Now that DENTAL IMPLANTS are currently accepted as a basis for prosthetic support for a broad range of cases, legitimate queries have arisen vis-à-vis the role of generalists. The cardinal principle that should be acknowledged at the outset of any discussion of this subject is the exemplary treatment of patients.
We must accept that less than 10 percent of the patients in the United States who could be treated with implants have been, that a clear therapeutic goal should be to substantially increase this percentage, and that this cannot be accomplished without generalist participation. A series of questions then arise and, as a profession, they must be well understood and answered.
Should cases be triaged for educational purposes and/or treatment?
It should be self-evident that many cases involving extensive trauma, partial or total jaw resection due to various tumors, dysplasic syndromes, or orthognathic surgery requiring hospital care and highly sophisticated restorative treatment, should be treated by specialists trained in postgraduate degree programs. This statement applies worldwide.
But with less complex cases is further triage recommended? Generalists who receive adequate training to the educational level of “competency” should be able to treat “garden variety” cases. As more experience is gained, the complexity of cases treated by individual generalists, both surgically and prosthetically, should increase. If generalists operate realistically within their comfort zones, exemplary treatment should be the norm.
The educational process involved can be called the “surgical method of training.” First, study. Second, observation. Third, assisting. Fourth, operating with assistance. Fifth, independent operation. Sixth, extensive operating experience. This refers to all phases of implant therapy – diagnosis and treatment planning, prosthetic and surgical preparation, surgery, provisional and definitive prosthetic care, and even maintenance. Marked deviation from this progression will indubitably result in compromised treatment, patient dissatisfaction, and quite often, legal action. Triage then is an advisable, if not necessary, process.
How should generalists “announce” implant services?
While there is significant variation in state law, it would seem that a general principle that should be respected is to communicate truthfully with the public. National ADA guidelines are somewhat compromised in fact and by Web sites, where there is little oversight, and by an overriding sentiment in favor of the Constitutional right to free speech. Many offices list services offered versus training and/or implied training. Specialists often place “dental implants” after their specialty as an appendage, also with non-specific implied training. Many such scenarios make Web sites critical to effective announcement as well as implant practice building success.
However, any seasoned general practitioner has the distinct advantage of internal marketing to a broad base of patients and the people they influence. Prudent generalists can also always refer to specialists for aid with complex cases. Referral patterns clearly favor the general practitioner.
What training options are available for generalists?
In the public mind today more than ever, there is an interconnection between dental implants and esthetics. Due to product emphasis on smiles, practitioners must deliver function or prosthetic support as well as cosmetically superlative finished restorations. Therefore, training, even after appropriate triage of cases, is an extremely complex issue.
Individual practitioners must realistically evaluate their own diagnostic, surgical, prosthetic and esthetics training skills. They should also realize that the field of dental implant therapy is constantly evolving. New techniques and materials are regularly introduced. Forget whether multi-center studies of adequate length, i.e. facts, should be what establishes the validity of products, and realize that today the products themselves are the facts. A practice commitment to continuing education is the only appropriate perspective for generalists. This point made, what training options exist?
Practically speaking, predoctoral training and general practice residency, or advanced education in general dentistry training for dental implant therapy, rises only to the level of familiarity at best. This is hardly adequate to list on a menu of services offered in a new solo practice. It would seem again that continuing education is the obvious answer. However, one must be mindful of the “gestalt” of necessary competency to provide the exemplary treatment which is the goal.
Anatomy, bone physiology, current radiographic techniques, hard and soft tissue surgery, bone grafting, facial esthetics, individual tooth esthetics, various implant systems’ armamentaria, treatment of complications, communication with patients, auxiliary training, and more, all must be learned or re-learned to feel comfortable, even when the generalist begins “garden variety” cases. Such an education laundry list is not in any way meant to intimidate generalists, but discourage participation in one training option, that is the classic “weekend course.”
It is, however, meant to affirm due to the remarkable advances in implant therapy the necessity for a decisive commitment to a much more studied, extensive and inclusive approach. To make the dilemma that generalists face more understandable, a simple question was posed to implant educators at an ICOI-sponsored European Consensus Conference in Baden-Baden, Germany in 2006. What was the ideal number of curriculum hours that predoctoral students should receive vis-à-vis implants? The answers ranged from 12 to 300.
A multi-session course over an extended time period with clinical benchmarks interspersed is ideal for generalist beginners. Many such courses are available. They usually do not include “beginner” in the course description for marketing reasons. But this type of initial exposure is advised. “Institute” courses then are available, usually with a surgical method of training employed. “Hands on” placement of implants in patients rather than on typodonts and much higher costs are the norm. Short courses are given by manufacturers for their specific products. These should not be substitutes for the multi-session courses mentioned above. Likewise, courses limited to specific techniques are offered to enhance the skills of the generalist as well as the specialist. There are also some full time, multi-year, clinically oriented programs available, but they are usually “certificate” programs due to the ADA’s position that dental implant therapy should not be considered a specialty. They rarely appeal to generalists because of practice interruption and cost. So much for practitioners. But what about the team?
How important is total team training?
If generalists pursue implant training so it can be seriously introduced into their practice and their “teams” are ignored, progress will be discouragingly slow. If, on the other hand, they involve their whole teams, implant therapy will become a significant part of their practices and enjoyment.
What is the total team? Again, “gestalt” is the perfect word. It is the generalist. It is the generalist’s front desk personnel. It is the generalist’s assistants and hygienists. It is the generalist’s laboratory personnel. It is the generalist’s patients and those they influence. And finally, it is the generalist’s family and friends and those they influence.
Early on the ICOI recognized the importance of excluding no one in implant therapy education. A team effort needs a team leader. That is the generalist. Disappearing for days from the office while the generalist is educated is not leadership. It is, simply put, irresponsible. A series of questions should clarify this position.
How can front desk personnel answer questions, schedule appointments, and be enthusiastic about implant therapy unless they are educated and trained by their peers? How can assistants be effective and efficient unless they can make ready, assist in and re-set procedures? Do they need general implant therapy knowledge and system specific knowledge? From their peers? From the generalist’s teachers? Is implant therapy hygiene just an extension of routine hygiene training? Or should peer education prevail? Are implant laboratory procedure skills again just an extension of routine laboratory training? Will the routine produce the exemplary?
When expanding an area of general practice, shouldn’t generalists and their total teams talk to, inform and create missionaries out of the pratices’ patients? Shouldn’t generalists’ family and friends be excited and knowledgeable about implants and communicate that excitement to everyone they know? The answers to all of these questions should be obvious. Yet very few implant societies offer total team training. The ICOI does and their auxiliary courses are heavily booked. Why? Because it is more fun to learn together. It is more effective. Individual and team benchmarks can be set.
Dental implant therapy is an integral part if not the capstone of what Walter Hailey called today’s “golden age” of dentistry. No area addresses what patients want so thoroughly. Since such a small percentage of people are treated, the generalist has an obligation to be involved and organized dentistry should highly encourage that involvement.
Several additional articles will appear this year in Dental Economics® addressing the relationship between general dentistry and implant therapy. The author would like to acknowledge the editors for their timely and much needed discussion of this subject.
Dr. Kenneth Judy is co-chair of the International Congress of Oral Implantologists (ICOI), the world’s largest implant therapy society and provider of related continuing education. He is Clinical Professor in Implant Dentistry at New York University College of Dentistry, as well as in Oral Implantology at Temple University School of Dentistry. Dr. Judy has been involved in implant research and practice for more than 40 years.