Today vs. yesterday: Generalists vs. specialists
Kenneth W. M. Judy, DDS, FACD, FICD
Having practiced oral implantology/implant dentistry for just over three decades, I have witnessed major paradigm shifts in the field. Early rejection by surgical and periodontal specialists, as well as by most generalists, was followed by rejection by organized dentistry, i.e., the American Dental Association. Early proponents of the field - implant manufacturers and researchers - persisted until FDA approval was obtained in accordance with the Kennedy/Rogers health bill. The ADA lagged behind the FDA and all but branded implantology experimental.
Consequently, curriculum time at the nation`s dental schools rarely was devoted to implantology, especially at the predoctoral level. Even the remarkable attitudinal change brought about by the presentation of significant research and prospective clinical findings by Branemark and others only impacted specialists. Most postgraduate programs were hampered by a lack of experienced faculty, due to this long period of rejection or denial. Generalists were left to sort things out for themselves or be aided by a small percentage of specialists, who also were just finding their way. Implant manufacturers continued to innovate and improve existing products. Surgical and periodontal specialists, as well as implantologist "specialists," adapted in a Darwinian fashion to provide superior services.
What, then, should generalists who are restoratively driven expect today? Has there, in fact, been a substantial clinical paradigm shift? I strongly feel that there has been and that it will bring about the "golden age" of oral implantology/implant dentistry. An understanding of the depth of the shift will have an enormous economic impact on practices that choose to recognize and take advantage of it.
The clinical paradigm shift
The best way to understand what has transpired during the last two decades is to look at what a generalist could reasonably expect clinically and economically after making a "specialist" referral for implants. Two easily understood cases can demonstrate the changes that have taken place over the past two decades and are indicative of the progress that has been made: The ideal edentulous, posterior-mandibular quadrant and the moderately-to-severely-resorbed, posterior-maxillary quadrant.
There also has been a paradigm shift in implant education, which will be outlined at the end of this article. This shift will be defining for future high-end practices in terms of how they incorporate implants into their routine roster of services.
Posterior mandibular quadrant
In the mid to late `70s, implant referrals resulted in modality selection by the implant surgical "specialist." Plate forms or root forms were chosen and placed without the benefits of CT scans, surgical guides, bone-grafting, etc.
The restorative generalist and the specialist worked apart, instead of together, with little concern for parallelism, ideal periodontal results, and common team communication with shared patients. Low levels of professional acceptance - reinforced by continued negative ADA attitudes - and low levels of prosthodontic education by implant surgeons and of surgical education by restorative practitioners were the main causes for this frustrating situation. What cannot be stressed enough is the basic failure of all parties to communicate effectively.
Today, by contrast, implant-knowledgeable restorative generalists should expect to be "captains of the ship" and consult with surgical specialists after having designed cases in advance from a thorough clinical exam, mounted study casts, and appropriate radiographic information. The implant surgeon should agree with the overall treatment concepts in order to provide maximum services to the restorative generalist and benefits to the patients. Also, both the generalist and the implant specialists should be trying to create value for each other, so the referral process can be repeated again and again. This mechanism properly understood and utilized will "bootstrap" dentistry into the "golden age" of oral implantology.
The oral-surgical community has increased tremendously its level of prosthodontic and periodontic knowledge vis-a-vis implants. Today, or at least in the very near future, it would not be unreasonable to expect a surgical referral to entail the following:
* a clear treatment plan, including sequencing, laboratory estimates, and patient fees,
* use of a provided surgical guide,
* use of the agreed-upon implant system,
* consideration of transitional implants,
* parallel implant placement,
* "zero"-pocketing periodontal preparation,
* monitoring during submerged healing,
* uncovering and placement of healing abutments,
* revision of periodontal care,
* placement of final abutments after laboratory-paralleling and inter-occlusal clearing,
* placement of laboratory-fabricated provisional prosthesis
The last two steps currently are not being done universally by surgical specialists. However, an increasing number of my colleagues are providing these services and many of my referrers request them. It will be only a matter of time before the "bar is raised."
Implant-knowledgeable generalists also should command a substantial diagnosis and treatment-planning fee prior to referral. They also should expect that the surgical specialist and his/her staff should provide maximum praise and support for the generalist and his/her staff. Following up or monitoring of patients over the years should be a shared responsibility.
The services, implants, parts, and prostheses delineated above should have standard fees and chairside time requirements. The implant specialist and the restorative generalist should agree upon the sequence of responsibilities and the fair and consistent amount each should be paid. Cut-rate implant fees or itinerate specialists are disturbing recent phenomena which will only result in diminished levels of care.
Posterior maxillary quadrant
In the mid-to-late `70s, implant referrals for the moderate-to-severely-resorbed posterior maxilla were only restored with unilateral subperiostal implants or shallow plate-form implants. Success rates were determined by numerous factors and, for the most part, these devices were only placed by "implantologists." Major bone grafts were not utilized and subantral augmentation or "sinus lift" procedures had yet to be developed or popularized.
Traditional surgical specialists rejected the concept of subantral augmentation until multiple practitioners from around the world achieved unquestioned success. Traditional periodontal specialists followed the same path of rejection, gradual acceptance and then considering the procedures routine practice. Both surgical and periodontal specialists again were faced with inexperienced postgraduate faculty. Manufacturers of augmentation materials greatly aided research, evaluation, and acceptance of this procedure. The radical soon became the routine.
Today, the implant-knowledgeable generalist, working in harmony with the surgical specialist, can expect a referral for a moderate-to-severely-
resorbed maxilla to result in the following:
* a clear treatment plan, including sequencing, laboratory estimates, and patient fees,
* use of a provided tooth-positioning guide,
* subantral grafting and/or onlay grafting to create the desired alveolar ridge,
* immediate parallel-implant placement (SA 3 cases),
* "zero"-pocketing periodontal preparation,
* post-subantral augmentation monitoring,
* uncovering and placement of healing abutments,
* revision of periodontal care,
* placement of final abutments after laboratory-paralleling and inter-occlusal clearing,
* placement of a laboratory-fabricated provisional prosthesis
In SA 4 or severely resorbed cases, a delayed placement of implants is done after graft maturity, and the above steps remain the same after "immediate parallel-implant placement." Superior graft materials now are coincidentally "in the pipeline." What the generalist can expect the implant specialist to do is to create the desired alveolar ridge for implant support, as well as the agreed-upon number of implants - ready to restore at the appropriate physiological time vis-a-vis bone maturation.
While the above processes might seem unduly complex to the generalist, there actually is not much difference analogously between simple and complex orthodontic cases and how they are treated prior to restoration. What the generalist needs to do is to acquire the necessary education and skills to develop a mutually nurturing relationship with an "implant specialist." Once several cases are begun and some are finished, the rewards from providing what patients really want in an elegant manner will become obvious. The admonitions of the author regarding fees, responsibilities, and time requirements still apply.
The educational paradigm shift
Specialists traditionally have provided only a small percentage of the services encompassed by the educational and behavioral objectives of their specialty. Generalists provide the bulk of surgical, periodontal, restorative, and esthetic-restorative services. The need, however, for specialty services vis-a-vis implantology has not decreased, but rather has increased because of expanded applications. Consequently, implantology training has become mandatory on the postgraduate level. On the predoctoral level, however, the ADA`s lack of supportive requirements will curtail implant training to any reasonable degree of proficiency for years to come. This is the tragic outcome of a reactionary attitude.
Generalists who wish to incorporate implants into their practices will have a limited number of educational choices, if their goal is to provide high-quality, total-team services for their patients. This is particularly true if those services are to be value-added and well-grounded educationally.
I firmly believe that two factors will drive the future growth of implantology: Generalists will have to enter into a continuum of courses prosthodontically and surgically to optimize the delivery of implant services in their practices. Furthermore, the generalist/specialist relationship will have to be re-learned and re-engineered substantially to be a win/win situation, with patients receiving an increasingly superior level of care.
In short, a strong, ongoing commitment to implant education must be made by successive graduating generalists. They must recognize that they will not receive adequate predoctoral training and that while manufacturers often present high-quality, entry-level training, it should not be their responsibility to continually provide the broad base of knowledge required for the truly successful practice of implantology.
The clinical and educational paradigm shifts described above will ensure that oral implantology/ implant dentistry will continue to be "mainstream" for years to come, both in fully developed and emerging economies. Much of what I`ve stated has been constructed to force specialists, as well as generalists, to rethink their roles in implant treatment.
ICOI`s educational alternative
In 1998, the directors of the world`s largest implant-dentistry educational society, the International Congress of Oral Implantologists (ICOI), unanimously voted to establish a section exclusively devoted to implant-prosthodontic education. This action was taken because many educators feel that implantology basically is a restorative-driven discipline with a surgical component. Today, the active members of ICOI`s Implant Prosthodontic Section are a highly progressive group made up of like-minded clinicians and technicians whose sole purpose is to communicate and exchange new ideas and techniques.
ICOI-ExperDent now offers hands-on implant-prosthodontic and surgical training for clinicians at all levels.
To help you determine your entry point, attend an integrated implantology one-day lecture titled, "It`s Easy When You Know How."
For more information on the ICOI, call (888) 449-ICOI (4264) toll-free or check out the Web site http://www.dentalimplants.com.
