April 2012, Volume 8, Issue 4
Published by AEGIS Communications
A Blueprint for Success
In the last five years, implant dentistry has made great in-roads into mainstream dentistry, with more states, insurance providers, dental educators, and practicing clinicians considering what used to be a last-resort treatment option to be the new standard of care.
Implant dentistry has, slowly but surely, become mainstream dentistry, despite ebbs and flows largely attributed to the economy. The number of dentists overall who are placing and/or restoring implants has rapidly risen in the last five years. In most states, a dentist is required to offer patients the option of a dental implant when applicable. Additionally, a growing number of dental insurance providers now have policies indicating dental implants as the standard of care, and patient awareness of implant therapy continues to grow.
“What’s interesting is just how different implant adoption or penetration is depending on where you are in the world. In the United States, it’s approximately 40 implants per 10,000 people, whereas in southern Europe it’s about 10 times that level of penetration,” explains Maggie Anderson, president of Biomet 3i. “The penetration is concurrent with how standard it is becoming as a mode of selection or, as when general dentists consult with their patients, how often they bring up implants as an option relative to crown-and-bridge.”
There are countries in the world—such as Israel, Italy, and Germany—that adopted implantology earlier and have risen to a utilization rate measured many folds, sometimes magnitudes, higher than the United States, explains Harold C. Flynn, Jr., president of Zimmer Dental. He adds that estimates are that there are almost as many implants placed in Brazil as there are in the United States.
James L. Bush, DDS, president of the American Academy of Implant Dentistry (AAID), the only implant organization with a court-recognized examination and credentialing process in implant dentistry, has witnessed the growth, noting a nearly 10% increase in AAID members in each of the last five years.
“We also see a growing number of registrations in our maxi-courses offered by the AAID,” Bush adds. “A growing number of practitioners are obtaining the proper training in implant dentistry and adding this as a service they routinely recommend to their patients.”
Hans-Peter Weber, DMD, professor and chair of the Department of Prosthodontics and Operative Dentistry at Tufts University School of Dental Medicine, estimates that soon general dentists will be placing the majority of implants.. More than 50% of general dentists have been involved in restoring implants in the last year. He also notes that the number of implants placed or dentists placing implants from 2008 until now stagnated somewhat due to economic influences.
“The industry has experienced a dramatic decrease in growth over the past three years, and the number of general practitioners treatment planning for implants has decreased at a similar rate,” explains Louis F. Rose, DDS, MD, clinical professor at the University of Pennsylvania School of Dental Medicine and professor of surgery in the Division of Dental Medicine at Drexel University College of Medicine. “General practitioners prefer to do what they do best, and that’s traditional crowns and bridges. Although they may be doing a number of single implants or maybe two or three implants, previously they were doing bigger cases.”
According to Lyndon F. Cooper, DDS, PhD, graduate program director and Stallings Distinguished Professor of Dentistry in the Department of Prosthodontics at the University of North Carolina School of Dentistry, a majority of adults between the ages of 35 and 44 years old have lost at least one tooth, and an implant can be an ideal replacement for that missing tooth. Considering that specialists receive in-depth education regarding implant surgery and restoration, the opportunities for managing simple and complex scenarios is high, he says.
In 2012 alone, approximately 100 million Americans will be missing one or more teeth, and 36 million of them will be edentulous in one or both arches, Rose observes. As a result, there is a great need for these individuals to have implants, and the challenge becomes how to capture those patients.
Contributing to the consideration of implants as the standard of care is maintaining bone, not destroying the teeth adjacent to a particular opening, and better long-term outcomes and prognosis. “Ultimately, it’s the best reasonable care available, but the most prevalent treatment for missing teeth remains traditional crowns and bridges that are tooth-supported,” Flynn notes.
Although the rise of modern implantology began in the 1990s, wider acceptance through the awareness phase of general practitioners in the United States occurred in the late 1990s and into the early 2000s. By way of indications related to single-tooth replacement and denture fixation, awareness continues to grow through the 2000s, explains Flynn.
Today, tapered, moderately rough-surfaced dental implants that promote bone-to-implant contact are the most prevalent in the marketplace, comments Thomas Olsen, president and general manager of Nobel Biocare, Americas.
The material that has been overwhelmingly used is titanium, either an alloy for strength or commercially pure, based on its biocompatibility, says Flynn. The paradigm tends to be a two-stage surgery with a threaded implant and an internal connection, with different features to manage the microgap and micromotion of abutments, he adds.
“The field has continued to evolve, but the common denominator is osseointegration,” Weber emphasizes. “The bone-anchored prosthesis has been established with implants composed of titanium, which is still the primary choice for implants; those that were threaded; and the press-fit implants without threads.”
In a referral-based market like the United States, it’s a challenge to move a patient through the process. It could take six visits and seven months in which a patient starts with a general dentist, visits the specialist, returns to the general dentist, and back and forth, observes Anderson. Unless the specialist and general dentist are well coordinated, it can be confusing for patients and the participants, which include the laboratory fabricating the final restoration.
Additionally, one consideration that may lead a referring general practitioner to switch to a traditional therapy rather than an implant treatment—and why implant therapy growth may have halted recently—is the fairly long time period between initiating work, referring the patient to the surgeon, and then restoring the implant. Flynn elaborates that the cash crunch might influence a practitioner’s decision about whether to keep the patient in practice with a 3-unit bridge and payment in three weeks, or recommend implant therapy.
“The biggest obstacle is probably not being involved in a team approach where the implant placement is guided by the periodontist or surgeon,” asserts Robert A. Levine, DDS, clinical professor in Post-Graduate Periodontology and Implantology at the Kornberg School of Dentistry at Temple University. “Dentists must have the comfort level to be walked through the procedures of restoring implants and collaborating to determine if a case is suitable for implants or not.”
Speculatively, one factor that may impede the selection of implants for tooth replacement is the educational level of the general dentist. With growing education and familiarity, professional recommendations for implant therapy may increase, Cooper suggests.
“An obstacle that’s seldom discussed is the level of comfort that a general practitioner has in recommending and selling implant treatment, something that’s two to three times more expensive than traditional therapies,” Flynn observes. “Practitioners typically did not enter dentistry to try to convince a patient to spend more money.”
To be good at something, dentists must be able to do a lot of it and improve over time. Weber asserts that the number of times and repetition helps, but when the procedure is specific to implant dentistry, not many general dentists will have acquired enough of that experience from their dental education.
“That’s the predicament for many practitioners,” Weber elaborates, noting that those dentists who graduated several years ago didn’t learn about implants at the undergraduate level. “If they have to learn implant dentistry after hours, it’s difficult to just attend courses. They do not provide experience by repetition.”
Rose clarifies that dental schools are increasingly becoming involved in implant placement by adding implant treatment to pre-doctoral programs so that dentists of the future really understand early in their experience the need for the modality. Additionally, dental school implant programs focus on diagnosis, treatment planning, surgery, and the restorative component.
“The biggest obstacle going forward will be the need for recognized credentials that ensure a certain level of knowledge and capability to the public,” Bush predicts. “The AAID is the only implant organization with a court-recognized examination and credentialing process in implant dentistry. We support a credentialing board that credentials both general dentists and specialists to ensure they have the proper training and experience in implant dentistry. This fellowship and diplomat credential ensures a proficient level of expertise and knowledge to the public.”
Today, in the academic faculty practice environment, Cooper observes that one of the greatest emerging challenges is the referral for correction of improperly placed implants or poorly managed alveolar tissues by inexperienced, but well intended, clinicians. He says that complex ethical issues make decisions regarding implants versus alternative prosthetic management anything but simple.
“Should the patient experience 12 months of grafting and surgery to achieve implant placement, or would they be better served by conventional prosthodontics?” Cooper asks. “Should the clinician provide a fixed partial denture (FPD) in order to possess all related revenues, or should the revenues be distributed between a referring surgeon and the restorative dentist? What are the relative risks and benefits of the implant versus the FPD and, again, is the clinician knowledgeable enough to properly inform the patient? These are real obstacles.”
Patient acceptance is increasing with their rising awareness of implants and the success of implant therapy, Cooper observes. “Patient acceptance is affected by so many factors, but it has been reported that fear of surgery actually kept one third of patients from accepting free therapy in a recent clinical study,” he says.
The time frame of therapy also has been reduced over the past decade, even for conventional therapies involving either two-stage or one-stage implant placement. Healing periods of between six and eight weeks have replaced the three- to six-month healing periods introduced in the mid-to-late 1980s, and immediate placement and provisionalization strategies remove months of waiting for the final restoration, Cooper adds.
Among those factors is the length of time patients must wait to return to normal function. Olsen says that implant surfaces that provide enhanced osseointegration have gained popularity. However, it is critical to consider macro-implant geometry, as it allows for innovative surgical flexibility through the primary stability achievable with innovative implant systems. This is important, because it allows clinicians to offer immediate loading and an expanded number of treatment modalities to the patient on the day of surgery while still having confidence in the long-term success of the treatment. However, immediate function is an option, not a must.
“The rapid healing from the osseoconductive surface has encouraged clinicians to offer same-day implant placement and temporization to patients who have no contraindications to this option,” Olsen adds. “This in turn has had a direct effect on case acceptance. If patients know they can have implants and a prosthesis placed the same day, it is much more appealing than a long, drawn-out process that traditionally could take six months or more.”
Another factor contributing to implant success is flapless surgery, Anderson notes. Previously, an implant procedure required cutting the gum, laying a flap, placing the implant, and then suturing it. Guided surgery enables clinicians to punch through the tissue, resulting in far less trauma and pain for patients.
More educational opportunities also have helped dental implants make in-roads into mainstream dentistry. According to Anderson, awareness is growing significantly in the United States, and that comes from universities, significant improvements, and increases in education from dental implant companies.
Organizations such as the Seattle Study Club, for instance, provide opportunities for a specialist and their referrals to meet on a regular basis to build rapport and learn cutting-edge techniques for providing optimal care to their patients, Olsen says.
“We’re finding that what’s driving the increase in general dentists adopting and restoring implants is the ease of use,” Anderson observes. “The traditional implant restoration would require general dentists to remove a healing abutment, place an impression coping, take an impression, and then replace the healing abutment. Oftentimes that required working below the gum line, which caused concern for some general dentists.”
Impression systems that enable general dentists to take an impression of a healing abutment in a simpler and less time-consuming manner (eg, BellaTek Encode Impression System) also drive ease of use, Anderson notes. The use of intraoral scanners, instead of traditional impression materials, enables dentists to capture the impression and transfer the files digitally.
“Technologies that make it easier for clinicians to engage in the practice of restoring dental implants helps to increase their adoption,” Anderson adds.
Low-cost suppliers have emerged, Rose has observed. Eventually those lower-cost suppliers will yield to bigger companies, with benefits and growth in implant dentistry further fueled by increased consumer awareness campaigns.
“The growth seen in recent years should return, making a weaker economy irrelevant,” Rose suggests.
Each patient and case is unique, which is why custom abutments are valuable to the restorative dentist, explains Olsen. The best outcomes in restorative dentistry can be achieved when individualized products are used to treat a patient, he adds.
In the 1980s, the introduction of customized abutments enabled clinicians to create the correct implant emergence profile to support the tissue and maintain the esthetic architecture.
“A patient’s anatomy is unique to the individual, and in cases that require a custom design, such as a missing anterior tooth, we have found that custom abutments will lead to the best outcome for the patient,” Olsen elaborates.
Access to custom-milled abutments may assist clinicians in restoring a dental implant, with advantages best reflected in the ability to view the proposed abutment using a 3D viewer to accept or reject the proposed model, Cooper explains. Another advantage is that an abutment may be made from different materials to suit the particular need presented by individual scenarios.
“The integrity of the custom-milled abutment solution may vary with the manufacturer, and the clinician must be aware of this through their interaction with the providing dental laboratory,” Cooper continues. “What a custom-milled abutment cannot do, however, is substitute for good treatment planning, excellent implant placement, and proper tissue management. Failure in these earlier steps toward implant excellence cannot be overcome by abutment manufacturing technology. It is a mistake to think that the custom-milled solution solves all problems.”
Flynn notes that custom-milled abutments can enable a general practitioner or restorative dentist to view the implant as if it were a prepared tooth. In some cases it provides an opportunity to change the business model in which a surgeon will place the implant, the custom abutment resembles a prepared tooth, and restoring dentists “do what they do every day, and place crowns more efficiently and effectively.”
“Custom-milled abutments are basically more of a service offered to laboratories, which for years have customized stock abutments,” Flynn elaborates. “In many ways, custom-milled abutments are patient-specific abutments, allowing dentists to treatment plan exactly what they would like for the esthetic and functional outcomes.”
Because the process becomes restoratively driven, the general practitioner can be more exacting about what they want, rather than having to select from several stock selections and then modify the abutments. Flynn adds that this also can translate to monetary savings for the practice, because they can reduce the amount of gold or precious metals needed when using a patient-specific abutment.
“Custom abutments allow individualized treatment and can improve the esthetic contours of a crown because the restorative platform is customized,” Weber says. “Today’s ceramic abutments allow for color and translucency in the transmucosal area.”
However, Weber emphasizes that dentists should not rely on custom abutments to offset problems created by poor implant placement. Although custom abutments can help correct the angle of malaligned implants, that should not be their primary purpose, he says. “We still should plan well ahead and optimally place the implant in a restorative way so that the custom abutment is a choice, not a necessity,” Weber adds.
According to Bush, the availability of custom-milled implants is a nice addition to a practitioner’s repertoire, but the focus should be on treatment planning and not as much on technology.
“We have come a long way with adopting technology, but there still needs to be some improvement,” Bush elaborates. “Nevertheless, the skill and acumen of a practitioner come first, and technology is a good adjunct to one’s armamentarium.”
Anderson notes that there are many advantages to the evolution of technology to help the general dentist and his or her colleagues make the procedure easier. For example, software is available that allows the general dentist, specialist, and laboratories to work digitally in a cloud where they start with a Panorex, decide they need a CT or intraoral scan, and have a conference call to talk about and then document their case plan, she elaborates.
Dental implant treatment is largely a discretionary purchase, and when the economy is not doing very well, patients are slower to select a treatment modality that’s not reimbursed,” Anderson explains. “In that environment, it’s even more important than ever for clinicians to be well educated about discussing the benefits of an implant over their lifetime versus crown-and-bridge and the short-term cost.”
Financial realities represent a major factor that affects acceptance of dental implants beyond psychological and biological reasons. One report suggests that spending on dental care has grown from $31.5 billion in 1990 to a projected $108.9 billion in 2010, Cooper elaborates. The numbers of patients with some form of dental insurance is growing incrementally, but coverage for dental implants is not commonplace.
In addition, there is fear of the procedure, and individuals may be concerned about implant longevity, Cooper shares. Fortunately there is good news on this front, and current concerns regarding peri-implantitis are reminders that even implants are not immune to plaque-mediated diseases.
“For many of our patients, their implants represent a second chance dentally. It becomes our challenge to educate them that poor choices and lack of re-care can result in losing this second chance,” Bush says. “Implant treatment often involves multiple steps and the need for a provisional temporary prosthesis. Careful follow-up to check not only wound healing but also pressure from the temporary prosthesis, excessive load, occlusal design, and adequate hygiene will greatly increase the likelihood of a smooth postoperative phase. At the conclusion of treatment, the focus should be on raising awareness about maintaining these implants and long-term re-care.”
Good patient education about what they can and can’t do, as well as what they shouldn’t eat, also help to ensure that early healing phases aren’t causing micro-motion, which could jeopardize the successful integration, Anderson says.
“Of paramount importance to compliance is expectation management and ensuring that patients are well aware of the stages, timing, and potential complications that might arise with implant therapy as opposed to the treatment alternatives,” says Flynn.
Currently, tooth replacement using an implant, an abutment, and a crown may be similar to the costs of a fixed dental prosthesis. Selection of the appropriate mode of therapy becomes an individual decision based on the local, biologic, and patient-based factors, Cooper says. Often these different factors favor the dental implant that is not covered or is incompletely covered by dental insurance. The emergence of insurance coverage for dental implant placement and restoration may change the acceptance level of patients, he says.
“The baby boomer generation is very in tune with their appearance, and much of our market research has shown they are also willing to pay for the proper treatment,” Olsen shares, adding that the obstacle to increased dental implant placement is not a lack of awareness from the public.
“The big hurdle is the need for additional education about treatment planning for many general practitioners. Nobel Biocare believes in a team approach to implant treatment between the specialist, the restorative doctor, and the laboratory,” Olsen says. “Our company has created a comprehensive program designed by clinicians that provides in-depth lectures, hands-on training, and treatment-planning experience for dentists who are interested in becoming proficient in restoring dental implants. We believe that improving the education and training available for general practitioners about dental implant restorations will lead to improved case acceptance of implant procedures in general.”
Rose notes that while many patients hear of implants, they don’t necessarily know anything about them. They are not truly educated. Additionally, cost is a factor, and even wealthy patients are waiting to see what will happen with the economy, he says.
“The trends that are now affecting implant dentistry include patient-friendly procedures and direct-to-consumer advertising that, along with information transparency, is becoming the norm,” Rose observes. “Patients want fast procedures that are minimally invasive, long-lasting, and esthetic—the latter being the priority among the more than 87 million baby boomers who turned 60 just six years ago.”
Among those patients who are educated, Levine is seeing an increase in the number of patients asking for implants because they’re sensible options, rather than destroying two teeth on either side of a space and creating a three-tooth problem. Patients choose a single implant to replace the missing tooth, and that trend is definitely on the rise and likely to continue, despite the economy, he says.
Unfortunately, although the faster procedures may be more patient-friendly, they may not be the most appropriate alternative, Rose cautions. The end result could create more complications or failures by bypassing or violating biologic principles. If the treatment progresses too quickly and time isn’t given for the bone to mature, the placed implants are doomed to failure, he says.
“There are certainly patients who should not receive implants due to systemic conditions, diabetes, or smoking,” Weber emphasizes. “There are relatively few of those cases, however.”
Preparing to Place
Obtaining education is both a pragmatic and an ethical issue, says Cooper. Clinicians today must ask themselves how and where they may receive sufficient training in order to offer patients safe and effective dental implant surgical and restorative therapy. Whereas general dentists who graduated from dental schools five to 10 years ago may not have had any formal didactic or clinical training in dental implant therapy, today’s undergraduate dental curricula—to varying degrees—provide such implant education.
“A basic education likely involves much more than a weekend course,” says Cooper. “Patient-based education is difficult to obtain for a busy clinician unwilling to enroll in a formal clinical education program. And after being educated, each clinician must determine what level of experience they have acquired and how that experience matches the clinical challenges ahead.”
When confronted with a potentially complex implant case, Weber says the SAC assessment tool (simple/straightforward, advanced, and complex) can help dentists analyze the given conditions of a patient and determine if they can proceed themselves, or if referring to and working with a specialist colleague may offer a more predictable outcome to the patient.
“Education is certainly the biggest factor in feeling comfortable about implant placement,” Weber says. “I don’t think they need a very specific practice set-up, but they do need an assistant who knows how to handle surgery and who can prepare everything for the surgery.”
Levine advocates study clubs as a means to share ideas regarding the teamwork involved—from diagnosis and treatment planning, the use of surgical guides and templates, and correctly positioning and sequencing implant placement. They enable general practitioners to become in tune with the importance of these aspects of implant therapy.
“However, I’m concerned about the trend I see of more and more restorative dentists jumping on the implant bandwagon without proper education,” Levine admits. “Some may think they can take a weekend course or be involved in a study club and acquire the necessary knowledge to surgically place implants. However, what is needed is to have comprehensive and extensive surgical and prosthetic training to do advanced and complex cases. Part of this ethical problem is being driven by some implant companies that are looking more at their bottom line than the patient’s best interest.”
Because there is growing concern about the long-term health of dental implants, three different time-dependent factors must be under continuous surveillance. First is the problem with cement retention and inflammation around abutments, implants, and their crowns. The inability to remove excess cement from abutments can lead to loss of crestal bone and eventually implant failure. Therefore, every cement-retained crown on an implant should be carefully inspected with the highest suspicion for retained excess cement and, when found, the cement should be carefully removed, Cooper cautions.
Second, peri-implantitis may occur, and the time-dependent process of peri-mucositis progressing to peri-implantitis can be recognized by bleeding of peri-implant tissues and progression to infection with bone loss. Third, excessive forces affect dental implant components, and any clinical feature that increases bending moments (lateral loading) should be addressed, Cooper elaborates. The wear of teeth on large implant prostheses or opposing implant prostheses can, over time, alter overjet and overbite to amplify these loads. Timely replacement of worn prosthetic teeth may prevent catastrophic loading and component failure.
“Managing implant patients requires continuous evaluation of their oral hygiene results, peri-implant tissue health, and prosthesis stability,” Cooper says “Patients must be consistently recalled, and implant inspection must be performed using a periodontal probe and appropriate radiography. Screw-retained prostheses may offer a select advantage of intermittent removal or inspection and professional prophylaxis.”
Anderson notes that whether it’s an implant procedure or any other kind of procedure, hygiene is a critical factor, and its importance to successful outcomes can’t be underestimated. She adds that the most successful clinicians she’s seen make an annual hygiene visit a part of their work guarantee, which tells the patient just how important it is for them to come back, be checked, and keep up with their hygiene.
Additionally, well-informed patients must sign a consent form prior to proceeding with implant therapy, Weber emphasizes. It is important for patients to understand from the beginning what their options are and the costs, along with risks and benefits, and what they can expect postoperatively.
There are pragmatic and ethical obstacles that interfere with placing dental implants within any practice. Pragmatic issues include investing in appropriate equipment and providing a state-of-the-art, accepted surgical environment for implant placement,” Cooper says. “Another pragmatic issue is training a general practice staff to manage the medicolegal issues, components and complications of implant-related procedures. This staff must also be prepared to manage patients whose therapy extends over six to 12 months. These matters require investment in training and organization.”
Weber explains that standard of care is not necessarily that dentists must perform a certain procedure, but that they suggest or propose a procedure as an alternative in the catalog of options, along with sufficient information for the patient to make an informed decision. Implants are obviously safe enough and have been shown to be a good, safe alternative in specific cases, he adds.
“In my opinion, dental implant treatment is the standard of care with the right patients. Not everyone is a surgical candidate, and dentists must address risk factors—including a patient’s health, smoking, compliance, and overall oral health,” Levine emphasizes. “Patients may require orthodontics prior to placing an implant, and there’s a whole treatment-planning sequence that must be determined before implant placement. As with every case, correct diagnosis is essential.”
That said, there’s still a long way to go regarding to implant dentistry, Olsen emphasizes. Proper education and effective communication between the specialist and the restorative dentist is key to increased case acceptance and success of dental implant procedures, he says.
“Education is the most important thing both for clinicians to gain confidence and for patients to receive a great outcome,” Anderson emphasizes. “When clinicians are well educated about how to perform the procedure and have treated multiple cases, they’re better at it and there’s a better ultimate result.”