“What’s done is done.” (Macbeth) encapsulates that critical aspect of Dental Implant Surgery: it’s not reversible without consequences. This leads us to consider the precautionary steps needed by every dental practitioner prior to surgically placing dental implants.

Presenting Case

A 56 year old female patient presents to you for the first time on recommendation from a friend who mentioned that “my dentist is very good with implants”. She has type 2 diabetes controlled by medication, with a history of periodontal disease. Her presenting condition was:

• Upper right first molar (tooth #16) lost several years ago from a root fracture
• The adjacent teeth are unrestored and this is her only missing tooth other than the third molars
• Her chewing is compromised and would like to have this space restored with an implant

Case Selection

1. History of the patient: A comprehensive medical, dental and social history would determine the suitability of the patient. Consultation with the patient’s Medical GP would add further valuable information.
2. Examination: A thorough extra-oral and intra-oral of the soft and hard tissues inclusive of periodontal health, occlusion and bone volume (Study models and photographs are an integral part of this step).
3. Investigations: Should be carried out in the form of radiographs, CBCT etc., as required.
4. Patient Expectations: Assessment of their reasons for seeking treatment, their dental needs and their concept of how to measure a successful outcome.
5. Diagnosis: Based on the information gathered.
6. Treatment Planning: Should go beyond the implant and include consideration of the final restorative result, which can then be achieved with provision of a surgical guide.
7. Treatment Options: Presented to the patient, detailing all available options with associated benefits and risks.
8. Consent to Treat and Financial Consent: by ensuring that the patient is made fully aware by the treating practitioner of all material risks, alternative treatments, likely outcomes, nature and purpose of the procedure.
9. Special considerations: Complex dental implant surgery requires detailed communication of possible complications and unexpected sequelae. Discussion should focus on the severity of the complication as well as its probability.

As dental practitioners, if we can evaluate each case with a structured and meticulous protocol, we can generally ensure a predictable outcome. A failure, complication or unsatisfactory outcome with dental implant treatment is usually the result of an error or omission in the preliminary stages of history, examination, investigation, diagnosis, treatment planning and consent.[1]

Are we ready to proceed?

As Dentists, we need to ask ourselves honestly whether we have the necessary skills, experience and adequate post-graduate training prior to placing dental implants. Here are some questions we all need to consider:

• Have I discussed my case with my mentor or teacher to gain further insight?
• Am I in contact with experienced clinicians who have years of experience in dental implant surgery that can give me feedback?
• Do I belong to a study group or an implant team in which I can discuss my case in detail with my peers?
• What are my limitations with respect to this case?
• Have I looked critically into my case and made a clever case selection decision?
• What could go wrong?

The Dental Board of Australia (DBA) Scope of Practice (SOP) for dental practitioners specifies that we must use sound professional judgement to assess our own individual SOP (full range of activities and responsibilities in which we are educated, trained and competent to perform).

Anticipated level of post graduate study and training

Dentists who place dental implants should have acceptable, recognised training over a long period and develop skills from treating simple cases, using the established protocols, prior to progressing to more complex and technically demanding cases.

In Britain, the General Dental Council (GDC) and the Faculty of GDP (UK) have published guidelines on training in implant dentistry for general dental practitioners which requires that a practitioner should have adequate practice in assessment, treatment planning and implant surgery under the guidance of an experienced implant clinician, until they are considered competent.[2]

In Australia, there is no special category for a general dental practitioner who surgically places implants. There might be a need in Australia to inaugurate guidelines similar to GDC (UK), specifically aimed at all clinicians surgically placing dental implants and recognised by the DBA

Preventing poor outcomes

• Assess, listen and consolidate information.
• Use a comprehensive treatment plan and list of treatment options.
• Involve your patient in your choices, communicate and obtain informed consent.
• Keep comprehensive and accurate records.
• Embrace protocols that are proven and predictable (don’t take shortcuts).
• Self-evaluate your skill and experience to deliver the proposed treatment.
• Above all, refer cases that are too complex.

The dental implant industry is growing rapidly each year and there is substantial pressure from dental implant suppliers encouraging clinicians to place dental implants even if they have minimum experience and knowledge. Don’t fall into that trap! Excellent planning and execution of a dental implant case can still result in complications and an unexpected outcome, but if the protocols followed are proven and predictable, the outcome is supported by evidence of accepted clinical practice.

A further important perspective: Guild Insurance’s Annual Review based on a five year analysis of dental claims made, established that of 850 claims incurred by 230 practitioners, one procedure contributed greater and more frequent claims (based on the number of insureds conducting this procedure)  than any other, and that is “Insertion of Endosseous Implants (not including restorative procedures)”[3]. Surgical placement of dental implants has a higher claims cost than any other procedure, as demonstrated by the diagram below provided by Guild Insurance:

Dentists who surgically place dental implants need to assure themselves that they have the necessary training and competency which you can’t attain through a weekend course: it takes long periods of study, education and practice. If you don’t commit to these criteria then you can anticipate future patient problems, conflicts and high insurance risk, none of which you can easily cotrol.

Key Statement

…. if we can evaluate each case with a structured and meticulous protocol, we can generally ensure a predictable outcome.

Key Point

1. Training + Practice = Competency
2. Case Selection is Critical
3. Ensure well informed consent inclusive of all relevant warnings.

by:  Dr. Sumanthi Mani, NSW Peer Advisor, Advisory Services

[1] Rees J. Medicolegal implications of dental implant therapy. Prim Dent J. 2013 Apr; 2(2):34-8
[2] Palmer, R.M: Risk management in clinical practice. Part 9. Dental implants: BDJ 209: No10
[3] Guild Insurance Limited (May 2016) Renewal Information