Loaded Question

The question of who should place implants is generating a great deal of controversy. Currently, general dentists and specialists place implants. Many of the specialists have been among the most vocal opponents of placement of fixtures by clinicians without advanced surgical training.

First, I need to express my biases. I am a periodontist and most of my income comes from placing implants. Having said that, I have been training general dentists to place implants since the early 1990s, and a large percentage of my referrals come from these dentists.

What are the two sides of the argument? Clinicians who have had three or more years of surgical implant training after dental school point to studies showing that implants placed by surgical specialists have the highest long-term success rates. On the other hand, dentists without specialty training say they should be able to perform whatever procedures they feel qualified to do. Their argument has been supported by several state governments, which advocate changing the definition of specialists to include, among others, general dentists with advanced training in implant dentistry.

Therapists need to evaluate their skills and limitations before attempting implant dentistry. Medicolegally, all implant dentists are held to specialty standards of care

Ultimately, what’s important is that patients are not harmed. This suggests that appropriate education should be obligatory before general dentists or specialists place implants. Yet there are no universal criteria defining the extent of this training. Consequently, therapists need to evaluate their skills and limitations before attempting implant dentistry. Medicolegally, all implant dentists are held to specialty standards of care.

The controversy has arisen partly due to the dental practice model. In medicine, a large percentage of physicians must be board certified in their specialty in order to practice. In addition, hospital privileges determine which clinicians are allowed to perform a given procedure. By comparison, a dental license theoretically allows any dentist to perform any procedure. One of the biggest negatives in the application of these principles in dentistry is that individuals may perform procedures for which they are not adequately trained.

But how much training is enough? There are countless courses in which surgical specialists, as well as nonsurgically trained dentists, can learn about implant placement and bone augmentation. It has been my experience that the most important takeaways from these courses are the importance of case selection, and understanding appropriate surgical techniques and applications. It is strongly suggested that a general dentist partner with a surgical specialist to further his or her clinical understanding, and to intervene in cases that are beyond the dentist’s level of training.

The most important consideration is knowing when — and when not — to place an implant. In my estimation, this calls for standardization in education and credentialing before clinicians are allowed to place implants. Our profession owes this to our patients.

From Decisions in Dentistry. August 2016;2(08):7.