This month, Dr. John Jameson interviews Dr. Charles English, the director of Alliance Dental Insti-tute, which is affiliated with Green Dental Lab in Heber Springs, Ark. This is a new clinical teaching facility for fixed, removable, and implant prosthodontics.
Dr. Jameson: As we look at implant design and utilization, is there a paradigm shift occurring compared to the way dentists practiced a few years ago?
Dr. English: It's kind of a paradox in that implant technology has improved radically over the last 15 years. Implant designs and concepts today are to the point that implant predictability is fine, but the acceptance of implant technology within the practice still has a long way to go. It's been said that approximately 60 percent of the dentists in the United States have never worked with an implant case. We have an enormous range of fabulous choices today. The problem is not with the technical side of implantology; I think that implants still have not been accepted as an integral part of contemporary treatment-planning. Implants really are an adjunct to sound restorative treatment-planning. They originally came into the teaching arena as a stand-alone concept, but I think, today, they are looked upon as something that can be used to help a case.
From a business standpoint, I see it as a mature technology, and I don't expect it to grow exponentially as it did in the 1980s. We will probably experience a 4 to 6 percent consistent growth in the industry, and that is not a figure that makes implant manufacturers comfortable. Many of these companies are adding adjunct technologies to increase cash flow. There's a three-legged milk stool for the implant business today. One of the legs consists of implants; another might be made of a bone-grafting material; while membrane would be the third leg. All of these have to be utilized to increase cash flow and as door-openers for these companies to enter a dentist's office that they couldn't enter with just implants as products. Once they get in with the bone-grafting materials, they can say, "Oh, by the way, we have some interesting implant designs you might want to see."
If you talk to surgeons around the country, they will tell you that they have a core of six or eight referral doctors who are their "bread and butter." Once they are comfortable and knowledgeable about an implant system, they become paranoid about making changes. As a consequence, I don't see a bunch of new surgical kits being sold. I think the market will continue at a relatively level rate. Unfortunately, there are a lot of patients who could benefit from this technology, but it isn't being used in the proper way.
Dr. Jameson: What kind of practice growth or improvement to the bottom line can practices expect from using implant technology?
Dr. English: It depends on if you are a surgeon or a restorative dentist. I don't see a growth in the number of dentists who are taking surgical courses to learn implant techniques. Here's the frustration to the surgical participant in the team: If he or she has a core of six to eight dentists and the dentists whom he or she wants to bring into the referral base are too busy with crowns and bridges, I think there's a lot of frustration. The addition of the other legs of the milk stool will be more beneficial, from a cash-flow standpoint, to the surgeon and not the general dentist. As a general rule, more money has been made on the surgical side than on the restorative side.
There also will be benefits to the general dentist, such as creating better site preparation for implant placement. Grafting technologies will be improving every year. My gut feeling is that we will see a greater growth in grafting technology than in implant technology.
I sense a lot of dentists in the United States are gunshy about getting involved with implants, because they were eaten alive in the 1980s by cases that weren't done well. They lost money and had to deal with a lot of frustration. They wondered why they should put up with that when they could do traditional dentistry and put the check in the bank.
Dr. Jameson: When we look at active implant practices, there has to be a major change in the relationship between the dentist and the laboratory he or she is using. What kind of changes have you seen?
Dr. English: The most successful implant practices in our country work hand-in-hand with a knowledgeable laboratory that understands implant technologies. Not all laboratories have the same degree of expertise or knowledge. In fact, some of the smaller labs are contracting out their implant work to others that have specialty implant departments. They don't want to handle the work. They don't know the parts, and they don't want to have to deal with the inventory problems. An experienced lab with experienced technicians can look at a case and see problems that the dentist can't see. They can give suggestions on saving time and avoiding headaches.
The laboratory industry has made some of the greatest improvements and strides in implant technology and abutment designs. Labs have made far more of these advances than manufacturers or clinicians. The UCLA abutment concept a technician's idea. Many rose out of necessity to deal with restorative challenges.
One of the major changes we're seeing today is more dentists working directly in the commercial dental-laboratory industry. There are currently more than 20 dentists working in laboratories. I think this is excellent, because it allows for professional communication between the clinical and technical sides, which helps with the transfer of information as well as understanding both sides of any issue that might arise.
Right now, there are only 14 dental-laboratory training schools left in the United States. Most of them have closed because of a lack of funding. The dental-laboratory industry is facing the huge task of finding labor. Other companies can pay almost twice as much as the laboratory. As a consequence, the labor force is being lost. The technicians needed for implant reconstruction have to be made mechanically and artistically adept, and they must have a tremendous insight into biomechanics. You can't just take people off the street and expect them to be able to do complex implant work. They must have five to seven years of experience before they can have the insight necessary to manage some of these cases. Dentists need to understand that - unless we support this industry with fair compensation - dentists will be back at the lab bench doing their own crowns and implant cases.
The average profit margin for a dental laboratory in the United States is 8 to 10 percent. Some larger labs may have a higher profit margin, but this is the average. That means that, if you're working at a 10 percent margin, for every one crown we have to remake because of a lack of communication, the next nine crowns have to be made at no profit. Labs lose money in two areas: having to pay overtime and in remakes.
Laboratories want their doctors to be successful. It has to be a win-win situation. The relationship has to be symbiotic and not parasitic. The laboratory is the most neglected source of great information in the entire industry today. Laboratory technicians see more cases in a month than most doctors see in a year. They can look at a case and immediately tell you what your problems will be. In general, the dental-laboratory industry is grossly underutilized for its technical implant expertise.
World-class esthetic restorations require premium lab fees. If a dentist wants outstanding esthetics, he or she must prep the teeth adequately and must understand it can't be done for a small amount of money. You get what you pay for!
As a rule of thumb, the esthetic information sent to the ceramist is appalling. It's not uncommon for implant cases to be sent to the laboratory with little information and no photographs. Sometimes, it is just the shade and impression and a note reading "V2B2, make bridge. Call me."
In general, restorative dentists throughout the United States undercharge for a single-tooth implant restoration. The dentist's fee must reflect the lab bill plus chairtime. When diagnostic time, provisionalization, "redos" because of ceramic mismatch, etc., are factored into the equation, most dentists are losing money on the single-tooth implant restoration.
The dentist has to work with the laboratory so that he or she and the patient totally understand the time and fees required. It is this variation and uncertainty that has created many problems with the single-tooth implant treatment.
Dr. Jameson: As we look at that improved relationship, what kind of continuing-education courses are available that can help dentists incorporate implant systems into their practices?
Dr. English: As a rule of thumb, most larger laboratories have continuing-education programs. Companies that manufacture implants also can recommend courses. These companies have a vested interest in making sure the dentist has the best training possible.
Dr. Jameson: From your experience, what kind of changes can be anticipated with future implant designs?
Dr. English: I think we'll see growth by steps instead of by leaps and bounds. I think we'll see subtle improvements to the interface technologies regarding the different kinds of implant surfaces. I think we'll see refinement in abutment-technology selection to deal with the esthetic challenges presented by various cases. I'd like to see more work done in the area of ceramic-abutment technology, because there are many single-tooth applications with a ceramic abutment that would be the best choice in terms of esthetics. I think most people are comfortable with the various systems that are available today. The patient wants something that looks natural, and so does the restorative dentist. The biggest emphasis will be on the restorative side - as it should be - in the next decade.
I think a lot of dentists have been sold a bill of goods about having a metal-free practice. That's just not possible! There will be "metal-reduced" practices, but there will be no such thing as metal-free practices. Metal ceramic will be around for decades, because it is the standard and the workhorse for implant prosthetics and complex traditional fixed-partial dentures. If you're only doing anterior single crowns or anterior fixed cases where you don't need strength, then you can get by with all-ceramic only. Otherwise, you can't.
Implant stats, according to Dr. English
- Today, less than 10 percent of cases are planned well.
- Lack of site development is the biggest problem in single-tooth implants.
- Out of more than 3,000 implant cases per year, 35 percent are bar overdenture, 35 percent are single-tooth, 20 percent are posterior fixed cases, 5 percent are anterior fixed cases, 5 percent are fixed detachable and modem rodemark, and less than 1 percent are full-arch fixed.
- Of the fixed cases, 96 percent are metal/ceramic, 3 percent are gold, and the rest are made of an all-ceramic material.
- Of the fixed cases, more than 95 percent are cement-retained; 95 to 98 percent are totally supported by implants.
- Of the abutments used, approximately 20 percent are custom-cast UCLA abutments and 80 percent are modified abutments from the manufacturer.
Dr. John Jameson is chairman of the board of Jameson Management, Inc., an international consulting firm. Dr. Jameson lectures internationally on high-tech dentistry and its integration into the dental practice. He provides research for manufacturers and marketing companies. Dr. Jameson may be reached at (580) 369-5555 or by e-mail at firstname.lastname@example.org.