BEST PRACTICE IN IMPLANT DENTISTRY

Prepared for and on behalf of the Australasian Osseointegration Society, NSW. (2007)

BEST PRACTICE IN

IMPLANT DENTISTRY

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FOREWORD

The advent of osseointegration brought about by the pioneering work of Per-Ingmar Branemark has revolutionised the restoration of edentulous spaces and requests for the provision of implant-supported restorations are multiplying in the community. In part, this demand has been generated by the marketing techniques of an ever-increasing number of implant manufacturers which, in turn, has led to a pressure on dentists to supply both the surgical and prosthetic component of implant treatment. The procedures are exacting if success is to be predictable and the research, technique evolution and knowledge base has progressed exponentially in the relatively short period of time since implants were introduced. Implant treatment often involves solutions to complex clinical problems such that the risk of failure in a poorly considered and executed treatment plan can be expensive to the patient, both in terms or morbidity and financial cost. There is always a time lag between the introduction of new techniques in dentistry and their acceptance and inclusion in the undergraduate curriculum. Thus, presently, most dentists come to implant treatment as a postgraduate where the acquisition of skills and knowledge is largely self-driven. This timely document provides a benchmark for the standard of care and training in implant dentistry by which skill levels and training courses can be evaluated. It is intended to be a dynamic document; subject to revision as the field develops. This document is not prescriptive. Instead, it is produced as a reference guide. The document may be used for the development of risk management strategy in the dental office and will help to improve the standard of patient care. It is also intended to be supportive of the profession rather than critical so that our patients can receive safe, successful and evidence-based treatment.

Hopefully, all the various parties involved in implant treatment - companies, clinicians, technicians and universities - will find this document a useful reference and will be prepared to assist in its inevitable refinement over time. George Pal President NSW Branch Australian Osseointegration Society

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TABLE OF CONTENTS

Members of ad hoc Committee Acknowledgement Preamble

1. The standard of care in implant dentistry

1.1 Introduction 1.2 Risk management 1.3 Clinical goals

1.3.1 The patient receives treatment of positive health benefit 1.3.2 Proper rationale for treatment 1.3.3 Informed consent 1.3.4 Set and achieve appropriate treatment objectives 1.3.5 Adequate documentation 1.3.6 Communication

2. Appropriate education and training

2.1 Adequate levels of Skill 2.2 Skill level requirements 2.3 Types of Postgraduate Training

2.3.1 Formal Training 2.3.2 Informal training 2.3.3 Self learn

2.4 Mentoring

3. Training Requirements

3.1 Surgical Training requirements 3.2 Restorative Training requirements 3.3 Surgical Training Requirements 3.4 Restorative Training Requirements

4. Success Criteria

5. Professional and Ethical behaviour

5.1 Introduction 5.2 Safe-guarding patient’s interest and well-being 5.3 Duty of care 5.4 Appropriate referral 5.5 Continuing Professional Development (CPD) References Appendix A

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Members of the Ad Hoc Committee on Best Practice in Implant Dentistry

1. A/Prof Stephen Yeung, Periodontist, Past President of Australasian Osseointegration Society, Current President of Australian Society of Periodontology.

2. Dr Alastair Stevenson, Oral Surgeon, Past President of Australasian

Osseointegration Society.

3. Dr David Sykes, Prosthodontist, Member of Dental Board of NSW.

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ACKNOWLEDGEMENT The Australasian Osseointegration Society gratefully acknowledges the contribution and advice to this document by the following individuals and organisations : Professor Mark Bartold Dr Greg Charlesworth Dr Richard Chan Dr Stephen Chen Dr Ivan Darby Dr Anthony Dickinson Dr David Grossberg Professor Patrick Henry Dr Paul Hogan Professor Saso Ivanovski Professor Iven Klineberg Dr Janis McAloon Dr George Pal A/Prof Terry Walton A/Prof Kwan-Yat Zee Academy of Australian & New Zealand Oral & Maxillofacial Surgeons Australian & New Zealand Academy of Periodontists Australian Society of Implant Dentistry Academy of Australian and New Zealand Prosthodontics Australian Dental Association Australian Prosthodontics Society Australian Society of Periodontology Australasian Osseointegration Society Griffith University, Faculty of Dentistry Royal Australasian College of Dental Surgeons University of Adelaide, Department of Dentistry School of Dental Science, The University of Melbourne University of Queensland, Department of Dentistry University of Sydney, Faculty of Dentistry University of Western Australia, Faculty of Dentistry

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Preamble The Executive of the AOS NSW has appointed an ad hoc committee to draft a paper on the guidelines for best practice in implant dentistry. This initiative arose from the concern expressed by some members of the Executive regarding the increasing number of implant-related complaints lodged with the Dental Board of NSW. AOS NSW is keen to assist its members in achieving the best result in implant dentistry. This paper is aimed at defining what is best practice in implant dentistry and offers suggestions on how best to achieve this goal. The first section of this document deals with the principles relating to a minimum standard of care in implant dentistry and its practical application. The second section deals with the appropriate education and training needed to prepare practitioners to practise implant therapy at various levels. The third and final section deals with professional and ethical behaviour when treating patients.

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1. The standard of care in implant dentistry

1.1 Introduction 1.1.1 This paper sets out to define the minimum standard required of

dental practitioners when prescribing implant therapy to their patients. The standard of care is a set of guidelines applied to patient care in a designated geographic setting (Australian States and Territories) and at a relevant time (2007). The rapid development in the science and knowledge of dental implants dictate that this set of guidelines will need to be reviewed and revised from time to time to maintain its currency.

1.1.2 A standard of care is not only concerned with treatment outcomes,

it is also concerned with the process of care. It is important to adhere to treatment methods and protocols that are evidence based. Evidence based clinical practice relies on peer reviewed, published scientific and clinical data, preferably further verified by an independent source.

1.1.3 It is important to recognise that implants are but one treatment

option for the restoration of missing teeth. Their use should be considered in relation to the many decision-influencing factors present in any one clinical case.

1.2 Risk Management - (Do no harm) 1.2.1 The paramount imperative is that the patient must not be harmed

as a result of implant treatment. Harm can be defined as an adverse treatment outcome that might include physical injury (e.g. trauma to the inferior alveolar nerve), disruption of normal physiological function (e.g. occlusal dysfunction) or other patient dissatisfaction with the treatment provided. There are degrees of adverse outcome ranging from a transitory post-operative complication to permanent and irreversible injury or even death.

1.2.2 A practitioner must take all reasonable steps to minimise the risk of

harm occurring to a patient as a result of any dental treatment including implant therapy.

1.2.3 Risk reduction measures for implant dentistry should include:

• Appropriate training and skill level acquired by the practitioner

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• Appropriately equipped operatory • Adequately trained assisting staff • Careful treatment planning in every case • Appropriate discussion with the patient regarding the proposed

treatment • Employment of the best available protocol for the procedure • Employment of best practice in infection control protocol. • Employment of carefully assessed implant systems and ancillary

equipment • Excellent communication between all clinicians and technicians

involved

1.3 Clinical goals 1.3.1 The patient receives treatment of a positive health benefit. 1.3.1.1 The placement of a dental implant must fulfil a prosthetic or

restorative goal on sound clinical grounds. There must be a demonstrable benefit to the patient as a result of the implant treatment. For example, the replacement of a tooth in an arch (such as a second or third molar) where there is no opposing tooth in function nor any future plan for the opposing tooth to be replaced, does not constitute a reasonable benefit to the patient. A patient’s request or demand alone may not be sufficient justification for implant placement.

1.3.1.2 Where a practitioner feels that the patient’s request is of

questionable clinical benefit to the patient or is contraindicated, the patient should be counselled and the risks and contraindications clearly explained.

1.3.1.3 It is an accepted standard of care to decline to provide a

requested procedure when it is contra-indicated. 1.3.2 Proper Rationale for treatment 1.3.2.1 Implant treatment should be seen in the context of a

comprehensive treatment plan that addresses the specific needs of a particular patient and the various treatment options available.

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1.3.2.2 Thus there must be a sound rationale for selecting implant

treatment during the treatment planning process over and above other treatment options with a clear and demonstrable benefit to the patient. The use of implants should be made in consideration of the following factors:

• Systemic medical conditions • Pre-existing dental disease • Patient motivation, hygiene ability • Financial constraints • A careful evaluation of the advantages and disadvantages of

alternative prostheses in relation to the presenting status of the surrounding teeth, soft tissues and associated structures.

1.3.2.2 The concept of Comprehensive Health Care is an overriding

principle governing dental implant treatment. 1.3.3 Informed Consent 1.3.3.1 The pre-treatment consultative process should include:

• a discussion of all the treatment options and their

relevant advantages and disadvantages, including those that do not involve implants,

• the rationale for choosing implant treatment • a clear explanation of all the risks associated with implant

treatment, • the cost and duration of treatment, • the necessary post treatment care and monitoring • the likely prognosis and lifespan of implant treatment.

1.3.4 Set and achieve appropriate treatment objectives 1.3.4.1 Careful treatment planning and meticulous execution of

treatment steps are designed to achieve the desired treatment outcome. Setting unreasonable treatment goals can lead to failure in the desired outcome and unhappy patients.

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1.3.4.2 Realism in objective setting involves consideration of what is possible in a particular case in relation to the technology available at a given point in time. This may change as techniques improve. Implant aesthetics is a particularly important area where this principle applies.

1.3.4.3 The management of on-going maintenance care should be

considered as part of the overall plan. The placement of fixtures and construction of a definitive prosthesis is not the end point of treatment. Maintenance care involves the patient and their future treating clinicians.

1.3.5 Adequate documentation 1.3.5.1 Good clinical records are a mandatory and critical part of

dental treatment and are especially important for implant related therapy. They help the practitioner to focus on the important and critical aspects of the case. They reduce the risk of misunderstanding, error in component selection and usage, and the omission of important steps in the delivery of treatment. They also form an invaluable defence tool for the practitioner when he/she is challenged by the patient either directly or through legal proceedings.

1.3.5.2 The minimum documentation for an implant case should

include

• Patient’s details • Patient’s complaint and requests • All clinical and diagnostic examination findings including

those from special tests such as radiographs and analysis of study models

• Treatment plan and rationale • Details of discussions with patient that form part of

informed consent • Clinical record of procedures performed • Treatment result (or outcome) • Financial transactions • Post treatment care and monitoring, including

complications

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1.3.6 Communication

1.3.6.1 Implant treatment usually involves several parties such as restorative dentist, surgeon, and dental technician. Excellent communication between these professionals at all stages in treatment, is imperative if a successful outcome is to be achieved. It has been recognised that poor communication has been a factor in unsuccessful implant treatment11. There is great advantage in establishing communication protocols in a practice providing implant treatment.

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2. Appropriate Education and Training

2.1 Adequate levels of skill 2.1.1 As a general principle, a practitioner must have the necessary skill

needed to carry out any specific procedure. However, in the current situation with the absence of any postgraduate assessment process setting target standards, an individual practitioner must ask himself/herself whether their skill level is consistent with what is required for any specific procedure. For instance, a practitioner with no surgical training or who has not performed surgical procedures for many years should not attempt to place dental implant in patient’s jaws without appropriate re-training.

2.1.2 This principle is codified in the Dental Practise Act, New South

Wales under Section 9.

9. Competence

For the purposes of this Act, a person is competent to practise dentistry only if the person has sufficient physical capacity, mental capacity and skill to practise dentistry and has sufficient communication skills for the practice of dentistry, including an adequate command of the English language.

2.1.3 Aggressive marketing of some implant systems may suggest to the

untrained practitioner that a rigorous surgical and restorative training programme can be avoided.

2.1.4 The following guidelines are designed to provide a basis for the

degree of postgraduate training that a practitioner should be expected to undertake before embarking on implant related treatment.

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2.2 Skill level requirement

2.2.1 Skill levels vary according to the degree of involvement a practitioner wishes to have in implant treatment. A clinician who only wishes to provide the prosthetic aspects of implant treatment will require a different level of training to one who intends carrying out surgical procedures. Similarly, there are different degrees of complexity in the provision of both the prosthetic and surgical phases of implant treatment.

2.2.2 It is logical to set levels of skill standards according to the

complexity of treatment provided. Detailed recommendations for various levels of skill requirements are set out elsewhere in this document (see Section 3).

2.3 Types of Postgraduate Training

2.3.1 Formal training

2.3.1.1 Formal training in a recognised educational institution is the most desirable mode of clinical training. It provides a structured program with both didactic and practical training in the relevant subject areas over a period of time. For example, the University of Sydney offers a Certificate and a Graduate Diploma course in implant dentistry and the University of Melbourne offers a Postgraduate Diploma in Clinical Dentistry. These and other Universities offer Masters or Clinical Doctorate courses in Oral and Maxillofacial Surgery, Periodontics and Prosthodontics.

2.3.1.2 The curricula of Diploma courses are designed to address

the skill requirement necessary for practitioners to engage in the basic level of implant dentistry. The Masters courses are suitable training programs to prepare graduates for the higher level of implant practice in the respective disciplines. Appendix A contains an example of a comprehensive Diploma course aims and objectives provided by the Faculty of Dentistry, University of Sydney. Other University based courses similar comprehensive training programmes.

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2.3.2 Informal training 2.3.2.1 There are numerous training courses and programs on offer

by implant companies, private “institutes” and society-sponsored programs such as those run by The Australian Society for Implant Dentistry and The Australian Osseointegration Society from time to time. These courses fulfil an important role in providing information related technique innovation and the introduction of new products. However, they lack the rigor of an external accreditation process and are thus difficult to assess in terms of their educational outcomes.

2.3.3 Self-learn

2.3.2.1 Self-learn refers to a process of self improvement and professional development through courses such as those offered by University and Australian Dental Association sponsored Continuing Education, Internet based broadcast and other forms of distance learning. Unfortunately this un-calibrated learning is also difficult to assess and is very dependent on the calibre of the individual. Such an approach would be the most variable in terms of outcome compared to the other two options.

2.3.4 Mentoring 2.4.1 Kay and Hinds3 have defined mentoring as ‘A relationship between

two parties, who are not connected within a line management structure, in which one party (the mentor) guides the other (the mentee) through a period of change and towards an agreed object.

2.4.2 There are many positive benefits in a mentoring arrangement

where an experienced practitioner provides advice and assistance to novice practitioners in both general and implant dentistry.

2.4.3 Clutterbuck4 defines a mentor as “a more experienced individual

willing to share their knowledge with someone less experienced in a relationship of mutual trust. A mixture of parent and peer, the mentor’s primary function is to be a transitional figure in an

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individual’s development. Mentoring includes coaching, facilitating, counselling and networking.”

2.4.4 There are great benefits to mentoring in conjunction with more

didactic training but mentoring alone lacks a formal process and curriculum and is thus inadequate as a stand-alone option. However, the availability of inexpensive computer-based communication combined with the generosity of experienced practitioners in implant dentistry, renders mentoring a viable training tool.

2.4.5 Mentoring should be encouraged for all forms of more structured

postgraduate implant training and can become a means of formal assessment of practitioner skill that may be relied upon by registering bodies as an indicator of practitioner competence.

2.4.6 Guidelines for mentoring

2.4.6.1 The following mentoring guidelines are desirable:

2.4.6.1.1 Establish clear goals for the outcome of the mentoring

process. These should include:

• Skills to be achieved at end of the process (ie restorative, surgical or both).

• Activities to be undertaken including specific training within or in conjunction with the mentoring program

• Level of contact required to achieve these goals • Method of contact (electronic, face to face, both) • Level of input required of mentee by mentor i.e.

o degree of clinical information required, o degree of personal oversight required by

mentor, o regularity of contact, o who initiates contact.

2.4.6.1.2 Set the duration of the mentoring program 2.4.6.1.3 Establish an agreement to achieve the above

2.4.6.1.4 Negotiate remuneration on an equitable basis if

appropriate.

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3. Training Requirements

3.1 Each training programme, be it University based or offered through the private sector, needs to have a clearly stated and structured curriculum to allow practitioners to evaluate its worth. Entry level training courses should have a basic set of educational and skill goals that can provide practitioners and the public with confidence that implant treatment will be provided in a safe and scientifically sound manner. The general principles have been discussed above.

3.2 The following basic requirements have been split into surgical and

restorative areas since there are practitioners who wish to practice solely in one or other area or within both. It is entirely appropriate that there are courses aimed at covering one or all the of the skill areas at both basic and advanced level.

3.3 Surgical Training Requirements

3.3.1 The Journal of Prosthetic Dentistry - Glossary of Prosthodontic Terms defines implant surgery as: the phase of implant dentistry concerning the selection, planning, and placement of the implant body and abutment.

3.3.2 The development of implants suitable to replace one or

multiple missing teeth and predictably remaining in function over a substantial time has radically expanded restorative treatment options. Dental practitioners must therefore now offer this treatment option, where appropriate, for the wellbeing of their patients. However, this places the dental clinician under the obligation to fully understand the physiological processes underpinning the techniques and have the necessary expertise to either safely provide implant treatment for their patients or facilitate the necessary referral for such treatment.

3.3.3 Dental practitioners intent on performing surgery associated

with implant placement procedures should not proceed until they can demonstrate satisfactory skills in all facets of surgical treatment such as outlined below. The development of these guidelines has been made with the assistance of the ‘Training Standards in Implant Dentistry for General Practitioners’ published by the Faculty of General Dental Practice, Royal College of Surgeons of England6

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3.3.3.1 Must be able to assess a patient’s suitability for

implants via a comprehensive history and examination.

3.3.3.2 Must understand the medical conditions that could preclude a patient from implant treatment, or complicate surgery.

3.3.3.3 Must have an understanding of the implant options available and their indications and contraindications for certain patient groups.

3.3.3.4 Must be able to inform the patient sufficiently about

implant treatment to obtain informed consent.

3.3.3.5 Must have a detailed knowledge of the surgical anatomy of the maxilla and the mandible. The standard of this knowledge should be equivalent to that necessary for passing post-graduate qualifications.

3.3.3.6 Must have a detailed knowledge of the pathological processes that occur in the maxilla and mandible.

3.3.3.7 Must have a detailed knowledge of the radiology and radiography of the mandible and the maxilla, and how to interpret the findings from radiological examinations.

3.3.3.8 Must understand in detail the healing processes that occur following implant surgery.

3.3.3.9 Must have a working knowledge of the principles for

constructing prostheses on implant fixtures.

3.3.3.10 Must possess a detailed knowledge of and have been trained in infection control and practical surgical aseptic techniques suitable for implant surgery.

3.3.3.11 Must understand antibiotic use in relation to implant surgery.

3.3.3.12 Must understand the appropriate circumstances

where sedation or general anaesthetic may be required.

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3.3.3.13 Must display competence to the delivery and the

maintenance of satisfactory local anaesthetic

3.3.3.14 Must display competence to design and the ability to raise and reflect a viable muco-gingival flap.

3.3.3.15 Must display an ability to extract standing and buried teeth, preserving alveolar bone and maintaining gingival architecture.

3.3.3.16 Must be able to harvest and place a connective tissue graft.

3.3.3.17 Must display competence in the use of suturing

material and techniques to close surgical wounds. 3.3.3.18 Must display competence in the use of occlusive

membranes and the associated techniques for tissue regeneration.

3.3.3.19 Must be able to manage any intra-operative or post- operative complications arising from their treatment.

3.3.3.20 Must understand the maintenance of healthy implants and recognise and manage complications including peri-implantitis and fractured implant body or any implant component.

3.3.3.21 Must be prepared to attend courses on a regular

basis to update and reinforce knowledge in implant dentistry.

3.3.3.22 Must have an established procedure in the practice

for dealing with complaints.

3.3.3.23 Must possess suitable medical indemnity cover against medico-legal disputes involving implants.

3.3.3.24 Must have appropriate premises in which to carry out

implant surgery.

3.3.3.25 Must know the limitations of their clinical skills and be able to initiate a referral to a more knowledgeable clinician.

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3.3.4 Advanced Surgical Techniques. After the completion and the

documentation of an appropriate number of simple cases, the dental practitioner may wish to gain the knowledge and expertise necessary to perform the techniques involved in harvesting bone from intra oral sites to use in minor augmentation of the alveolar ridge and maxillary sinus graft during implant placement.

This knowledge would include an understanding of the use of exogenous bone or bone substitutes for minor augmentation. If the practitioner wishes to perform these more advanced grafting procedures they must have undertaken a formal course in the surgical techniques ideally including assisting during the completion of such procedures and operating under supervision.

3.3.5 Placement of implants with major bone augmentation and/or

modification of anatomical structures. Before progressing onto this type of advanced surgery a person must be competent and experienced in the placement of implants as described above.

3.3.5.1 The placement of implants with bone augmentation or minor

modification of anatomical structures demands a high level of surgical experience. The ability of a person to do such treatment should have been mentored and formally assessed by a suitably competent and experienced clinician.

3.3.5.2 The person must have attended courses and be specifically

trained in these techniques and have successfully passed a formal assessment. The person must be competent to deal with immediate and long-term complications of the treatment.

3.4 Restorative Training Requirements

3.4.1 The Journal of Prosthetic Dentistry - Glossary of Prosthodontic terms5 defines implant prosthodontics as: the phase of prosthodontics concerning the replacement of missing teeth and/or associated structures by restorations that are attached to dental implants. Implant dentistry is defined as: the selection, planning, development, placement, and maintenance of restoration(s) using dental implants

3.4.2 Thus restorative implant dentistry can be defined as: the selection, planning, development, construction and maintenance of prosthetic restorations attached to dental implants and replacing missing teeth.

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3.4.3 Basic level restorative skills that would be expected to be covered in an entry level restorative implant dentistry course are as follows. The development of these guidelines has been made with the assistance of the ‘Training Standards in Implant Dentistry for General Practitioners’ published by the Faculty of General Dental Practice, Royal College of Surgeons of England6.

3.4.3.1 A working knowledge of the anatomy of the maxilla and mandible. Whilst this might not need to be as detailed as for those clinicians carrying out surgical procedures, the placement of implant fixtures is so fundamentally related to local anatomy that a sound working knowledge is required for treatment planning

3.4.3.2 A working knowledge of the pathological processes that occur in the maxilla and mandible. This is a requirement for any general dental treatment but recognition of pathology is an essential part of implant treatment planning.

3.4.3.3 A detailed knowledge of the radiology and radiography of the mandible and maxilla, and how to interpret the findings from radiological examinations. It is important that radiological interpretation is not considered solely the province of the surgical clinician.

3.4.3.4 Understanding the healing processes that occur following implant placement and how to deal with post-operative complications. Although clinicians restricting themselves to restorative treatment might not have primary responsibility for surgical post-operative complications, patients can and do present to the restorative dentist initially before seeking the assistance of the surgeon and simple matters can easily be managed at this contact.

3.4.3.5 Understand antibiotic use in implant dentistry.

3.4.3.6 Understand the clinical assessment of a patient’s suitability for implants, and the medical conditions that could preclude a patient from implant techniques, or complicate surgery. This would include:

• The necessary historical detail required to evaluate the

patient’s desires and medical and dental background

• The clinical information and other records necessary to carry out a thorough pre-operative examination.

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• The relevance of periodontal health, caries incidence, dietary, habits, salivary status, occlusal presentation and parafunctional activity to implant treatment.

• The engineering and biological principles required for the construction of successful implant prostheses.

• The surgical techniques available to allow fixture placement including soft and hard tissue augmentation techniques.

3.4.3.7 Understand the implant options available and their indications and contraindications for certain patient groups.

3.4.3.8 Understand patient consent and how to obtain it prior to implant placement. 3.4.3.9 Understand the clinical procedures and fundamental principles in constructing non-implant related fixed and removable prostheses in both the partially edentulous and edentulous jaw.

3.4.3.10 Understand the clinical and laboratory techniques used to restore the most common implant restorations. This should include:

• Single tooth restorations • Multi unit bridges in the partially edentulous mouth • Implant-supported over-dentures • Implant supported bridges in the edentulous mandible

3.4.3.11 Recognise the technical and cosmetic limitations of implants, especially in the anterior maxilla.

3.4.3.12 Understand the maintenance of healthy implants

3.4.3.13 Possess a thorough knowledge of the assessment of implant

fixtures and implant-supported restorations together with the management of the failing or fractured fixture or restoration.

3.4.3.14 Understand the component options and instrumentation use for any implant system used.

3.4.3.15 Understand one’s personal skill level limitations and the type of case requiring referral to a more experienced practitioner

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3.4.4 Advanced level restorative skill would, in addition to the above

3.4.4.1 An understanding of the patient assessment and planning

• Full arch implant-supported fixed bridges in the maxilla

n the

ral

3.4.4.2 An understanding of the advanced surgical techniques and

3.4.4.3 An understanding of the special clinical and laboratory

skills, include the following:

requirements for constructing complex implant-supported prostheses; such as:

• Combination fixed and removable prostheses • Construction of implant-supported prostheses i

severely compromised patient, arising from either systemic medical complications or compromised opresentation.

implant fixture options involved in treating the compromised patient.

procedures for the long term maintenance of complex implant-supported prostheses.

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4. Success Criteria 4.1 Salinas and Eckert7 have stated that published implant

success rates for single tooth implant treatment often concentrated on simple survival of dental implants. Clearly, there are several factors other than the successful osseointegration of the implant(s) that contribute to overall implant prosthesis success. These include an absence of surgical complications, successful prosthesis construction and function, satisfactory aesthetic outcomes, an absence of prosthetic complications and long term stability of the implant-prosthesis complex.

4.2. The ultimate success criterion is patient satisfaction with the treatment. Many methods of success evaluation have been proposed8-10. Most of these have been aimed at quantitative evaluation of implant treatment for scientific purposes and, whilst important, are not entirely necessary to assess individual patient’s treatment in a practice setting. A clinician must, however, have a method of evaluating patients over time so decisions on intervention can be made at an appropriate time. The following criteria are suggested:

• Ongoing implant prosthesis comfort • Appearance of soft tissue health around each fixture with respect to

gingival inflammation, lack of increasing peri-implant pocketing, absence of pus exudate

• Absence of individual implant fixture mobility • Integrity of the implant prosthesis and absence of unusual

prosthesis complications. • Stability of marginal bone around fixtures as evaluated by

radiographs • Absence of other pathology around fixtures as evaluated by

radiographs.

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5. Professional and Ethical Behaviour

5.1 Introduction 5.1.1 A code of behaviour for professional and ethical conduct forms an important guide for the practitioner to follow. It also signals to the community that the profession is serious about maintaining high standards among its members. The following principles are important:

5.2 Safe-guarding the patient’s interest and well-being 5.2.1 The over-riding consideration during the treatment process must be the safe-guarding of the patient’s interest and well-being. The treatment must be aimed at achieving, as a minimum, a positive health outcome for the patient. 5.2.2 Thus, when formulating a treatment plan for the patient, the practitioner should take into account all relevant information gathered during the history taking and clinical examination steps and derive a plan appropriate for the best long term health of the patient’s dentition. A short term benefit that compromises the likely longevity of teeth or oral health is not appropriate. The treatment rationale should be clear and evidence based. . 5.3 Duty of care 5.3.1 All practitioners should be aware that the duty of care in implant dentistry includes post-treatment monitoring and maintenance care. Unresolved symptoms such as pain on loading or function, an unstable prosthesis, and mobile implants are not acceptable treatment outcomes. 5.3.2 The practitioner has a responsibility in law to provide “goods” fit for service. Correcting deficiencies in a prosthetic device is the responsibility of the treating clinician. 5.4 Appropriate referral

5.4.1 Knowing one’s clinical limitations in skills, knowledge and experience is an essential part of a practitioner’s ethical

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responsibilities. It is imperative that a clinician is able to recognise when it is in the patient’s best interest that they be referred to a more experienced practitioner.

5.4.2 Similarly, when there are complications or problems which cannot be resolved by the practitioner, the patient must be referred to an appropriate practitioner for further management and care. In addition, the practitioner should ensure that the referral has been acted on and the patient has indeed received appropriate care. 5.5 Continuing Professional Development (CPD)

5.5.1 Continuing professional development is expected of all health practitioners and is imperative in the rapidly changing area of implant treatment. A firm commitment to CPD is a cornerstone of ethical dental practice.

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REFERENCES

1. APP supplement. Parameter on placement and management of the dental implant. J Periodontol 2000;71:870-872.

2. AAP Academy Report. Position Paper. Dental Implants in Periodontal Therapy. J Periodontol 2000;71:1934-1942.

3. Kay D, Hinds R, A Practical Guide to Mentoring. How To Books Limited, Oxford, U.K., 2002

4. Clutterbuck D. 1991. Everyone Needs a Mentor. London Institute of Personnel and Development

5. Glossary of Prosthodontic terms, J Prosthet Dent, 2005, 94(1):10-92 6. Training Standards in Implant Dentistry for General Dental

Practitioners. December 2005, Faculty of General Dental Practice, Royal College of Surgeons of England.

7. Salinas TJ, Eckert SE. In patients requiring single tooth replacement, what are the outcomes of implant- as compared to tooth-supported restorations? Int J Oral & Maxillofacial Implants, 2007 (Supplement) 22:71-92

8. Albrektsson T. et al. The long-term efficacy of currently used dental Implants: A review and proposed criteria of success. Int J Oral & Maxillofacial Implants 1(1):11-25, 1986.

9. Smith DE, Zarb GA. Criteria for success of osseointegrated endosseous implants. J Prosthet Dent 1989; 62:567-72.

10. AD, Scurria MS, Shugars DA. A conceptual framework for understanding outcomes of oral implant therapy. J Prosthet Dent 1996; 75:633-9

11. Guidelines On Standards For The Treatment Of Patients Using Endosseous Dental Implants. Supplement to the British Dental Journal, March 25, 1995.

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APPENDIX A Oral Implant Education (University of Sydney) Revised 28/2/2007 Aims

1. Core Level - Undergraduate

• To develop an understanding of the underlying physiology and biomechanics

of dental implants.

• To develop an understanding of the role of dental implants in restorative care.

• To develop an ability to assess treatment plans and provide clinical care for

simple cases involving dental implants.

• To develop an ability to recognize and differentiate between simple and

complex implant cases and make appropriate referrals.

2. General Level – General practice


of dental implants.


• To develop an ability to assess treatment plan and provide clinical care for

complex cases involving dental implants where the patient is not medically

compromised and the implant sites are not physically compromised.

• To develop an ability to recognize complex implant cases where a specialist

team approach is required and be able to make appropriate referrals.

3. Specialist Level – Specialist practice

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of dental implants.


• To develop an ability to assess, treatment plan and provide clinical care for

complex cases involving dental implants where patients may be medically

compromised and the implant sites may be physically compromised.

• To foster the involvement of specialists in implant teamwork and to act as

mentor and/or team leader in implant cases, irrespective of the degree of

difficulty.

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Objectives

1. Core Level – Undergraduate - BDent

A. To have a good knowledge of:

1. the psychology of partial and total edentulism.

2. the biomechanics of osseointegration and dental prostheses.

3. the relevant regional anatomy associated with dental implant placement.

B. To understand:

1. the various options for tooth replacement, their relative prognoses and

the cost effectiveness of various treatment options.

2. the peri-implant tissue and its response to putative pathogens.

3. the principles of bone physiology, metabolism, biomechanics, tissue

(wound) healing, osseointegration and the soft tissue-implant interface.

4. aspects of imaging related to site evaluation for implant treatment.

5. the principles of occlusion related to implant supported prostheses.

6. the principles and options of space management.

7. the principles and applications of medical imaging related to simple dental

implant treatment.

8. extraction techniques for maximum tissue preservation.

9. the principle design for implant supported prostheses in less complex

cases.

10. the requirement for monitoring and maintenance of implant supported

prostheses.

C. To recognize:

factors and conditions which may affect successful implant treatment.

D. To be able to:

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1. carry out patient assessment and understand how relevant medical history

can influence restorative treatment options.

2. produce cases documentation of appropriate standard.

3. direct (refer) patients who require more complex treatment for the

appropriate care.

4. estimate the cost of implant treatment.

5. carry out simple implant treatment within treatment teams for mandibular

implant overdentures and single tooth (bicuspid) implant replacement.

2. General practice

All of the above objectives listed plus

A. To have a good knowledge of:

1. abutment selection options and their applications.

2. medico-legal aspects of implant therapy.

3. complications and their management.

4. the requirements for infection control and equipment in the surgical

environment.

B. To understand the principles behind:

1. the functional, aesthetic and phonetic needs of patients with implant

supported prostheses.

2. the radiographic imaging of bone and its relevance in treatment planning.

3. the rationale for linking implants with natural teeth in fixed bridgework.

4. the surgical principles as applied to implant treatment.

5. the contemporary concepts and gingival techniques related to the timing

of implant placement and loading.

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C. To be able to:

1. treatment plan, design and deliver overdentures.

2. design and deliver single tooth implant replacements.

3. design and deliver simple implant-supported bridges.

4. design and construct diagnostic and surgical templates.

5. maintain implant stock control.

6. coordinate a team approach for implant treatment.

7. carry out maintenance and management of bone and soft tissue changes

following implant placement.

8. understand and critically analyse the implant literature.

3. Specialist practice

All of the above objectives plus

A. To have advanced knowledge of:

1. occlusion and loading in restorative dentistry.

2. abutment selection including custom designed componentry.

3. materials as they relate to implant supported prostheses.

4. prosthetic complications and retrieval/repair techniques.

B. To understand:

1. the principles and techniques of bone and soft tissue grafting.

2. the treatment of atrophic maxillary and mandibular cases.

3. the treatment of patients with cleft palates.

4. zygomatic implants.

5. craniofacial reconstruction using implants.

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6. hyperbaric oxygen and implant treatment for patients who have received

radiotherapy to the head and neck.

C. To be able to:

1. manage implant treatment for medically compromised patients

(prosthodontic and surgical).

2. carry out guided bone regeneration (surgical).

3. carry out complex and full arch/mouth reconstruction cases

(prosthodontic).

4. carry out difficult and multiple implant installation in complex and full

arch/mouth reconstruction cases (surgical).

5. carry out appropriate implant site preparation including soft and hard

tissue augmentation (surgical).

6. manage complications (prosthodontic and surgical).

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BEST PRACTICE IN IMPLANT DENTISTRY