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Building an Implant Practice
Practical advice to create a foundation for long-term clinical success
It’s been nearly 60 years since Swedish orthopedic surgeon Per-Ingvar Brånemark coined the term “osseointegration” to describe his surprise discovery that bone grew around titanium implanted into the leg bones of rabbits, thus initiating the chain of events leading to his creation of dental implants in 1965.
Until relatively recently, dental implant placement was restricted mainly to specialists. But technological advances such as cone-beam computed tomography (CBCT) and surgical guides, innovative implant designs, and a growing body of knowledge are allowing more and more forward-thinking general practitioners to gain the expertise and confidence to replace their patients’ missing teeth with implants.
What does it really take to build a successful implant practice? Education is at the heart of the matter, but not just for clinicians—making sure that patients are well informed and dental teams can provide needed support is also critical to success.
When it comes to replacing a hopeless or missing tooth—or teeth—patients and their dentists have options other than implants. But implants—including implant-supported dentures—are the treatment of choice, when appropriate, mainly because they are widely believed to be the closest thing to natural teeth in terms of how they function.
According to Sanda Moldovan, DDS, MS, CNS, a periodontist in Beverly Hills, California, unless dentures are implant-supported, they replace only about 10% of tooth function, which affects patients’ chewing ability and nutritional status. Moldovan, who holds a master’s degree in nutrition as well as a dental degree, explains this can significantly impact patients’ overall health. Because oral health and function “affect the whole body,” and implants are the treatment most like regular teeth, she believes they are hands down the best currently available option and recommends them when appropriate.
Understanding a Patient’s Problem
Implants are not for everyone, however, for a variety of reasons, including finances, health conditions, and even lifestyle choices such as smoking or an overly casual approach to oral hygiene. Nor should they be placed by all dentists—including specialists such as periodontists, prosthodontists, and oral surgeons—unless they have the required training and experience.
And even when placed by the most experienced dentists in appropriate candidates, implants are not immune to complications, or even failure, particularly when not maintained properly. Therefore, prospective implant patients should be vetted for realistic expectations and a commitment to hygiene, including regular recall appointments, as well as their suitability based on both oral and overall health conditions.
While the doctors interviewed differed in their attitudes about and approaches to implant treatment, they all agree on one thing: The dentist should focus first on the presenting problem.
Neal S. Patel, DDS, a private practitioner in Powell, Ohio, explains, “Potential implant patients should be treated exactly like all others. Always start first with their request and their goals.”
Frisco, Texas, private practitioner G. Scott Sauer, DDS, puts it this way: “People aren’t coming to me specifically because they want an implant. They come to me because they want me to help solve a problem—usually related to appearance or chewing ability—caused by a missing tooth.” Understanding their main concern, he says, not only helps him hone in on the appropriate treatment, it helps him present his ultimate recommendation as a solution to the problem presented.
He says an implant may be just one option offered in terms of good, better, and best approaches to solving their problem. “In my office, when it comes to replacing missing teeth, implants are nearly always the first line,” he says. “We’re not likely to include a removable partial because that’s not going to solve their problem.”
Issues to Consider
Whether or not implants are in fact the solution to a given patient’s problem comes down to a thorough evaluation of the patient’s oral health and a medical history that probes for keys to patients’ overall health status and presence of issues that could complicate or even contraindicate implant treatment.
Like Sauer, private practitioner Isaac Tawil, DDS, of Brooklyn, New York, says he likes to get a sense of the patient before discussing treatment. “I never like to give a patient a treatment plan the day they come in. I like to sit back and do an evaluation first. I want to come up with more than one treatment option, and let them know we want to work with them, that we want to be their dentist and take care of their needs.”
Implants are not indicated for some patients, including those who are immune-suppressed or have active cancer or certain heart conditions—particularly those affecting the valves. Others at higher risk for complications due to illness, bisphosphonate use, or smoking may be considered on a case-by-case basis.
As a nutritionist, Moldovan is perhaps more attuned than most to what she calls “silent chronic inflammatory conditions”—including pre-diabetes. “As dentists we have to evaluate the wellness of a patient, not just the illness. Just because someone hasn’t been diagnosed with disease doesn’t mean he/she is healthy,” she says. “As practitioners, we have to look for signs—eg, dark, puffy circles under eyes—indicating chronic generalized inflammation, which could potentially affect the healing of the dental implant.”
Because of the quality of life benefits implants offer, clinicians may choose to make judgment calls when it comes to case selection. Tawil says he is willing to provide implant treatment to patients others might turn away due to health issues. “As I see it, it’s not for me to say whether it is or isn’t ‘worth it’ to place implants in patients with life-threatening illnesses. We’ll do whatever is within our capabilities as long as we have medical consent.” He says he has placed implants specifically to improve quality of life, including one patient with terminal cancer whose treatment included immediate implant placement and stabilizing an existing denture.
Sauer notes that uncontrolled periodontal disease must be brought under control prior to treatment, but it is also important for practitioners to address occlusive disease such as clenching and grinding.
“I’ve seen heavy bruxers shear off screws due to heavy grinding,” says New York City practitioner Sonny Torres Oliva, DDS. He adds, “Understanding these factors is important in determining whether a patient is a candidate for implant treatment.” As Oliva further explains, occlusion is a major consideration in implant loading. “If you place the implant where there is more stress, it will need more support—for example, three implants splinted together would likely last longer than two with a cantilever.”
Patients may set themselves up for disappointment, says Patel, if their expectations are unrealistic. “An implant is not a ‘bionic tooth’ that is immune to the factors that may have set the stage for the demise of the tooth it replaced. They need to understand that an implant is a replacement for something they no longer have, a tooth that failed due to decay, fracture, whatever.”
He says he considers it the obligation of clinicians to counter misinformation—much of it oversimplified on the Internet—with reality therapy that includes odds of success and patients’ need to take responsibility for maintenance. “Even patients who think they want implants may think again when they learn about what it entails,” Patel says.
Oral Hygiene–Related Risks
It is precisely because success of the procedure may hinge on excellent home care and adherence to the recommended recall schedule that Moldovan and Oliva are reluctant to offer implant treatment to those at higher risk of failure.