Dental News - Academy of Osseointegration’s clinical guidelines answer critical questions about implant therapy

Stephen L. Wheeler, President, Academy of Osseointegration, USA

Mon. 10 February 2014

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NEW YORK, N.Y., USA: Thirty years ago when I started placing dental implants, the highly specialized therapy was in its infancy. At that time, implant dentistry was performed by an oral surgeon-prosthodontist team, and general dentists were not involved at all except as a referral base. What a difference a few decades make.

Today, implant dentistry has developed into a standard of care, and professionals involved in the specialty include not only oral surgeons and prosthodontists, but also periodontists and increasingly, general dentists. The therapy also is more widely available than ever before. While this evolution has brought many positives for the specialty and for patients, it also has created some challenges. As implant dentistry has become increasingly mainstream, training is highly variable — ranging from comprehensive, in-depth instruction to weekend courses.

Those of us who specialize in the field have seen the catastrophic failures that can occur when someone is not properly trained — and we are often left to do the reconstruction. Improperly placed implants can get infected — or worse — and these types of scenarios can contribute to an undeserved negative public image for implant dentistry.

It’s important that specialists and general dentists involved in implant dentistry work together to represent the field in the best light possible. As implant dentistry grows in popularity, we must ensure that those offering implant reconstruction to their patients have the training and background to provide excellence in their care. It is also critical to follow evidence-based clinical guidelines focused on achieving the best possible patient outcomes.

Advancing the vision of implant dentistry

As the president of the Academy of Osseointegration (AO), I strongly support our mission “to advance oral health and well-being globally by disseminating state-of-the-art clinical and scientific knowledge of implant dentistry and tissue engineering and by defining expertise in the field.”

AO is taking a multi-pronged approach to achieving this goal and advancing the vision of implant dentistry through:

Our “Guidelines for the Provision of Dental Implants and Associated Patient Care” (more on that later in this article).
The Academy of Osseointegration Annual Meeting, which takes place this year March 6-8 in Seattle — as well as our other educational and professional initiatives such as regional training and consensus conferences. We offer continuing education and actionable advice for all clinicians who perform implant dentistry. All told, AO comprises 6,000 members from 70 countries, including periodontists, oral surgeons, prosthodontists and general dentists.
Our focus on evidenced-based research, which is presented at our medical meetings and in our International Journal of Oral & Maxillofacial Implants (JOMI).
Our role as a nexus where specialists and general dentists come together to share best practices and coordinate optimal patient care. Whether general dentists are performing dental implants, referring to specialists, or performing long-term maintenance, they are part of the clinical team and need to be knowledgeable about implant dentistry.

AO clinical guidelines

AO published in 2008 its first set of clinical guidelines focused on dental implants. The purpose of the guidelines was to establish guidance based on the provision of patient care and the results of AO’s 2006 Consensus Conference on the State of the Science on Implant Dentistry.

In 2010, AO updated the guidelines to provide an update and expansion of its recommendations for safe and effective implant dentistry. The Academy’s “Guidelines for the Provision of Dental Implants and Associated Patient Care,” which were published in JOMI, are available to download in their entirety via AO’s home page at: www.osseo.org.

Highlights of AO’s guidelines include:

Training: Whether a specialist or general dentist, AO is determined to underline the importance of adequate training in the surgical and/or prosthodontic aspects of implant dentistry. Training pathways now exist through monospecialty training programs, as well as a wide variety of courses offered through institutions both in the United States and abroad, and by private individuals and companies. Training must be comprehensive enough to not only meet legal standards of care, but also to ensure optimal patient outcomes and maintain a positive public image of implant dentistry. At minimum, clinicians who place, restore and/or maintain dental implants should be well-versed in implant dentistry techniques, technologies and best practices for basic to complex cases; diagnosis and clinical care plans; patient selection and education; surgical protocols; minimizing risk and treating complications; ethical considerations; and maintenance and long-term management. In addition, because the field of implant dentistry is always advancing and changing, clinicians must be committed to ongoing training and education.
Legal standard: The law holds that any practitioner (generalist or specialist) undertaking any surgical and/or prosthodontic procedure, particularly one deemed to be of a complex nature, should do so to the same standard of care expected of a specialist; or in the case of a specialist, to a standard equal to a reasonable body of his/her peers. In particular, the ability of a practitioner to predict, recognize and treat complications arising from treatment is of paramount importance.
Therapeutic goal: Implant dentistry should be a restoratively driven therapy whereby the therapeutic goal determines the treatment plan and subsequent surgical placement of dental implants. Assisting in the ongoing maintenance of the remaining intraoral and perioral structures and tissues remains part of the therapeutic goal.
Pretreatment considerations: It is important to emphasize that the need for a dental implant is a prosthodontic diagnosis and the prescription of a dental implant is part of a restorative treatment plan. This will involve a number of stages, which can be distilled into the following headings: appropriate medical and dental history; thorough intra- and extra-oral examination; appropriate radiographic examination and any other relevant investigations; and provision of a comprehensive report, treatment plan (including schedule), and estimate of treatment cost.
Diagnostics: The following aids are recommended for use in reaching a presurgical diagnosis to assist in determining the complexity of the case as well as the number, location, type and angulation of the implants and abutments to be placed: mounted diagnostic casts; imaging techniques; radiographic guides and templates; and computerized planning software
The at-risk patient: Possible contraindications to implant therapy and risk factors for implant failure include: smoking, diabetes, periodontal disease, osteoporosis and certain types of radiotherapy.
Implant placement: The surgical approach should be based on the pretreatment evaluation and the type of implants and/or graft procedure to be utilized. The surgical risk should be assessed and classified according to the Surgical Classification System (scale 1 to 4) as set out in the “Parameters of Patient Care” document of the American Association of Oral and Maxillofacial Surgeons (AAOMS).
Grafting procedures: For the purposes of classification, grafting can be categorized as dentoalveolar or anatomical.
Postoperative management: It is a central requirement in all patient care documents that a patient be provided appropriate instructions for postoperative care. These instructions may be verbal, but a written, individualized, instruction sheet is recommended with information on bleeding, pain control, swelling, the need for antibiotics, the use of chlorhexidine or similar mouthwashes, etc.
Prosthodontic considerations: Implant dentistry is a restoratively driven therapy, and as such, the prescription of implants will have been taken in light of all other prosthetic considerations—including an evaluation of the preexisting condition of teeth adjacent to edentulous spans, alternative methods of tooth replacement, and the condition of the soft tissues, which may be critical to the anticipated results.
Management of implant and peri-implant tissues: Periodic evaluation of implants is a requisite component of patient care. The responsibility to perform this evaluation falls on the providing clinician(s). In the case of a team approach, an agreement should be in place as to whether one or both members of the team (i.e., surgeon and/or prosthodontist or general dentist) will follow the patient. Recall appointments should involve a careful examination of the suprastructure, the surrounding peri-implant tissues, and an assessment made of the patient’s oral hygiene. Considerations recommended by the American Academy of Periodontology (AAP) in the evaluation of implants at recall are: oral hygiene status; clinical appearance of peri-implant tissues; bleeding on probing and/or presence of exudate; pocket probing depths and alveolar bone level; radiographic appearance of implant, peri-implant bone, and alveolar bone levels relative to the implant abutment junction; stability of prostheses and assessment of occlusal screws or cement; assessment of veneering material for presence of fractures; occlusal assessment; patient comfort and function; and assessment of appropriate maintenance intervals
Outcomes assessment: The desired outcome of successful implant therapy is not only the achievement of the therapeutic goal but also the maintenance of a stable, functional and esthetically acceptable tooth replacement for the patient.

While AO’s guidelines provide information and recommendations, they are not intended to be all-inclusive. Clinicians also should consider recommendations set out in comparable documents offered by other specialist bodies and organizations.

As with any specialty, new studies and recommendations regarding implant dentistry are always evolving. As such, AO constantly evaluates emerging research, technology and techniques to ensure its members have the most important and timely information to apply in their practices.

AO is focused on providing objective, unbiased clinical information and providing its members the valuable tools and qualifications they need to succeed with implant dentistry. Implant dentistry has changed significantly since its inception and will continue to evolve — and it’s important that we change with the times, too.

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