Profiting from implant dentistry
James T. Ellison, CDT
Depending on whose numbers you read, about 32 million people are edentulous in the United States. That represents 12.8 percent of the total population. Estimates are that about one-third of those can afford to be restored with an implant-supported overdenture. That means that there are about 10 million prospective patients in the United States for this one area of implant prosthetics. That`s without considering the even-larger number of partially edentulous people who would be possible candidates for implant restoration. With only about 120,000 patients being treated annually with implants, it is easy to see that there is an enormous opportunity for growth.
Getting started
So, how do you profit from all this potential work? Well, there are different levels of involvement. If you want to go with the traditional six to eight implants in the anterior mandible, restored with a screw-retained fixed bridge, you have a lot to learn. Your potential profit is high, but there are many problems that you will have to deal with. Many practitioners think that this type of restoration is best left to those who have invested a significant amount of time and effort into perfecting the skills needed to make this a predictable and, therefore, profitable part of their practice.
But, implant-supported overdentures, crowns on single implants, and small bridges can be created easily and profitably by any dentist with average prosthetic skills.
Many successful implant overdentures are retained by as few as two implants. Although most dentists will refer more extensive implant placements to a specialist, more and more general dentists are acquiring the relatively simple skills to place two implants in the anterior mandible. An abutment can be screwed into each implant and the retainer processed into the denture in a chairside procedure.
In fact, if the patient has been wearing an acceptable complete denture, the retaining attachment may be processed into the existing denture. Because the cost to the patient may be kept quite low, this probably is the fastest growing area of implant dentistry, and it`s where you can begin to tap into those large numbers mentioned above. With Branemark and his colleagues reporting a better than 95-percent success rate, this also can be very predictable.
The replacement of one tooth probably is the second-fastest growing area of implant dentistry. After all, patients don`t want implants, they want their teeth replaced with something that looks and functions just like what was there originally. With solid connectors and bone loss under pontics, the three-unit bridge just doesn`t do as good a job as the single implant with a crown. This is particularly true if it involves preparing healthy teeth. With the advent of anatomically shaped, preparable abutments, implant restorations have been simplified to the level of traditional crown and bridge.
In these cases, the abutment is prepared like a tooth and the crown is cemented in place. Nothing could be simpler. For the first time, we can create crowns on implants that function and look just like real teeth. Some would point out that implant dentistry is significantly more expensive than the traditional restorative methods. It isn`t in this case. The cost to the patient for this restoration usually is very close to the price of the three-unit bridge. The same technique of cementation to prepared implant abutments is used with small bridges.
After considering this information, many dentists are convinced that implants, under the right circumstances, should be part of their practice. In fact, if you do not include implants as part of your treatment-plan presentation, you may be leaving yourself open to a malpractice suit. At a recent educational program that I attended, there was a discussion about this subject. A leading provider of malpractice insurance for dentists is warning clients that those who do not inform patients of the option of implants are being sued, and the patients are winning.
Once you have decided to add implants to your practice or to expand the number that you do, you need to become comfortable with the techniques involved. A number of companies, including Sterngold, offer courses on how to place implants and how to restore them. You can begin with a short evening lecture and work yourself up to a hands-on course over several days. Some universities, such as Johns Hopkins, offer excellent courses for those who want to learn how to place implants as well as for those who wish to restore them.
It doesn`t require a lifetime of study to achieve proficiency with the simpler implant restorations. A few days invested in education can provide a significant economic return.
Next, how do you find the patients? I often have had dentists say to me that they would be happy to do the implant cases if I would find them the patients. My usual response to them is that they see potential implant patients every day. The easiest place to find an implant patient is in your chair. Any patient who is missing one or more teeth is at least a potential candidate for an implant-supported restoration.
Some types of patients have a poor success rate with implants. Most doctors will not place them in patients who have the following conditions: uncontrolled diabetes, smokers, uncontrolled blood pathologies (hemophilia, low blood pressure, aspirin therapy, etc.), osteoporosis, and those undergoing chemotherapy.
Reduce bone loss
The biggest advantage of implants is that they reduce bone loss. This is what sets them apart from the more traditional forms of restoration. If patients are going to accept implant therapy, they must understand the detrimental effects that bone loss will have on their appearance and their ability to masticate food. This point must be effectively communicated.
Opinions differ on how to present the various options for treatment, but a number of successful practitioners prefer to offer the traditional restorative options first. It then is easier for the patient to understand the advantages when the implant option is explained.
General discussions should focus on the patient`s specific problem and the choices for restorations. You should be prepared to list the advantages and disadvantages of each option. Discuss costs after laying out the advantages of the implant option.
Don`t get very involved with explaining surgery or the implant parts that are involved. Usually, patients don`t want to know all the details; they just want teeth. Risks and complications should be discussed only after the implant treatment has been chosen.
Teamwork
Now the real work begins. If you are not placing the implants, you must develop a relationship with someone who does. Check with your colleagues to find out who they enjoy working with. An important point to remember is that the restoring doctor is the one who runs the show. He or she should choose the implant based on how the case will be restored.
One of the biggest mistakes that a general dentist can make is letting the surgeon place an implant that cannot be restored in the way that was planned. In other words, the abutment dictates what implant is placed - not the other way around. Not all implant systems have the same restorative options. In fact, not all sizes of implants from a particular manufacturer will have the same restorative options.
Besides the implant companies, one of the best sources of restorative information is the dental laboratory. Consultation between the laboratory and the surgeon and restoring dentist is essential before the implants are placed.
If you are not placing the implants, you should attend the surgery. Many surgeons say that another set of eyes helps with alignment. It also helps with communication and makes the patient feel more comfortable.
A surgical guide is appropriate in all but the simplest cases. A few dollars spent here will save many dollars and prevent headaches. The days are gone when poor implant placement could be blamed on lack of bone or shape of the bone. Bone augmentation is simple and predictable, and it`s often necessary in cases where teeth have been missing for some time.
When dealing with complex implant cases, the laboratory can make things go easily or it can eat away at your profits with remakes. But, with the simpler restorations that I have suggested, the laboratory work is traditional and uncomplicated. Many labs can produce a very predictable result with a simple overdenture or a cemented crown on a prepared abutment.
With a little education, good case- planning and presentation, and a good working relationship with your lab and surgeon, you can minimize the problems and maximize your profit.
