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Inside Dentistry

March 2006, Volume 2, Issue 2
Published by AEGIS Communications


Are Dental Implants Your First Choice?

Allison M. DiMatteo, BA, MPS

There is now consensus among many members of the dental profession at large that for certain indications, the placement of a dental implant is the standard of care. Last year in the United States alone, more than 1 million dental implants were placed—for an estimated $200 million in total sales—and that number is expected to increase by close to 20% annually for at least the next 5 years. According to Millennium Research Group (MRG), a medical and dental industry analyst firm in Toronto, Canada, the regular diameter implant market—which includes implants with a diameter greater than 3 mm—should produce sales in excess of $560 million in 2009 .a

If dental implants are not your first choice for replacing a single missing tooth or for securing a mandibular overdenture, there are many compelling reasons that they should be. A combination of proven success rates, technological advancements, and new technique protocols are making this tooth replacement option more feasible, less daunting, and more esthetic.b What’s more, the clinical benefits for patients that can be achieved from this treatment modality are equally matched by the profit potential implants can provide to the dental practitioners who place and/or treatment plan and restore them.a (See Why You Should Be Choosing Implants)

“From a production standpoint, dental implants are one of the key areas that are not just an option, but a necessity for many practices as they look at growth in the future,” asserts Roger Levin, DDS, CEO of Levin Group. “To grow practices responsibly, I think dental implants are a terrific option.”

Reasons for anticipated growth in dental implant placement include a stable economy, which will enable more patients to take advantage of this treatment; long-term functionality that is becoming better understood by the public and the profession; and enhanced implant education for both practicing clinicians and future dental school graduates. As a result, now’s the time to learn more about what the current and future patient population will be demanding and who’s going to satisfy their needs, how today’s implant options compare with earlier generations, and why—for certain indications—implants should be your first choice. Here’s the Inside look at what you need to know to make dental implants a part of your practice.

The Ups and Downs of Implant Popularity

Dental implants weren’t always the popular choice. Ken Judy, DDS, co-chairman of the board of the International Congress of Oral Implantologists (ICOI), recalls that in the late 1960s and early 1970s, many practitioners were condemned for placing implants.

“Osseointegration didn’t really come into this country until the early 1980s, but there was a fair number of us who had been placing them since the 1970s, and few people—courageous people, I might add—had been placing them even earlier,” Judy says. “Osseointegration wasn’t an unknown concept; it was just a misunderstood concept.”

However, as early as 1978, the National Institutes of Health held a consensus conference during which they examined whether or not there was adequate evidence to support that the success rates of dental implants were acceptable for use on the public. At that time, and again during a second consensus conference in 1988, it became evident to dentistry that implants were working, and working well, Judy says.

Regardless, integration into dental practice was slow. MRG cites the high costs and traditionally long healing times of implant procedures—as well as a lack of awareness and acceptance of techniques by clinicians—as the reasons that many patients and dentists in the United States have elected more conventional alternatives (e.g., traditional dentures, crowns and bridges) over the functional and esthetic benefits of implants.a

In 2002, an MRG survey showed that 75% of both oral surgeons and periodontists were placing implants, but only 5% of general practitioners were. A year later, survey results published by Dental Products Report showed that the number of general practitioners placing dental implants had nearly doubled to 9%, and an additional 4% of general practitioners said they planned to start placing implants within 12 months.a

According to Russ Bonafede, vice president of global marketing for Implant Innovations, Inc. (3i), only about 20% to 30% of general practitioners are currently referring dental implant cases on a regular basis. That leaves an estimated 70% to 80% that are either very infrequently referring patients for dental implants or not referring them at all.

“There is tremendous opportunity in the United States for the level of implant referrals to increase amongst the general practitioner community,” Bonafede says. “There are also opportunities for them to get involved with implant placement, but doing so would require an adequate amount of education and training in the form of a mini-residency to truly gain proficiency.”

What’s interesting to Carl E. Misch, DDS, co-chairman of the board of the ICOI, is that 15 to 20 years ago, 15% of general dentists were placing implants, but the numbers started declining. Now, he says, they are steadily increasing. Today, 90% to 95% of periodontists and oral surgeons place implants, he says, and approximately 90% of general dentists have at least restored a dental implant in the past.

Last year’s figures for the number of implants placed showed continued promise. In the second quarter of 2005, MRG surveyed a statistically significant number of general practitioners, oral/maxillofacial surgeons, and other specialists regarding dental implant placement and restoration. According to Kevin Flewwelling, a research analyst with MRG, of only those general practitioners surveyed, 0.8% performed implant placement only, 73.3% performed implant restorations only, and 21.7% placed and restored dental implants.

Both Flewwelling and Melicent Lavers, a manager at MRG, caution that there is natural bias in the results of this particular survey, noting that the actual percentage of general dental practitioners placing dental implants is probably closer to between 10% and 15%. Regardless, the percentage of clinicians placing dental implants in 2005 represents an increase over previous years.

Dissecting the Demographics of Potential Implant Patients

According to those Inside Dentistry spoke to, baby boomers and younger patients are more likely to pay a premium for dental implants based on the long-term functional and natural-looking esthetics this treatment modality can provide. MRG notes that dental implants require less frequent repair or revision than crown and bridge treatments—in addition to offering long-term cost savings for younger patients—which could help explain why implants are an attractive option to those who may live with prosthetic teeth for many years.a

“Patients are much more discerning these days, and they have a lot more information accessible to them about treatment alternatives,” explains Kevin Mosher, vice president and general manager for Nobel Biocare, North America. “Consumers are more aware of the options available to them, and they are seeking them out.”

Overall, MRG predicts that as the United States population ages and an increasing number of affluent baby boomers face tooth loss, demands for dental implants will increase dramatically.a Between 1999 and 2002, almost 25% of the United States population aged 60 and over was edentulous, notes Christina Mathew, a senior analyst for MRG.

“If you look at the market potential, it’s dramatically under-penetrated,” observes Mosher.

Other data bode well for the future of implant placement, also. According to Misch, who is also the director and a professor of oral implantology at Temple University School of Dentistry, 70% of the US population is missing at least one tooth. More specifically, 30% of people between the ages of 50 and 59—which represents about 20% of the US adult population—are missing one or two teeth between existing posterior teeth.

“There are about 40 million people that are missing posterior teeth in the United States,” says Misch. He also notes that the edentulous population in the United States totals 20 million people, and another 10 million people have no teeth in the maxilla. “So, it is obvious from these statistics that we have a great need for tooth replacement in this country.”

What’s more, according to Bonafede, baby boomers are heading into their retirement years with more disposable income. They’re embracing an active lifestyle and don’t necessarily want to spend those years wearing dentures or denture adhesives because they’re more conscious of their appearance and esthetics.

“Patient awareness of dental implants is increasing,” explains Lavers. “People are taking better care of their teeth and not losing all of them the way they used to, so the demand for implants should ultimately increase.”

In 2002, Roger K. Rempfer suggested—based on Academy of General Dentistry statistics—that to satisfy current implant needs, every dentist in the United States would need 20 appointments per month for the next 20 years in order to place and restore fixtures for what was then the current level of missing teeth.c Additionally, he indicated that increased dissemination of information—such as through the Internet—would further fuel patient demands for better treatment options as their awareness and understanding increased.c

So, despite a lack of organized, industry-wide public awareness initiatives, Judy explains that there is what he calls a subliminal implant marketing campaign taking place. Yellow-page advertisements and mainstream media are informing patients about the implant option and its benefits.

“Most people don’t want the implants,” Judy clarifies. “They want the benefits of the implants. In other words, they want the teeth.”

The Implant Evolution

The advent of antibiotics and the injuries sustained by soldiers in World War II were the impetus for many people to attempt new methods of restoring patients’ mouths. Pioneering modern day implant dentistry was Professor P.I. Brånemark, who first noted the phenomenon known as osseointegration when he attempted to remove bone-anchored titanium microscopes from the living bone tissue to which they had irreversibly bonded (http://dentalimplants-usa.com). He placed the first Brånemark dental implant in 1965—the first practical application of osseointegration—and according to Mosher, his patient is still alive and well and functioning with his implant.

Original dental implants were developed to mimic natural tooth root forms and were screw shaped. Subsequent developments led to thin ridge or blade implants, as well as subperiostial implants that covered but did not go into the bone. Some 50 years later, notes Judy, the profession has returned to the original implant form, and today’s clinicians, for the most part, place root-form implants.

However, those early implants were not long-term fatigue tested. Additionally, pre-titanium materials from which implants were manufactured included aluminum oxide and vitreous carbon which, according to Judy, looked good during year 1 but were virtually lost by year 10.

“We went through what I would call a period of clinical investigation,” Judy explains. “Today, everything that is introduced must be evidence based and meet government standards.”

During the evolutionary cycle, the design of implant systems has evolved considerably. Industry analysts cite the major change in the design of dental implants as being from a cylinder, non-threaded implant to a threaded, tapered implant. Although Lavers notes that there are concerns that tapered implants could compress the bone supporting the dental implant, they are recommended following a tooth extraction and can be placed where anatomical limitations, such as convergent roots, exist. In 2004, the demand for tapered implants in the United States rose despite the availability of other types of implants, such as parallel wall and cylindrical implants.b

Thread designs—which are recommended to facilitate initial stabilization, increase surface area, promote precision placement, and help with load distribution—have also changed.d Essentially, threads are the screw pattern built onto the body of the implant. Misch explains that initially, a cylindrical implant design was used in which there weren’t any threads. These were replaced by implants with a V-shaped thread and, more recently, by those with a more square design that load the bone better on compression, he says.

Additionally, the connections that are used with dental implants have changed. In the early years, implants featured an external hex connection by which the prosthetic tooth would be attached. It is still the most common connection and is used on approximately 60% of implants placed in the United States.d Today, most companies in the marketplace have moved toward internal connections that offer some advantages in terms of esthetics, strength, and load distribution, Bonafede says. The evolution of the implant/ abutment connection is among the factors that have helped increase the placement of dental implants by enabling the use of simplified procedures and more conventional prosthodontic techniques.d,e

More noteworthy to analysts, however, has been the shift toward roughened implant surfaces and surface treatments. Earlier surface treatments included hydroxyapatite and titanium plasma spray, both of which are now giving way to a roughened treatment that research is showing promotes greater osseointegration with the tissue, explains Mathew.

“Roughened surfaces are gaining increasing importance, and there has also been improvement to the existing roughened surfaces by industry manufacturers,” Mathew notes.

That increasing significance is reflected in the fact that the demand for roughened/noncoated implants exceeded that of any other implant surface in the United States dental implant market in 2004.b Means by which manufacturers roughen the implant surfaces include, but are not limited to, blasting, etching, and electrolytic anodizing, but there is little evidence that one roughened surface is better than another.d

According to Bonafede, almost all of the implant manufacturing companies today are producing proprietary surface treatments on their implants that enhance the implant’s ability to osseointegrate. This, he says, has helped improve success rates, particularly when implants are placed in areas where there is poor bone quality.

Today’s Implants—Responding To Clinician & Patient Needs

Since their introduction, implant manufacturers have been responding to clinician and patient needs by introducing products and techniques that remove challenges to the integration of implant treatments.a The delivery of components has become simpler, and it’s now easier to use restorative components and achieve highly esthetic outcomes than in years past. Additionally, manufacturers are promoting techniques and devices that reduce the time required for healing and the number of surgical steps.f

For example, clinicians report the ability to replace hopeless teeth with implants simultaneous to the extraction procedure (i.e., immediate placement).f,g Evaluations of such procedures have suggested that the short-term survival rates and clinical outcomes of immediate and delayed implants are similar and comparable to those of implants placed in healed alveolar ridges.g However, factors that influence a clinician’s ability to load an implant in an accelerated fashion, as well as the restoration decisions, include bone quality and quantity, implant design, splinting of implants, and prosthetic design.h

Mosher notes that the first thing general practitioners should understand about today’s implant options is that they are far more acceptable to patients. Looking back only a few years ago, implant treatments involved a 9- to 12-month cycle.

“With the development of things like immediate function and implant placement upon tooth extraction, there are now solutions that have dramatically shortened the treatment time for implants,” Mosher says. “There are also procedures that are performed in a flapless technique, so there is less pain and swelling for the patient.”

Overall, today’s implant treatment modalities are much faster and more patient-friendly than before. For example, 1-stage surgery is gaining in popularity among United States practitioners. Here, the dental implant and abutment attachment are placed in a single procedure. This can eliminate up to 6 months of time traditionally required for osseointegration and reduce the surgical process to 3 stages.a

“These [1-stage] implants aren’t necessarily simpler, but there are fewer stages required, so it makes the implant procedure overall easier for dentists to think about and incorporate into their practices,” explains Lavers. Mosher adds that several manufacturers offer implant products that, in many cases, require 33% to 40% less drilling steps than before.

In 2004, 1-stage implants, including those originally intended for 2-stage procedures but used in 1-stage treatments, accounted for more than half of the dental implants sold.b According to MRG, dental practitioners are becoming increasingly convinced that a 2-stage procedure is not necessary for every case. It is expected that this, coupled with the increased quality of tissue healing and improved mechanical properties of 1-stage implants, will lead to an increase in sales of 1-stage implants compared to their 2-stage counterparts from now until 2009.b However, the 2-stage process may still be the most beneficial for some patients (i.e., those with insufficient bone mass to allow a 1-stage procedure).a

Currently, attention is turning to immediate load implants and techniques, which enable clinicians to place the implant, abutment, and restoration in a single procedure.a In 2004, such implants accounted for more than 10% of dental implant sales in the United States. Although they are unlikely to match the popularity of 1-stage implants, immediate load implants are expected to account for slightly less than 15% of all sales by 2009, according to MRG. In such cases, anatomic location, implant design, and restricted prosthetic guidelines are paramount to ensuring successful outcomes.i

“There is a variety of implant designs available today, and we have many more prosthetic alternatives as a result ofmuch more sophisticated manufacturing processes,” observes Kim A. Gowey, DDS, president of the American Academy of Implant Dentistry. “They achieve better tolerances so the fit is good, and surface treatments have improved, so there isa plethora of devices available to suit whatever your needs may be.”

According to David Sklarski, president and chief executive officer of Sterngold Dental, LLC, implants have also evolved from being surgically driven to being more prosthetically driven. Specifically, he notes that the products available today provide better esthetics, function, and comfort for patients.

However, part of the evolutionary process has been clinicians’ approach to implant placement. Misch says that much has been learned since the early days, including the fact that techniques should be modified, especially in the softest bone types, so that bone isn’t removed but rather compressed before implant placement. For harder bone types, improved drill designs, speeds, and irrigation are important. Considerations of bone type have also led to innovations that enable clinicians to select implant designs that best suit their needs and a given case.j

Conclusion

As in years past when general practitioners integrated endodontics into their practices and perhaps even orthodontics, some assert that the time has come to incorporate dental implants. And, according to Mosher, offering dental implants as a treatment option is an opportunity for dentists to differentiate their practices from others, regardless of whether they place them or not.

“If you look at general dental practices today, they’re not the way they used to be. Dentists are no longer just drilling, filling, and billing,” says Sklarski. “Implants are the next thing for clinicians to add to their practices to offer to their patients.”

Those dental practitioners who do treatment plan, restore, and/or place dental implants are no longer pariahs among their peers. Rather, these forward-thinking clinicians are among a growing segment of the profession that acknowledges dental implants as the standard of care for certain indications and patients.k

“If clinicians haven’t looked at implant dentistry in a while, they should look at what treatment modalities are available today, because we’ve come a long way,” says Mosher. “It’s a whole new world.”


a Dental implants: taking a bite out of the US market.Medical Industry Intelligence. September 2005; 4-7.Millennium Research Group, Toronto, Canada.

b US Markets for Dental Implants and Final Abutments 2005. Millennium Research Group,Toronto,Canada. 2005.

c Rempfer RK. Changing issues and demographics affecting periodontal and implant therapy. J California Dent Assoc.May 2002. www.cda.org.

d Hunt PR, Gartner JL, Norkin FJ. Choice of a dental implant system. Compend Contin Educ Dent. 2005 April;26(4):239-250.

e Finger IM, Castellon P, Block M, et al. The evolution of external and internal implant/abutment connections. Pract Proced Aesthet Dent. 2003 Sep;15(8):625-32.

f Gelb DA. Dental implants as treatment of choice: beneficial, predictable, and straightforward. Dentistry Today. 2005 Feb;112-117.

g Chen ST, Wilson TG Jr, Mammerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. 2004;19 Suppl:12-25.

h Morton D, Jaffin R, Weber HP. Immediate restoration and loading of dental implants: clinical considerations and protocols. Int J Maxillofac Implants. 2004;19 Suppl: 103-8.

i Gapski R, Wang HL, Mascarenhas P, et al. Critical review of immediate implant loading. Clin Oral Implants Res. 2003 Oct;14(5):515-27.

j el Askary AS, Meffert RM, Griffin T. Why do dental implants fail. Part II. Implant Dent. 1999;8(3):265-77.

k Marder MZ. Medical conditions affecting the success of dental implants. Compend Contin Educ Dent. 2004 Oct;25(10):739-742,744,746.

SIDEBAR 1

The Inside Look FROM...
In each issue of Inside Dentistry, the publishers and staff strive to deliver clear, objective, and relevant reporting of the thought-provoking issues facing the dental industry. We gratefully acknowledge the following individuals, without whom this Inside look at dental implants in today’s practice would not have been possible. Their candid comments and professional insights were invaluable to developing a comprehensive and timely presentation.

Academia

Michael Alfano, DDS, PhD
Dean
New York University College of Dentistry
mca1@nyu.edu

Jack Dillenberg, DDS, MPH
Inaugural Dean

James Bell, DDS
Executive Associate Dean
Arizona School of Dentistry & Oral Health
jdillenberg@atsu.edu

Consultants/Analysts

Melicent Lavers,
Manager

Kevin Flewwelling,
Research Analyst

Christina Mathew,
Senior Analyst
Millennium Research Group
www.mrg.net

Roger Levin, DDS
CEO
Levin Group
rlevin@levingroup.com

Practitioners/Society Representatives

Kim A. Gowey, DDS
President
American Academy of Implant Dentistry
kimgowey@hotmail.com

Ken Judy, DDS
Co-chairman of the Board
International Congress of Oral Implantologists
dorjudy@aol.com

Carl E. Misch, DDS, MDS
Director & Owner, Misch Implant Institute
Co-chairman of the Board, International Congress of Oral Implantologists
Director of Oral Implantology & Professor
Temple University School of Dentistry
info@misch.com

Industry

Russ Bonafede
Vice President of Global Marketing
Implant Innovations Inc. (3i)
rbonafede@3implant.com

Kevin Mosher
Vice President & General Manager, North America
Nobel Biocare
kevin.mosher@nobelbiocare.com

David Sklarski
President & CEO
Sterngold Dental, LLC
david.sklarski@sterngold.com

SIDEBAR 2

Why You Should Be Choosing Implants
Whether you place them, treatment plan for them but refer the patient elsewhere, or restore them, Inside Dentistry interviewees agree: getting involved with implants is the right thing to do for patients. Some say it’s also an excellent way for clinicians to become excited about their chosen profession again by offering a service to patients that reaps many rewards.

For example, the single missing tooth with two healthy teeth adjacent to it could previously only be replaced with a 3-unit bridge, requiring the preparation and ultimate destruction of otherwise healthy, virgin tooth structure. Today, a single tooth implant is considered the standard of care for this indication.

Another popular indication for implants is the retention of mandibular overdentures. By using between two and four implants to help anchor the denture, patients experience greater support of their prosthesis and are able to more comfortably and confidently eat and enjoy other day-to-day activities.

If you’ve been on the fence yourself about whether implants are all they’re cracked up to be, the reality is that dental implants—with proper placement and for the right indications—have extremely high success rates. They’re easier to place today than in even recent previous years, and today’s implants integrate in the bone within a relatively short period of time. And, some say, because patients are becoming more educated, if clinicians don’t supply them with the solutions they’re looking for, somebody else will.

Here, we present just a few of our experts’ reasons for why if the case is right, implants should be, too.

Better Patient Care
According to Michael Alfano, dean of the New York University College of Dentistry, the paradigm shift in the standard of care regarding lower dentures is based on the fact that implant placement to help retain them is highly preferred by the patient, more functional for the patient, and most importantly, retains the alveolar ridge to support the denture. For single tooth replacement, it is driven by the desire to not destroy teeth and make them abutments for crowns that support a 3-unit bridge. What’s more, notes Ken Judy from the International Congress of Oral Implantologists, placing a dental implant helps sustain the supporting bone in that area by ensuring it continues to be stimulated by transferred biting forces.

In the edentulous mandible, stabilizing the lower denture with implants eliminates the majority of problems that patients have with dentures and makes them much happier, asserts Kim A. Gowey, a practicing dentist from Wisconsin and the president of the American Academy of Implant Dentistry. “Because the predictability of implants is so good, it’s the right thing to do,” he says. “Many patients struggle with their lower dentures, and implants can make a big difference in their quality of life.”

According to Russ Bonafede from 3i, tooth loss without any subsequent replacement of the root form puts little function on the underlying bone, ultimately leading it to resorb. That could result in undesirable changes to the facial anatomy and structure.

“There is an esthetic and medical rationale for placing implants, such as being able to sustain bony volume and facial contours,” Bonafede says. “There is also the self-esteem aspect. The implants, unlike dentures, are very stable and analogous to having natural tooth roots in your jaw bone. The stability provided gives a renewed level of self-confidence for these patients.”

Additionally, Carl E. Misch, who is the director and a professor of oral implantology at Temple University School of Dentistry, notes that between only 8% and 10% of patients floss on a regular basis. When teeth are joined with a bridge, there is an increase in the likelihood of plaque build-up, the risk of decay, and the need for endodontic treatment. There is a 20% chance that teeth will decay with a bridge, compared to only 3% with a crown. Additionally, he says that the chances that the patient will need root canal therapy increases to 18% when a bridge is placed, compared to less than 3% for a crown.

Further, when patients are missing all of their teeth, Misch asserts that there is no way to restore them to normal function without dental implants.

“People with dentures bite down with a force of between 5 and 50 pounds,” he says. “People with their own teeth bite down with a force of between 250 and 1,000 pounds. Implants allow patients to function like a normal individual again.”

In fact, patients who have received implant treatment have experienced improvements to their diet, their lifestyle, and their overall health. According to Misch, several studies have demonstrated that complete tooth loss is associated with illness, and 17% of edentulous people take medications for gastrointestinal disorders. In addition, edentulous people require 17% more medications than people the same age who have their teeth.

High Predictability
Gowey explains that for single tooth implants, long-term predictability is high. In fact, failures are universally under 5% for dental implants.

“It is probably one of the most predictable procedures in dentistry today,” he says.

What’s more, according to Judy, single tooth implant restorations have been shown to last longer than a 3-unit bridge. Most bridges predictably fail in 5 or 6 years, whereas clinicians and researchers are finding out today that some implants are going on 10 or 15 years of function, he says.

More specifically, Misch explains that 30% of bridges must be replaced before 10 years, and 50% of them must be replaced before 15 years. What’s more, when they are replaced, most likely one of the teeth that had been prepared is often lost as a consequence, so the 3-unit bridge becomes a 4-unit bridge. From there, it could escalate into a partial denture and then full denture, he says.

“The advantage of having a single tooth implant is that rather than having a 30% to 50% failure rate at 10 and 15 years, respectively, the implant success rate for that time period is about 97%,” Misch notes.

Of course, success rates do vary for different indications. The highest success rate is 97% for single tooth replacement, followed closely at 96% by implants placed to retain a mandibular overdenture, Misch says. Implants supporting a maxillary fixed partial have a 90% success rate, and the lowest implant success rate is 85% for maxillary overdentures.

“However, all of these success rates are higher than the rates for the devices the implants are replacing,” Misch notes. “All of these implant supported devices are more successful than traditional bridges or partials that attach to teeth.”

Patient Acceptance
“Patient acceptance today is much higher because there has been more publicity about dental implants,” Gowey believes. “There have been many more done in recent years, so it’s not uncommon for a patient to know somebody who’s undergone the procedure and then come in and ask about the implant option.”

But, he notes, people aren’t seeking out implants because they want them as the end result. “They come to you for teeth. The implants are just another method of supporting replacement teeth.”

Practice Profitability
According to Millennium Research Group, dental implant placement and the procedures associated with attaching a final abutment and prosthetic restoration are among the most lucrative in dentistry.1 In fact, they can provide up to 20 times the profit of alternative techniques.1

“Those general dentists who restore implants will have an additional service to offer patients,” Roger Levin points out. “This service will be a higher production service, so it will increase practice production and profitability.”

Levin explains that dental implant cases—even those for which the general dentist is only restoring the implants—typically tend to demand a higher fee. This is based on the fact that the restorative needs related to implants are slightly more complex and, therefore, may take longer and command a higher fee.

“Even if general practitioners refer patients for implants, when you look at the profitability studies, they show those types of referral relationships to be very profitable for dentists,” comments Kevin Mosher from Nobel Biocare. “Offering implants is an opportunity to help grow their practices through differentiation from dentists who don’t offer this service.”

Personal and Professional Satisfaction
“There is nothing you get like the reward of helping somebody who has suffered for years with loose dentures, who couldn’t eat, who was embarrassed to be in public,” Gowey attests. “When you can provide this kind of treatment to them and make this kind of difference in patients’ lives, you can’t go wrong.”

What’s more, Levin explains that dental implant restoratives are well-received by patients. They receive an excellent quality treatment, one that they really love, he says.

“By restoring dental implants, the dentist has the satisfaction of having done an excellent job for the patient,” Levin emphasizes. “Additionally, they also derive increased earnings.”

David Sklarski from Sterngold Dental, LLC, agrees. Placing dental implants, he says, is probably the most rewarding thing a practitioner can do in their practice.

Notes Jack Dillenberg, the inaugural dean of Arizona School of Dentistry & Oral Health, general dentists today have done a wonderful job with preventive, restorative, and some specialty procedures, such as periodontics and endodontics. Implant dentistry, he says, provides them with the opportunity—if they’re so inclined—to enhance their surgical, restorative, and collaborative skills to best serve their patients.

1 Dental implants: taking a bite out of the US market. Medical Industry Intelligence. September 2005; 4-7. Millennium Research Group, Toronto, Canada.

SIDEBAR 3

How to Get Started
To ensure your success in the implant arena, it’s important to realize that there’s more than one way to be involved. Academics, industry analysts, and practitioners alike agree that general dental practitioners can treatment plan for implants and refer patients to specialists for implant placement; place/restore the implants themselves; or only provide the prosthetic restorations for the implants.

Whichever you choose, education is key. One place to start is with dental implant manufacturers, many of which have relationships with private institutes and dental schools to provide comprehensive continuing education programs. Professional organizations are also helpful and influential in terms of providing guidance for the education you need based on your existing skill set and comfort level.

Get Involved with Referrals and Restorations
To begin the immersion into implant dentistry, Carl E. Misch, the director and owner of the Misch Implant Institute, encourages dentists to first restore dental implants. By doing so, practitioners gain a perspective of what implants are, how they fit into the treatment plan, and what’s involved with creating the restorations placed on them.

For someone with no experience with implants whatsoever, he advises establishing a relationship with a specialist and laboratory skilled in dental implants. When a patient presents with missing teeth, refer him or her to the specialist for consultation regarding implants. The specialist can then guide you through the process of making the restoration, while the laboratory can explain the other devices required for treatment.

Begin the Education Process
“Before placing implants, clinicians really need to educate themselves, and the more, the better and the safer,” believes Kim A. Gowey from the American Academy of Implant Dentistry (AAID).

To this end, dental societies and private institutes—in addition to some dental schools—conduct structured, comprehensive dental implant education programs that span weeks and months, usually for an entire year. As an example, the AAID offers two 300-hour maxi-courses, one at the Medical College of Georgia and the other at New York University College of Dentistry. Such programs provide detailed instruction in relevant areas of basic science, bone physiology, material science of implants, implant restoration, treatment and patient management, and a gamut of other topics.

“The dentist practicing today is either going to get education from the manufacturers who are sponsoring courses, or through organizations such as the International Congress of Oral Implantologists (ICOI),” comments Roger Levin, DDS. “In addition, there are a number of institutes that offer quality education, such as the Misch Implant Institute and others, so there are many educational opportunities to help dentists to prepare to understand implant surgery and the restorative process.”

Most manufacturers support and/or organize a variety of extended dental implant training and education programs across North America and overseas. (See 2006 Dental Implant Education Opportunities) Their Web sites list their continuing education opportunities, as well as any mentoring programs with specialists and/or industry leaders that are available for additional support and guidance.

“Manufacturers are supporting any number of meetings around the world because the field is growing so rapidly,” comments Ken Judy from the ICOI, which offers dentists three levels of advanced international recognition (i.e., Fellowship, Mastership, and Diplomate). “They have supported a large number of education mechanisms over the years and they are critical to the development of the field because they also finance a lot of education for dental students.”

Additionally, dental schools also offer continuing education programs in implant dentistry. NYU, for example, conducts two separate year-long programs that involve 1-day-a-week participation. The school also offers other programs that are clustered over a series of weekends. All programs, according to Michael Alfano, dean of the NYU College of Dentistry, involve hands-on training in a structured environment.

“What scares me with implant placement is somebody taking only a 2-day course and going back to their practice to perform implant placements on somebody without realizing what the complications could be, how to handle them and how to avoid them,” admits Gowey. “To place implants, we really need to be educated in the discipline in order to be competent and fair to the patient.”

Alfano advocates a continuum of education opportunities and much more extended training than would typically be provided during a single weekend or 1-day continuing education course. Implant training is not about a lecture, but rather about a lecture coupled with patient experiences, he says.

Judy agrees, emphasizing that the most important thing clinicians interested in providing implants can do is to participate in a structured course of training. The worst thing they could do is take a little bit here and a little bit there.

“Clinicians must realize that learning to do implants is a multi-day, multi-weekend effort,” Judy asserts. “They have to make a significant investment in terms of time, educating their staff, and modifying the way they do things.”

To help clinicians find the educational venue that’s right for them, the ICOI provides a referral service to educational programs conducted throughout the United States. These may be at dental schools, corporately sponsored, or at any of the dozens of private institutes across the country.

Once educated, the AAID offers credentialing for those who have studied and wish to demonstrate their education and proficiency in implant placement. The examination, which was developed according to psychometrically valid testing specifications, includes written, oral, and case presentation sections. However, obtaining credentials is not required in order to place implants in a general or specialty practice.

Build Your Implant Team
Levin encourages clinicians to involve their whole team in the implant education process. He notes that one of the most limiting factors for practices offering dental implants is not understanding the true team approach necessary to make the process work.

“In most cases, referrals between general dentists and specialists are fairly isolated. We send off a root canal case, the endodontist performs the procedure, and the patient returns for the restoration,” Levin explains. “When it comes to implants, there is a higher level team approach that is needed, and we need much more communication.”

The intense communication process begins with educating the patient and garnering patient acceptance of the implant treatment. From there, if the case is referred to a specialist for implant placement, the interdisciplinary process must be streamlined so that the specialist and restorative/referring dentist understand the case requirements.

“Very often a patient will return to the general practitioner’s office, but the dentist won’t quite understand what was done or what’s now needed, or what the component parts selected need to be,” Levin says. “There can be a lot of confusion.”

For this reason, some organizations conduct programs that teach the entire office staff a systematic approach to implants in the dental practice.

“With implants, scheduling and referring between offices is a little more complicated,” Judy explains. “For example, referring a patient for a tooth extraction isn’t a big deal. But, if it’s for an implant, there must be agreement about how many will be placed, when they should be placed, when the implants should be loaded, etc.”

Begin Slowly and Network
When ready to start placing implants, Misch suggests first placing them in the posterior of the mouth to replace a single tooth. The second easiest procedure to master is placing implants in the anterior mandible to support a lower denture.

“The advantage of implant surgery is that it is actually easier to learn than a root canal,” Misch says. “Instead of trying to negotiate canals that are torturous and fill pulp chambers with moldable materials, with dental implants you are drilling a round hole with a round drill and filling it with a round implant.”

Interacting with other clinicians experienced with implant placement will be beneficial also, Misch believes. Organizations such as the ICOI and the AAID represent a broad spectrum of dental professionals, so those interested in more advanced training and organized education have a multitude of potential colleagues with whom to study.

What’s more, as the ICOI, its members, and implant manufacturers come together to deliver a unified public awareness message regarding the benefits of implant dentistry, those involved with the organization will have a networking and referral resource upon which to help build the implant aspect of their practices. Therefore, Misch encourages dental practitioners to participate in industry-wide campaigns to not only benefit the public, but also their practices.

Jack Dillenberg, inaugural dean of Arizona School of Dentistry & Oral Health, notes that there are wonderful resources available throughout the industry, at local dental schools, and through professional societies to help general practitioners do a great job placing implants. Additionally, these resources can also help clinicians by providing influence to prospective patients.

Manage the Implant Business
Further, running the implant side of a practice is very different from managing the rest of the dental practice, Levin notes. Essentially, implants become a business within a business, he says, one that requires different fees and different management systems in order for that segment of the practice to grow.

For example, while it might be tempting for clinicians to handle and schedule implant cases the same as any other, doing so can actually leave practices overwhelmed and having to limit the number of cases they can treat. Levin advises working with a surgical practice to understand what needs to be done and what fees are appropriate, and then build from there.

SIDEBAR 4

Preparing Dental Students for Implant Dentistry
Dentistry and dental education are witnessing a period of rapid change. According to Kevin Mosher from Nobel Biocare, dental schools are now aggressively incorporating implant training into their pre-doctoral programs in preparation to meet the demand for implants that will come in the next 5 and 10 years and beyond.

While many dental schools provide pre-doctoral dental implant education and clinical training for exceptional students, very few had requirements in the clinical aspects of implant dentistry. In this area, educators say, big change is now coming. Much of it, says Jack Dillenberg, inaugural dean of Arizona School of Dentistry & Oral Health, can be credited to a meeting 2 years ago between dental school deans and industry leaders during which academia was educated on the importance and significance of dental implants.

The Pre-doctoral Clinic
Thirty-five years ago, dental implants were taught didactically as something almost experimental. Given the many more problems experienced with the treatment modality back then, dental implants were not integrated into the fabric of dental treatment, nor dental school education. Slowly, however, the didactic aspects expanded and, in recent years, a very rapid scaling up occurred, with students now being required to develop some clinical experience and expertise with dental implant techniques.

“I think the change is driven by a growing realization that the standard of care is changing for certain types of dental problems,” cites Michael Alfano, dean of New York University College of Dentistry. “The two most obvious areas that are relevant here are the full mandibular denture and the single tooth replacement, regardless of where it might be in the mouth.”

The biggest problem most dental schools have, explains Dillenberg, is translating an acknowledgment of the need to teach dental implants into an accommodation in the curriculum. The curriculum is so full that it’s a struggle for most schools to find a place for implant education, he says.

“Because we are a new school, we recognized that implant dentistry is something we wanted to educate our students in, so we went forward with it. Implants are essential experiences in which all of our students are thoroughly exposed,” Dillenberg says. “I think it’s taking a little time with other traditional, established dental schools because they are not set up to respond quickly to curriculum changes.”

The realization regarding implants as a standard of care did help dental schools like NYU in its decision to change the management of patients in its pre-doctoral clinic. “We want all of our patients with mandibular dentures who would otherwise be qualified for implants to certainly be offered the option of an implant supported overdenture as the treatment of choice,” Alfano explains.

During the November 2004 meeting of the Dean’s Council, there was great consensus among the deans in attendance that dental schools move in the direction of making clinical implant training—particularly for single tooth replacement and retaining lower overdentures—part of the fabric of dental education. Clearly, the dental school clinic is an integral part of the process, but the typical patients that present in pre-doctoral education programs tend to be among the poorest, Alfano notes.

“So, it is very important, but also very difficult, for dental schools to deliver implant services at a fee that is affordable by these patients,” Alfano explains. “What NYU and other schools have done—and will continue to do—is partner with dental implant companies to get materials at low and in many cases no cost, as well as assistance with training systems and materials so that students can actually have the instruments they need to practice.”

For example, Arizona School of Dentistry & Oral Health is entering into a relationship with Nobel Biocare to provide continuing education for clinicians at its clinic. There, the school will establish a training area to allow students and clinicians to work on patients in a teaching environment, as well as in a simulation clinic, for true hands-on experiences, Dillenberg says.

Supporting the Curriculum
At NYU today, pre-doctoral dental students are required to study implants, and elements of implant training have been incorporated into all 4 years of the curriculum. The education includes the anatomy of the edentulous ridge and its relationship to the appropriate sighting for implant placement. The pre-clinical experience includes work on models of edentulous ridges so that students also gain exposure to restoring implants.

At Arizona School of Dentistry & Oral Health, second year students begin having some clinical experiences, while third year students are in the clinic and involved in diagnosing and treatment planning implants. According to James Bell, DDS, executive associate dean, students are assisting in the surgical placement of implants now and restoring them as soon as appropriate. It is anticipated that fourth year students will place implants themselves.

“We are very proactive in how our students see our patients regarding implants,” Bell says. “When they go out into private practices—general practices—they will be well-prepared to be involved with implant treatments.”

But providing this type of educational environment is not without its costs. To broaden the scope of the soon-to-be general dentist but current pre-doctoral student first requires faculty that are comfortable both placing and teaching dental implants, explains Dillenberg. First and foremost, however, the school’s leadership must be willing to commit to dental implant education.

“Finding room in the curriculum at dental schools is not an easy task, but it is such an important component of patient care that it needs to be integrated within the curriculum. Period,” Dillenberg says. “That commitment needs to start at the top, with the dean, and with the department chairs. Once the decision is made to augment the curriculum to accommodate dental implants, then you must incorporate it in stages, beginning in the early stages of the first year and following through, so that you have an established continuum.”

Providing this type of education is challenging, admits Alfano. There is a need to train faculty, some of whom grew up in a different era and do not do implants in their private practices. There is also a need for both faculty and students to be comfortable with the philosophy and the specific techniques that are going to be incorporated, he says. Finally, cost is a factor, also.

To help alleviate the latter challenge, a number of partnerships between dental schools and implant companies are developing and deepening. These are allowing the schools to deliver implant services and education at quite a reasonable cost level.

“What’s great about it is that implants are better for the patients, so you have a triple-win situation,” Alfano says. “The school and its students are served, the implant company is served, and most importantly, the patient is served.”

Manufacturer support for implant education at the dental school level has been overwhelmingly supported by industry since the 2004 Dean’s Council meeting, during which members of academia and industry met to discuss the problems associated with aggressively driving implant education into the pre-doctoral curriculum. The Implant Workshop conducted by the deans at this meeting was made possible by $250,000 that was raised primarily from implant companies to provide a grant to the Geis Foundation to help support this landmark effort.

“The Workshop was very successful and very well-received,” notes Alfano. “People are now beginning to follow up, and implant companies have become even more forthcoming in support of curriculum changes and financial assistance.”

The Future is Now

Now and moving forward, dental implant education will fully begin at the dental school level. To rise to the challenge, the number of dental schools in the United States that are adding dental implants to their general curriculum is increasing, according to Millennium Research Group. Such actions, the industry analyst group says, will help ensure that future generations of dental professionals will be capable of performing implant surgery.1

1 Dental implants: taking a bite out of the US market. Medical Industry Intelligence. September 2005; 4-7. Millennium Research Group, Toronto, Canada.

SIDEBAR 5

Enhancing the Placement Process
Among the technologies and techniques to facilitate greater implant success and procedural predictability are bone grafts and site enhancement, as well as CT scans, computerized imaging, and surgical guides. Overall, practitioners comment that today’s implant procedures are guided by more planning than years ago, which helps alleviate many of the trials and tribulations of by-gone days.

“Years ago, we were faced with having to work with what we had, such as insufficient bone,” recalls Kim A. Gowey, a general dentist practicing in Wisconsin and president of the American Academy of Implant Dentistry. “Today, if what we have is inadequate, we can ensure we have a proper base into which to place the implant.”

CT scans—in conjunction with software planning—are now used to generate images of the proposed implant sites to determine if sufficient bone exists, as well as for use in fabricating surgical guides. They are also helpful in treatment planning some of the restorative aspects.

Although previously there were concerns about radiation dose levels from CT scans, Kevin Mosher from Nobel Biocare notes that today’s options enable scans at significantly lower doses. Yet, they still provide clinicians with far more visibility into the surgical site than they ever had before.

Explains David Sklarski from Sterngold Dental, LLC, CT scans enable clinicians to determine prior to implant placement exactly where an incision will be placed, the density of the bone into which they’ll be placing the implant, and the location of the mental foramen. An additional benefit, notes Mosher, is that this technology facilitates a flapless approach because clinicians can now “see” the bone via a CT scan.

Surgical guides, on the other hand, are placed into the mouth and used to direct the drilling for implants based on the information provided by the CT scan. According to experts, this makes the implant placement procedure quite accurate in terms of replicating the plan at the actual surgical site.

“This ensures that you angulate and position the implant properly in the bone, rather than doing it by eye,” Gowey explains.

SIDEBAR 6

2006 Dental Implant Education Opportunities

April

Lab Certification Course with the SPI System
Instructors: Todd Fridrich, CDT, and Terry Charters
Sponsor: Thommen Medical USA, LLC
Date: 4/1/06 4/2/06
Location: San Francisco, CA
For more information: 866-319-9800

Atlas Implants Hands-on Workshop
Instructor: Dr. Keith Rossein
Sponsor: Dentatus
Date: 4/5/06
Location: Washington, DC
For more information: 800-323-3136

Hard and Soft Tissue Regeneration for Ideal Implant Placement
Instructors: Dr. Michael Sonick and Dr. Stephen Wallace
Sponsor: 3i
Date: 4/6/06 4/7/06
Location: 3i’s Institute for Implant & Reconstructive Dentistry 4600 East Park Drive Palm Beach Gardens, FL 33410
For more information: www.3i-online.com or 800-717-4143

MDI 1-Day Seminar
Sponsor: IMTEC
Date: 4/7/06
Location: Vancouver, British Columbia, Canada
For more information: www.imtec.com or 800-879-9799

Basic Implant Surgery Workshop II
Instructors: Drs. L. Lum, C. Mason, and M. Chen
Sponsor: MicroDental Laboratories
Date: 4/7/06 4/8/06
Location: Pleasanton, CA
For more information: www.innovalife.com or 800-718-5157

Atlas Implants Hands-on Workshop
Instructor: Dr. Keith Rossein
Sponsor: Dentatus
Date: 4/7/06
Location: Baltimore, MD
For more information: 800-323-3136

Superior Osseointegration with Primary Stability

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