Moldovan stresses the importance of good oral hygiene for implant success and recommends that patients use a water flosser to clean around implants. She says good oral hygiene is so important to success that she recommends against placing implants in patients with poor home care because “anything we do will fail with poor hygiene.”
Oliva takes a hard line with smokers in particular, who have a 50% higher risk of implant failure than nonsmokers. He requires them to sign a “smoking cessation waiver” and refuses to initiate treatment until they quit. This, he says, not only delights their spouses, but may put them on a new, healthier path. “It can be a life changer in that it reminds patients they have been given a second chance,” he says.
An unfortunate reality of implant treatment is their expense relative to other treatments. Tawil recognizes that smokers and patients with chronic conditions such as diabetes are at a somewhat higher risk for complications, but says frankly that the greatest obstacle to proceeding with treatment—at least, in his own practice—is financial, not medical. Finances are so significant a restriction for many—especially for complex cases involving numerous implants and and site preparation—it could be considered a de facto contraindictation. But some of these concerns can be addressed by giving patients more information and options, which is why excellent case presentation is a critically important part of an implant practice.
Getting Patient Buy-in
Even patients who are excellent candidates may be reluctant to accept their dentist’s recommended implant treatment plan. They may be concerned about the expense, that the implants won’t look like real teeth, or that the process might involve prolonged “toothlessness.” But most of all, they ask about pain.
Sauer, who placed his first implant in his own mother, says pain has not been a significant issue for his patients. “The thing that amazes me is how comfortable patients are after having an implant. I can count on one hand the number of times patients reported the need to take more than ibuprofen after implant placement. Even when implant placement occurs immediately after tooth removal, patients tend to have significantly less pain than if only extraction is performed.”
Dentists can counter patients’ fear of the unknown by comparing it to a procedure they’ve already experienced, such as an extraction or root canal.
Tawil says patients need to know that for involved procedures that could cause moderate pain, there is effective pain control. “We are able to offer sedation, which many choose, and it means we can use their IV to load them up with different steroids and antibiotics to minimize pain and prevent infection.”
Oliva also mentions recent advances that make implant placement easier for dentists and easier on their patients. “Patients who have heard horror stories about implants should know a lot has changed in recent years,” he explains. “It’s much less aggressive and more routine, recovery is shorter, and the procedure is now better, simpler, especially using advanced technology such as CT scans and implant-planning software.”
Moldovan says she often explains the consequences of not getting implants—eg, how it will affect their bone structure long term, as well as their temporomandibular joint issues, chewing, and nutrition status. She also mentions a benefit that may resonate with the esthetically motivated: “The addition of dental implants changes the jaw structure as well as the bite and muscles of the face.” As a result, there is a significant esthetic bonus. “They’ll get an almost immediate nonsurgical facelift when the muscles on both sides start getting used again,” she says.
When the concern is pain in the wallet, John C. Minichetti, DMD, of Englewood, New Jersey, says, “It can help to make treatment affordable by offering financing or payment options, so patients can get the best treatment option that is appropriate for them.”
Tawil agrees that the ability to provide financing or connect patients with such resources can make all the difference in their receptiveness to pricey treatments. “These financial institutions can make it work like a car payment, which helps tremendously. They can pay $700 to $800 a month for their mouth for a $40,000 treatment.”
He points out, too, that dental insurance, which was once available only through group coverage, such as that offered through employers, is now available to everyone as a result of the Affordable Care Act (ACA). Further, more insurance plans, including those through ACA, offer some benefit for implants. “The plan we recommend with Spirit Dental & Vision (www.spiritdental.com) covers dental treatment right off the bat—there’s no waiting period,” Tawil says.
The Role of the Office Dental Team
Minichetti says he is not always the one privy to patients’ questions, even when he explains the treatment to them face to face. Instead they may turn to staff members, who have a different skill set, with questions such as, “Does it hurt? Does it work? What’s it like during the treatment period?”
“You have to educate patients about what to expect. They need to understand that it won’t look perfect during the process; basically, they need to understand exactly what they’re getting from the start,” Minichetti explains. He says his staff is accustomed to answering such questions and addressing their concerns. “It is important to get staff on board with educating patients properly. They can tell them about the post-op recovery, what to expect, financing, etc.”
Oliva, too, recognizes that he can’t be all things to all patients and that some patients relate better to his staff than to him. “I think more than anything, sending a message that is consistent is essential. I find that my treatment coordinator actually may be able to relate better to the patient than I can; sometimes patients feel more comfortable talking to them about certain procedures.”
For this reason, he says, it’s important to have a team that is fully coordinated and completely understands the recommended treatment to be able to explain them in detail factually, following guidelines.
“My staff is trained to understand procedures, so if they are asked certain questions, they know answers,” he says. “For example, the hygienist can explain and reinforce regular maintenance for implants, and assistants can help explain procedures and answer questions on a more personal level, using less scientific terms.”
The son of a dental laboratory owner in the Philippines, where he himself was a CDT and prosthodontist before becoming a dentist, Oliva is well versed in the restorative aspects of dentistry, including implants. Both he and Sauer describe the “backwards” approach they both take to treatment planning. This means starting at the end, determining first how the final restoration—whatever it turns out to be—should look. This, says Oliva, includes gingival and soft-tissue architecture, the overall restoration design, and the shape and color of the teeth.
Sauer says starting with the end in mind provides a roadmap for the steps he needs to take to achieve the desired result. “I not only think about what the restorations should look like, but also what I need to do to ensure that the final result will look like a tooth,” he explains. Often what he prefers to do is refer patients to his periodontist or oral surgeon to handle hard or soft tissue augmentation prior to implant placement by him. “I have them do the ridge augmentation, lateral sinus lift, or gingival graft or connective tissue graft so that the site is prepared and ideal, so that when I place the implant, I’m placing it in an ideal site.”
The Team Approach
All interviewed stressed the importance of knowing when to refer a case to a specialist or colleague with more experience, technology, or services, such as general anesthesia. The threshold for seeking help will be different for everyone, but the time to initiate a relationship with a specialist is not when a case is going south.
Moldovan suggests GPs forge a good relationship with a specialist who places implants in the event of a problem or question, and that they refer—rather than retreat—a failed case. Patel says having specialist colleagues to turn to for advice and collaboration is especially important for doctors who are relatively new to implantology.