Competition for implant patients:an inconvenient truth

Kenneth W.M. Judy, DDS, FAGD, FACD, FICD

In Dental Economics®, November 2008, I opined that if the profession were to allow commercial entities to decide who should place implants, our “golden age“ would be severely shortened. Desire for corporate profit, increased market share, and glitzy advertising should not drive the nature of patient care or the distribution of caregivers. But often they do. Two other factors which are causally related have begun to shrink the implant market generally and on a per unit patient fee basis.

First, we have a challenged and contracting global economy with decreased discretionary income. Second, the specialist versus generalist conflict continues unabated but has morphed into a new specialist versus specialist confrontation. The best way to illustrate this is to describe what happened recently in a senior year dental hygiene class in Florida.

CT-assisted preoperative planning for placement of four small diameter implants. Patients appreciate the commitment to the latest technology and the cost savings involved. Courtesy of Dr. Alvaro Ordonez, Miami, Fla.

A local oral surgeon was invited to lecture on dental implant surgery. He ran 30 minutes beyond his allotted time and then magnanimously took questions for an additional 15 minutes, encroaching upon the next speaker's presentation, which concerned hygiene education and care for implant patients. Rude? Yes. Instructive? Judge for yourselves.

The oral surgeon spoke extensively about small diameter or mini dental implants. He stated that most of them broke upon insertion and that generalists then switched to another site and left the broken segments in situ. He further stated that they were “all wrong because they were not manufactured from commercially pure titanium.“

He did not seem to be aware of Dr. Gordon Christensen's recent excellent article on small diameter implants or the fact that they have FDA approval. The oral surgeon then championed a two-stage surgical protocol with four- to six- month healing intervals.

He went on to condemn all forms of immediate loading protocols as not being research based and advised that they “be avoided at all costs.“ Not content to confine himself to these outlandish “surgical“ statements, he then entered the restorative arena by condemning bars with Harder clips because “with locator attachments there was no need for implant parallelism.“

He closed by presenting a number of failures or case complications or diagnostic errors that his generalist colleagues had made and bemoaned the fact that as an oral surgeon he was always being called upon to “fix the implant mistakes of others.“ He was further dismayed by those generalists who were “weekend warriors who took a few days of corporate training and then began their implant practice on Monday morning.“

To top this off, he then strongly advised his audience of future hygienists to be very wary of working with generalists or even periodontists who chose to place implants themselves instead of referring them to oral surgeons.

It would be an understatement to say that I was shocked to read the report I received of this incident and of the ex cathedra statements that were made. My initial anger gave way to wanting to memorialize the event, to understand it, and then to provide an educational perspective to my colleagues, both generalists and specialists.

First, he should realize that such a presentation violates the Code of Ethics of the American Dental Association (ADA) in making claims of superiority vis-à-vis his colleagues. I wonder if he is even an ADA member. I can just see him saying, “Who needs them anyhow? I am an oral surgeon.“

Similar finished case with four small diameter implants which provide immediate increased prosthesis retention, stability, and patient satisfaction. Courtesy of Dr. Henriette Lerner, Baden-Baden, Germany.

He should consider who refers patients to him. Second, he should be more aware of the level of implant training in periodontal and prosthodontic postgraduate programs. Third, he should realize that the majority of implants placed and restored are done by generalists, and I can assure him that they take continuing education very seriously and are not “weekend warriors.“ Fourth, he should look at himself honestly and try to become aware of why he acted so unprofessionally.

I would suggest a minimalist assumption using the principle of Occam's razor and conclude that his greed and ignorance were the operative motivational factors. Greed needs no explanation. Ignorance of Dr. Gordon Christensen's query, “Who are the victims … of turf battles?“ is not excusable since it is the public we all should serve.

How to serve the public is at the heart of the matter. Proper informed consent is both an ethical as well as a legal issue. The oral surgeon's ignorance of the success rate of small diameter implants, admittedly higher in the mandible than in the maxilla, guarantees his being guilty of malpractice since he has personally ruled out presenting all treatment alternatives to his patients as well as the advantages, disadvantages, risks, and costs. I would again refer him to Dr. Gordon Christensen's article in this regard in the October 2008 issue of Dental Economics®.

A more positive point of view, which was recently articulated to me by my colleague, Dr. Alvaro Ordonez, from Miami, was that the total professionalism of one's office as well as its commitment to current technological advances, such as CT implant planning and CT-assisted implant placement, are significant factors when presenting treatment alternatives that have very different prices (e.g., small diameter implants to provide increased denture stability and retention versus “four on the floor“ with a milled connector bar and a new over-denture prosthesis).

Not everyone can afford the most expensive form of treatment. The totality of our commitment to education for ourselves and our office teams as well as our willingness to refer when a case or an element of a case exceeds our competence should eliminate the inappropriate competition that our changing economic conditions seem to be fostering.

Dr. Kenneth Judy is co-chair of the International Congress of Oral Implantologists (ICOI). 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. He has been involved in implant research and practice for more than 40 years.