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.
Why Implants?
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.”
General Health
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.
Oral Health
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.”
Realistic Expectations
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.
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.
Finances
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.”
Treatment Planning
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.
Sauer relies on specialists not so much to take his complex cases as to resolve issues such as periodontal disease, inadequate bone, and gingival architecture. Sauer’s proactive approach, he says, is his key to implant success. “We try to take the time to get things set up to have an optimal situation.”
In keeping with his “keep it simple” approach to implants, Sauer says he often lets his CBCT be his guide. “That has probably been one of the most significant tools that I have added to my arsenal over the last 10 years. It can tell me beyond a shadow of a doubt if I may be getting into something that’s over my head or not.”
The ability to deal with complications is a prerequisite to having an implant practice, but clinicians should also be realistic and know their own limits. Sauer says two situations he tends to steer clear of are all-on-4 surgeries, “unless they are slam dunks,” and cases where a failing natural tooth causes the adjacent implant to fail.
Oliva, too, notes the importance of understanding your clinical expertise, and says he has criteria he calls “valves” created for his own practice. “If this patient is X, Y, Z, I will treat, but if they are A, B, C, I won’t. This is better for me and my practice.” He says he routinely performs sinus lifts—eg, crestal sinus technique, lateral window—using new techniques that make the procedure easier and more predictable, with less likelihood of perforating the sinus. “However, if a patient is medically compromised, suffers from certain systemic situations, or needs serious harvesting like block grafting, nerve-repositioning procedure, I refer them to specialists,” he explains. “You can’t spread yourself too thin, especially in this field—it’s better to do one thing really well than everything less well.”
Patel says everyone wins when GPs and specialists team up on implantology cases. Specialists benefit from referrals from GPs, who see more potential implant patients—many of whom would be better served by the specialist. In return, the GP has a go-to source of collaboration and, sometimes, advice.
Complications
Moldovan points out a fact of life among those who specialize in placing implants: Complications are inevitable. “Someone who hasn’t had a complication hasn’t done enough implants,” she says. However, “If you don’t know how to treat the complications, don’t do the procedure.”
Patel agrees. “What defines us as clinicians who are actually ready to be placing implants is not our ability to put them in, but our ability to deal with the complications that arise during or after placement,” he advises. Of course, avoiding complications altogether is best, says Oliva. “Like my dad said, measure three times and cut once.”
To avoid or minimize complications, Moldovan says patients should be followed closely—especially during the first year—with x-rays and probing when needed—and prompt treatment should be initiated at the first sign of trouble.
Quality Education Counts
Minichetti is quick to remind that learning to place implants is not as easy as some manufacturers might make it seem. “It’s far more than a scan and guide and having it milled by a lab; it involves smile line, lip line, incisal edge, vertical dimension. There are so many factors that need to be in place for the prosthetic result before you can even decide on the surgery.”
He therefore urges would-be implant doctors to seek training, especially in the comprehensive prosthetics that is the basis of implantology. “Proper training, which wasn’t available to me when I started, is so important,” Minichetti explains. Such training, he says, is available from numerous sources, including the 300-hour American Academy of Implant Dentistry (AAID) Maxicourse® in Implant Dentistry credentialing programs. Minichetti, the Director of the Las Vegas AAID Maxicourse, says, “These programs are designed to prepare doctors for comprehensive implant treatment planning and diagnosis and surgery and restorative, providing the understanding and clinical skills to do comprehensive prosthetics.” Further, Minichetti says, the AAID makes sure its training is nonbiased, noncorporate, and multidisciplinary.
Putting It All Together
As those interviewed made clear, placing implants is easier now than it was previously, thanks to advances in diagnosis and treatment planning and in implants themselves. But implant dentistry should not be attempted—even by specialists—without the specific training today’s implants require.
Doing implant dentistry right starts with a commitment to high-quality training and building relationships with a network of trusted colleagues for referral, collaboration, or advice. Even with the right training and tools, establishing a successful implant practice hinges on consistently achieving excellent results. This calls for careful case selection that considers patients’ general and oral health, as well as their motivation, hygiene habits, and mental state. Indeed, an implant practice benefits enormously when the clinician and dental team take the time to listen to patients’ concerns and educate them about implant benefits and risks.
When complications arise, a clear protocol, which may include referral, can make all the difference. In addition, a successful implant practice knows how to best collaborate with others to achieve the best esthetic and functional outcomes for their patients. This means having the wisdom to know what they can and cannot do, which cases they should or should not take, and when they should forge ahead or step aside.
Who Is Qualified to Place Implants?
John C. Minichetti, DMD, is a GP, not a specialist. However, credentials from both the American Board of Oral Implantology (ABOI), of which he is a diplomate, and the American Academy of Implant Dentistry (AAID), of which he was immediate past president, attest to his qualifications to concentrate in implant dentistry, which he does in his Englewood, New Jersey, private practice. He therefore describes himself as an “expert” or “keynote clinician” when it comes to implants.
Similarly, Brooklyn, New York, private practitioner Isaac Tawil, DDS, is a highly sought after implantologist who often trains others, including specialists. His qualifications include diplomate with International Academy of Implant Dentistry, fellowships with the International Congress of Oral Implantology and the Advanced Dental Implant Academy, and an advanced periodontal training certificate from Harvard School of Dental Medicine.
Minichetti says specialist interest groups in some states have attempted to prevent GPs—including those with training such as his—from placing implants. For that reason, he is involved in AAID efforts to have its credentials recognized as a dental specialty, and to defend against litigation initiated by such groups. “Already the AAID has won lawsuits in Florida and California, and is currently involved in one in Texas,” he says.
“Just because you’re a specialist doesn’t mean you know how to do implant dentistry,” he insists. “Both GPs and specialists need to refer appropriately, and it helps when those who have received the proper training can be tested to verify that they can perform implant procedures to a certain level. AAID is one group that provides bona fide testing.”
Tawil adds, “It is especially important for clinicians to acquire such credentials early on, because, without proper didactic training, you can have problems in today’s litigious society.”
