Implant Dentistry - Demands, Benefits & Risks

Implant Dentistry - Demands, Benefits & Risks
ProNational Insurance Company
By David W. Swan, DDS
The goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics, speech and health. With recent advances in implant dentistry, the profession is better equipped than ever to help patients achieve this goal. As such, implants should be offered to patients as an option when indicated.
More than 65% of general dentists have used implants for supporting fixed and removable prostheses.1 The increased need and use of implant-related treatments result from the combined effect of a number of factors including:2
aging population;
tooth loss related to age;
anatomic consequences of edentulism;
poor performance of removable prostheses;
psychological aspects of tooth loss;
predictable long-term results of implant-supported prostheses; and
advantages of implant-supported prostheses.
Key Benefits
A primary reason to consider implants to replace missing teeth is the maintenance of alveolar bone. There is a 25% decrease in width of bone during the first year after tooth loss and an overall 4mm decrease in height during this first year following extractions for an immediate denture.3 With implants, the teeth may be positioned to enhance esthetics and phonetics. The facial profile may also be enchanced for the long term with implants. Implant-supported prostheses significantly improve a patientÇƒÙs occlusal awareness and proprioception. This allows the patient to function in a more consistent range of occlusion and allows the restoring dentist to control the direction of occlusal loads by design rather than by chance.
Potential Risks
Surgical placement subjects the patient to the risk of bleeding, infection, swelling, paresthesia and bruising. Pre-operative medical screening is required to evaluate potential risk factors for implant failure.
Once implants have successfully integrated and are ready to load (restore), they may still fail due to a variety of factors. Clinical failure necessitating removal of the implant is defined by any pain, vertical mobility, uncontrolled progressive bone loss, or generalized peri-implant radiolucency. The restoring dentist needs to be well versed in controlling these factors through appropriate occlusal schemes, control of parafunction, and the use of progressive bone loading protocols related to bone density.
Bone loss is one of the more problematic complications associated with implant dentistry. The most common cause of bone loss during the first few years of function is related to factors of stress.4 Radiographic evaluation of crestal bone levels should be done at three, six and twelve months after loading, and annually thereafter. Poor oral hygiene resulting in Çƒ?peri-implantitisÇƒ? and infection is another cause of implant failure; patients must be willing to perform and capable of excellent home care. When treatment planning, it is important to start with the desired final prosthesis design and then construct the appropriate foundation (i.e., number and location of implants.) Of course, all decisions must take into account bone volume and quality.
Planning Treatment
Three of the biggest concerns of dentists when treating their patients are simplicity, predictability and longevity. The most knowledgeable member of the team should plan the caseÇƒÓideally, but not necessarily, the restoring dentist. Knowledge and skills will improve with experience.
An ideal way to get started is to learn a technique for a simple mandibular bar overdenture (this requires minimal tools and some basic attachment knowledge), and single tooth replacements in the non-esthetic zone (cemented prostheses utilizing conventional crown and bridge techniques.)
Coverage Implications
Liability insurance carriers have differing requirements of dentists who perform implant procedures. ProNational requires general dentists who perform restorations on implants to obtain an initial 30 hours of continuing education in restorative work; these dentists can then avoid higher premiums. All dentists who place implants are rated in a higher risk classification than general dentists who do not perform these procedures.
Achieving Success
Can dentists achieve predictable success with dental implants? The answer is yes. According to ten-year survival surveys of fixed prostheses in natural teeth, decay is indicated as the most frequent reason for replacement; survival rates are approximately 75%.5 A major advantage of the implant-supported prosthesis is that the abutments cannot decay. The implant and related prosthesis can attain a ten-year survival of greater than 90%.6
There is little in dentistry that is more predictable in the long range than implant dentistry. Dental implants should be discussed as a treatment option with patients considering replacement of missing teeth or stabilization of a removable prosthesis. The current trend to expand the use of implant dentistry will continue until every restorative practice includes this modality for abutment support of both fixed and removable prostheses.7
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Watson MT: Implant Dentistry: A Ten Year Retrospective Report, Dental Products Report, 26-32, Dec 1996.
Misch DE: Contemporary Implant Dentistry, 2d ed., Mosby 1999.
Carlsson G, Persson G: Morphologic Changes of the Mandible After Extraction and Wearing of Dentures: a Longitudinal Clinical and X-ray Cephalometric Study Covering Five Years, Odont Rev 18:27-54, 1967.
Misch DE: Contemporary Implant Dentistry, 2d ed., Mosby 1999.
Walton JN, Gardner FM, Agar JR: A Survey of Crown and Fixed Partial Denture Failures: Length of Service and Reasons for Replacement, Prosthet Dent 56:416, 1986.
Misch DE: Contemporary Implant Dentistry, 2d ed., Mosby 1999.
Misch CE: Dental Education: Meeting the Demands of Implant Dentistry, Am Dent Assoc 121:334-338, 1990.
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Dr. Swan practices in Traverse City. He is a graduate of the University of Michigan School of Dentistry, Sinai Hospital GPR and the Misch Implant Institute. He is president of the Northern Michigan Implant Study Club and a Fellow of the International Congress of Oral Implantologists and the Academy of General Dentistry. Dr. Swan has over 14 years experience with dental implants and performs both the surgical and reconstructive phases as part of his dental practice.
Implant Dentistry
Risk Management Considerations
Implant dentistry poses a number of benefits for patients. These recommendations should help educate your patients and assist in providing appropriate care. Additionally, consideration of these risk management issues should help protect your practice from potential liability exposure.
When proposing implant dentistry, be sure to discuss the following with patients:
a description of the treatment, including the length of time the patient will be edentulous;
the benefits of implants, and why implants are recommended for the patient;
risks and complications associated with implant dentistry;
other treatment options available to the patient; and
projections on how long the implant and restorative work will last.
Patients should be asked to sign a consent form, and the informed consent discussion should be documented in the chart as well.
When treating patients with dental implants, donÇƒÙt ignore other dental problems, such as periodontal disease. A number of claims have involved dentists who focused on the implant or restorative work and failed to address the patientÇƒÙs other dental needs.
Often the implant patient has a history of poor oral hygiene. Continue to make recommendations for proper oral hygiene and document those recommendations along with patient noncompliance.
Lastly, closely monitor patients (especially their periodontal condition) after restorative work is completed. Schedule patients for return appointments before they leave the office. If patients miss subsequent appointments, document Çƒ?no-showsÇƒ? or canceled appointments in the chart. Attempt to contact the patient to encourage them to return to the practice. All follow-up attempts should be documented in the chart.
Lizabeth F. Brott, J.D.
Director of Risk Management Services
ProNational Insurance Company