preventive check-ups •Protection: (a) Splint: is important, not so much (b) Splint material: soft splint gives more compliance, hard splint is less comfortable, hard splint is comfortable, (c) Splint design: should allow freedom of movement, thin (d) Advices and awareness regarding bruxism during the day •Materials/technical issues, variety of views: diameter, strength, number of implants, implants blocked, bone augmentation, occlusal pattern, material of crowns, technician skills, informed consent, advices to referring dentist •Removable prosthesis: (a) Concept A: as much as possible mucosally supported so that pain is felt when bruxing, bite not too high, lingualized bilaterally balanced occlusion (b) Concept B: strong basis with soft teeth, teeth wear, and are replaced, basis does not break (c) Taken out during sleep

3. Communication with patients

•Discuss beforehand: risks/expectations, protection, FP out during sleep, written informed consent •Awareness of problem: pictures, feel the fremitus, discussion in order to increase acceptance, so that blame will not be put on dentist, increase compliance with advices, some are already aware •Discussion may come across with denial or intervention with private issues

4. Role of general practitioners

•Important for longevity of implant-supported restorations •Should pay more attention to occlusion and articulation when placing suprastructure •Role of preventive check-ups for early detection in occlusion and articulation changes •Communication about materials/protection/advices for canine guidance •Complications due to improper implant component handling

5. Sources of information

•Literature, courses, undergraduate education •Experience, intuition

3. Diagnosis of bruxism

1. Importance of diagnosing bruxism

•Very important, should be part of routine •It would be nice to know •Not per se recognizing bruxism, but in general being able to discover the cause of failures is important

2. Diagnostic approaches

•Extraoral examination: shape of face/muscles, activity of jaw, general appearance/temper •Intraoral examination: tooth wear, presence or history of fractures, endodontic treatments, mobility, furcation problems, cheek lines, lost teeth, type of bite (deep/open) •Anamnesis: self-report, partner report, temporomandibular joint complaints •Other: “a feeling,” knowing the patient, experience

3. Challenges

•Uncertainty about diagnosis: •Importance of intraoral and extraoral signs? (validity) •Importance of self-report? (patients not aware, denial for the sake of not taking responsibility/financial aspects, privacy issues) •What is the definition of a bruxer, how do you know if someone is currently active

4. Improvement of care in the future

1. Role of education

•Attention of general practitioners for occlusion and articulation, learn how to see signs of bruxism and take it into account during treatment planning

2. Role of diagnostic approaches of bruxism

•It is important: treatment should be based on good diagnosis, improve compliance of wearing protective splint, difficult since bruxism can fluctuate, simple chair-side tool, device for home, referral clinic for extreme cases •Not important: complications mainly due to infection, constructions already strong enough for everyone (bruxers and non-bruxers)

3. Role of treatment approaches of bruxism

•Does not seem to be an important issue for implantologists, but may be for dentistry in general •Use of botulinum toxin

4. Other issues

•Define who is a bruxer •Information brochures regarding bruxism/more understanding from patients •Other/improved materials •No reason for further research •Splint features