by Gordon J. Christensen, DDS, MSD, PhD
This article will probably upset you if you are satisfied with the current high cost of implant dentistry, the turf battles raging over who places implants, and the lack of access to dental implant treatment for many patients who need them.
During my career, several highly significant innovations have come into the dental profession. Some innovations, such as the air-rotor handpiece, have made dental treatment faster and more acceptable to both patients and dentists.
Other innovations have made significant improvements in patient care, such as resin-based composite restorative materials, crown-down endodontic techniques, or zirconia-based restorations. However, one of the most important concepts introduced during my career has been root-form dental implants.
As a prosthodontist, I have been placing and restoring dental implants for about 25 years. Early in my implant experience, I doubted the service potential of implants, and some early implant forms failed soon after placement.
With the advent of pure titanium and titanium alloy implants, I recognized clinical success immediately. I was able to treat patients successfully who were nearly impossible to treat before. To my astonishment, the implants continued to serve at an unprecedented and unexpected level of 95% or more over many years.
The most significant upgrade that root-form implants made in my clinical repertoire was my ability to treat edentulous patients, especially mandibular edentulism. When I treated these dental cripples with simple, relatively inexpensive implant-supported removable prostheses, or with more expensive implant-supported fixed or removable prostheses, patients' lives changed positively.
In many debilitated edentulous young and old patients, I observed major life changes after I had placed implants and restored edentulous patients. They felt, looked, and acted younger. They had renewed self-esteem. Their self-confidence and their ability to lead normal lives were increased.
Soon, use of root-form implants to support removable partial and fixed partial dentures was accepted by the profession and the patients they serve. Later still, use of implants as single-tooth replacements evolved, bringing significant improvements in function and esthetics to millions of patients with these less-severe dental defects.
Many of you reading this article have had experiences similar to those I have described, and you know the unbelievable benefits of root-form dental implants. Root-form dental implants are a blessing to dentists and patients, but we have some major problems with the concept. The purpose of this article is to identify, discuss, and make suggestions about three obvious and growing problems concerning dental implant therapy:
- The rising cost of implants from manufacturers
- The concomitant rising cost of implants for patients
- The raging turf battles among dentists about who is capable of placing implants and who should be placing them
The cost of implants from manufacturers and practitioners
How does a few cents worth of titanium or titanium alloy used to make a root-form implant, and a few minutes of machining that metal, grow into many hundreds of dollars? I fully understand the research and development that goes into such endeavors as designing and manufacturing implants, the advertising that must follow to stimulate implant sales, and the sales teams that have to sell the products. The price range of implants from various manufacturers is appalling. These small pieces of metal, accompanied by a few screws, have a price range that varies more than 800%.
If the lower-cost implant companies are charging enough money to advertise, accomplish research and development, and still make a profit, what are the reasons for the prices of the higher-cost implants? If you could buy an adequately performing new car for $25,000 and one similar in all ways that sells for $200,000, which one would you buy? Variation in cost is not limited to manufacturers. What about practitioner fees for dental implant placement?
Although the range of fees for implant placement is not as large as the manufacturers' range in prices for the implants, practitioner fees still range up to 300% different from one practitioner to another. Such a variance may be explained by geographic cost of living and level of education, but it is still not feasible or justifiable to me.
Why am I complaining? The net result of the high cost of implants from manufacturers and practitioners is that most average-income patients cannot afford to have dental implant treatment. Those patients who need implants desperately, such as elderly edentulous patients, cleft palate patients, accident victims, and others, often go without implants, having to rely on conventional, non-implant oral care because of the high cost of implant therapy.
In my opinion, implant-supported dentistry has grown into treatment for the affluent and privileged. On hearing the presentations in implant meetings and observing publications about implants, it appears that every patient can afford expensive grafting, laborious and time-consuming multi-appointment treatment plans, and esthetically oriented over-treatment promoted by many clinicians and manufacturers. Who treats the majority of patients with average incomes and major oral treatment needs, and with what treatment modalities?
I'm sorry if I just don't understand who we are. In my opinion, we (dentists) are a health profession. We have committed ourselves to treatment of all of the public at a justifiable fee. It appears to me that we have deviated from our charge!
In my opinion, after observing the well-proven success of dental implant therapy and the great need of the public to have it, some radical action is needed. Now is the time to encourage manufacturers to produce moderate-cost implants and for dentists to patronize companies that produce quality implants sold at a reasonable price. It is time to plan and emphasize effective implant treatment for patients that can be produced at affordable fees without elaborate, expensive techniques. It is time for dentists to evaluate and contain implant placement costs and to provide this fantastic service to patients at reasonable fee levels. Such treatment should include, but not be limited to, practical, simple, non-invasive implant-supported removable prostheses as alternatives for the exotic expensive treatments promoted by many companies and clinicians.
Subduing the ongoing turf battles
I candidly ask any reader of this article who places implants: how difficult is the placement of root-form implants in healthy patients who have adequate bone? After several decades of practice and successful placement and restoration of many implants, I can state with no reservation that many techniques I accomplish in dental practice on a routine basis are much more difficult than placing implants in healthy patients with adequate bone present. Certainly, the more difficult implant placement situations require more experience and expertise.
It is significant to note that dental implant placement did not evolve from the dental surgical specialties. It is well known that placement of dental implants evolved from general practitioners approximately 40 to 50 years ago.
Those practitioners were criticized by peers, and they accomplished their questionable procedures under scrutiny and without acceptance for many years. Only when the non-dentist Professor Per-Ingvar Brånemark developed the root-form implant and its success was recognized could these implant-placing general dentists and some prosthodontists come out into the open and proclaim what they were doing. About that time, an elitist group of specialists, supported by certain companies, overtly took over the placing of implants as if they had invented them.
Currently, implant placement in the U.S. is accomplished by most oral surgeons (~7,000) and periodontists (~5,000), many prosthodontists (about one third of 3,500), a few endodontists (a small percent of 4,000), and an estimated 6% of 140,000 general dentists (~ 8,500 — this is a guess, since estimates vary widely). It may be surprising for some U.S. dentists to know that in numerous other countries, most general practitioners place root-form implants.
Some dental implant manufacturers are reluctant to promote implant placement by general dentists because they are being criticized by specialists who feel that they will lose revenue if general dentists place implants. In my many years of experience, this belief is entirely unfounded and incorrect.
As general dentists learn to place implants, most determine in which type of patient and under what circumstances they will place implants, and therefore their involvement in implant surgery is self-limiting. Most GPs soon determine in which situations they feel more comfortable, referring to other practitioners for implant placement. The result of implant placement by surgically oriented and trained/educated GPs is that more patients are treated and more difficult patients are referred to specialists. Some manufacturers tell me that they do not want to educate general dentists how to place implants because their main revenue source from implant sales is specialists.
Of course, it is specialists. General dentists have more than 100 oral procedures they accomplish, and implant placement is only one of them. The more general dentists who learn how to place implants, the more revenues will come to implant companies from this source.
Who are the victims of high implant costs andturf battles?
Is there any question? The public we dentists have pledged to serve are the victims. Many cannot afford treatment. Patients living in remote or rural areas cannot have implant therapy simply because of lack of access to those specialists who place them. At this time in history, implant dentistry is still in its infancy. Implants are serving only a minute fraction of the public. Most patients who really need implant therapy either cannot access it or cannot afford it.
Conclusions
Root-form implants are the most effective, and in many cases the only effective treatment for some patients, but those patients are most often the ones who cannot afford implant therapy. The cost of implants from some companies appears to be unjustifiably excessive. The fees for placing implants by some practitioners appear to be unjustifiably high. Exotic, extensive treatment plans are emphasized by both clinicians and manufacturers. Simple, less expensive, easily accomplished implant treatment is often overlooked. Embarrassing turf battles rage on unjustifiably, limiting access of patients to implants, and discouraging more dentists from learning to place implants.
It is time to analyze the foolishness of both the high cost of implants and the turf battles, return this great service to what it is — health care, and provide implant services to more of the public at affordable cost.
Additional views on implant therapy by Christensen
1. Christensen GJ. What is the role of specialties in dentistry? JADA 2003; 134 (11):1517-1519.
2. Christensen GJ. The dental implant dilemma. JADA 1991; 122 (5):79.
3. Christensen GJ. The most needed application for dental implants. JADA 1994; 125(6):743-746.
4. Christensen GJ. Implants and the general practitioner. JADA 2000; 131 (3):359-361.
5. Christensen GJ. Treatment of the edentulous mandible. JADA 2001; 132 (2):231-233.
6. Christensen GJ. Selecting the best abutment for a single implant. JADA 2008; 139 (4):484-487.
7. Christensen GJ. Three-unit fixed prostheses vs. implant supported single crowns. JADA 2008; 139 (2): 191-194.
8. Christensen GJ. The "mini" implant has arrived. JADA 2006; 137 (3):387-390.
Dr. Christensen is a practicing prosthodontist in Provo, Utah, and Dean of the Scottsdale Center for Dentistry. He is the founder and director of Practical Clinical Courses, an international continuing-education organization initiated in 1981 for dental professionals. Dr. Christensen is a cofounder (with his wife, Rella) and senior consultant of CLINICIANS REPORT (formerly Clinical Research Associates), which since 1976 has conducted research in all areas of dentistry.
