Advancements improve the financial rationale
Russell J. Bonafede
The use of endosseous root-form dental implants as a therapeutic option for the replacement of missing teeth has grown steadily since the early 1980s. Recent estimates suggest that over 400,000 dental implants are placed on an annual basis in the United States alone. Despite this impressive market growth, implant dentistry remains a form of therapy that clearly underperforms its true market potential. Although the limited public awareness of this treatment modality may correlate to current procedure volume, clinician adoption rates also play a pivotal role. Misconceptions regarding the complexity and potential profitability of dental-implant restorations may be contributing factors to this modest uptake, especially among general dentists.
For any form of therapy, it is suggested that the long-term financial benefit to the clinical practice can be assessed by an analysis of several key factors:
x Does the therapy have credible support of its clinical efficacy?
x Do the demographic and socioeconomic trends support this form of therapy given the advent of additional competition?
x Are cash flows dependent upon potentially changing third-party reimbursement patterns?
x Does the procedure generate an acceptable margin when compared to other procedures in the clinical practice?
x Does the procedure fall within existing levels of expertise?
Dental implants have been used clinically for over 30 years. Although originally indicated for full-arch restorations, implants now are commonly placed in more challenging situations to include freestanding, single units in highly esthetic zones. There is ample retrospective and prospective evidence to support longer-term success rates in the mid-to-upper 90th percentile.
Although constantly striving for even higher success rates, these figures actually are quite admirable. If we were to compare and contrast the success of dental implants with surgical implants in other disciplines (i.e., orthopedic hip implants), the success rate would be quite gratifying. The literature is replete with articles that support the use of implants to replace missing teeth. A simple search of the MEDLINE database under the term "dental implants" yields over 4,400 hits. Clearly, dental implants are a well-established form of therapy and no longer can be considered experimental.
The demographic support for dental implants is astounding. Data from the National Institutes of Dental Research (NIDR), collected in the early 1990s, indicate that approximately 20 million Americans are totally edentulous. Other data cite an additional 40-45 million are partially edentulous and yet another 45-50 million are missing a single tooth other than a wisdom tooth. This yields a total domestic market potential of over 100 million individuals.
Focusing on older patients, the trends are equally impressive. In 1995, it was estimated that approximately 26 percent of the U.S. population was age 50 and older. This figure is expected to grow to just over 35 percent or 115 million individuals by the year 2020. Economically, the over 50 population accounts for nearly half of all disposable income and 77 percent of the total financial assets in the country. Other social trends also are aligned with implant therapy, as patients continue their quest for improved esthetics and a better quality of life.
At face value, the costs of implant-based restorative treatment are more expensive than the costs attributed to conventional restorative dentistry. The increased costs are, to some extent, related to the costs of the restorative components, as well as the initial increase in the time needed to perform the procedures. As proficiency increases, chairtime to perform the necessary implant procedures may decrease relative to conventional restorative dentistry. For the patient, the discussion of pricing has to become more value-based rather than strictly comparative. The stability, longevity, esthetics, prevention of additional bone loss, and ability to eliminate prepping virgin teeth are all advantages of implant therapy that must be factored into a patient`s price-value relationship.
Because a dental-implant case often involves more treatment-planning than a conventional case (exams, radiographs, diagnostic casts, surgical stent fabrication, etc.), these factors should be evaluated by the restorative dentist and considered for independent fee quotation. Other case requirements such as relining of existing dentures or fabrication of a transitional prosthesis (both post-initial and second-stage surgery), component costs, and abutment connection need to be taken into account as fee considerations. The profitability of implant restorations is directly attributable to a clinician`s ability to assess all costs of a chosen case plan and develop a corresponding fee schedule.
In comparing the profitability margin of implant cases vs. other procedures, a fundamental understanding of key practice financial parameters is required. Calculation of fixed overhead rates, dedicated procedure expenses, average procedure time, and desired profitability rate will yield an analysis that derives the minimum required procedural revenue to meet the profitability target. Procedures with revenue in excess of the target profitability plus total expenses will be profitable. The hypothetical example provided in the table above demonstrates this calculation for a single-tooth implant restoration.
The general dentist often is the point person for the dental implant procedure. As the primary point of contact for the typical patient, the general practitioner is in the best position to render an empirical diagnosis and initial consultation regarding the dental implant alternative. Despite the large prospective patient pool, it is generally estimated that less than 40 percent of general practitioners are involved in the restorative phase of implant therapy. Many of these clinicians do only one or two cases per year. This is in stark contrast to their specialist counterparts.
About 95 percent of the oral and maxillofacial surgeons are involved in the placement of dental implants. This figure is over 65 percent for periodontists. Prosthodontic restorative specialists have 90 percent of their membership routinely involved in the restorative phase of dental-implant therapy. Concerns among general practitioners regarding profitability and complexity of implant restorations have contributed to the smaller percentage of them doing implant therapy.
In terms of procedure complexity and the ability to incorporate implants into the practice, protocols have evolved over time to more closely mimic conventional crown and bridge dentistry. Surgically, implants are being placed more frequently in single-stage protocols, eliminating the need for a second surgical intervention to place a healing abutment for guided soft-tissue healing.
From a restorative perspective, preprepared titanium abutments are available that closely resemble the geometries of natural tooth preparations. Compared to a natural tooth, the majority of the prepping has been done by the manufacturer. These abutments still are adjustable by the restorative dentist to produce finish lines that ideally follow the gingival margin. This provides an ideal fit between crown and abutment and minimizes the amount of excess subgingival cement.
Improvements in the precision fit between implant components, advanced screw designs that allow for the application of more preload, and availability of dedicated wrenches for the generation of ideal torque have dramatically increased the predictability of cementable implant restorations. The incidence of screw-loosening, degree of component micromovement, and extent of microleakage have all been diminished with the introduction of these technical improvements.
In some instances, these cementable prosthetic posts can be seated by the surgical specialist, allowing the patient to present to the restorative dentist with the components already in place. A traditional direct impression can be taken, followed by conventional fabrication of the prosthesis by the laboratory, making this procedure nearly identical to crown and bridge restorations on natural teeth.
Perhaps the most significant recent advance in oral implantology is the introduction of early loading protocols. Advancements in implant-surface technologies have demonstrated increases in the rate and extent of bone healing, thereby allowing for earlier loading of the dental implant. Implant restorations can be completed in as little as two months following the placement of the implants.
This has a dramatic financial ramification for the general practitioner in terms of cash flow. Where a maxillary implant case could typically take over 30 weeks to complete from start to finish, the case can now be done in as little as two months. Not only is the procedure approximating conventional crown and bridge therapy in terms of therapeutic time, but the payment schedule also has been adapted. Clinicians are able to get paid faster and to complete cases in less time with a fewer number of appointments. This can allow the clinician to potentially treat a greater number of patients in an equivalent time period. In some instances, early loading protocols have allowed clinicians to reassess their fee schedules. With cases cycling through at a faster rate and, in many instances, requiring less chairside time, some clinicians have lowered fees. The goal behind the lower fee schedule is to generate an elastic demand scenario where the increases in the patient pool more than offset the lower revenues and profits on any one case.
In summary, implant dentistry clearly is supported by evidence-based research and has a strong demographic foundation to support additional growth - even if more general practitioners adopt this form of therapy. As a predominantly out-of-pocket expense for the patient, this treatment modality will persevere, regardless of future changes in third-party reimbursement.
With a detailed assessment of all the tasks involved in the case plan, an appropriate fee schedule can be generated that makes implant restorations equal or superior to conventional restorations in terms of profitability. Early loading protocols, combined with simplified prosthetic components and procedures, makes implant dentistry potentially even more profitable, while increasing the predictability and familiarity of the procedure.