During recent years, the number of dental practitioners performing implant surgery has increased, allowing dentists to improve the quality of life of their patients. However, with this increase in the number, the variety and severity of the surgical and prosthetic complications from dental implants have also risen.
Many patients consider implantation a major decision because of the fear of the unknown and the high costs involved. Complications and delays can be quite demoralising and disappointing, leading to loss of confidence in the clinician. Occasionally, a patient cannot accept alterations of the original treatment plan and interprets them as negligence and malpractice, and might even file legal claim against the treating dentist.
This article highlights the importance of hands-on training for dentists wishing to add implants to their income stream, including mentoring, and looks at some of the main risks and complications associated with implant dentistry.
Mentorship, training and GDC guidelines for practitioners providing implant treatment
In response to growing concern about the delivery of implant treatment in general dental practice, the General Dental Council (https://www.gdc-uk.org/), in conjunction with the Faculty of General Dental Practitioners (UK), published guidelines on training in implant dentistry for general dental practitioners (https://www.fgdp.org.uk/). The use of mentoring as a key part of a structured implant training programme is strongly advocated.
The guidelines aim to ensure patient protection by establishing and maintaining standards of training in implant dentistry.
There were a number of important fundamental recommendations:
'Before starting to place implants a general dental practitioner should have practiced clinical assessment, treatment planning, and the placement of implants in the presence of an experienced implant clinician, as part of a course in implant dentistry meeting these standards. This mentoring should be continued until the experienced implant clinician considers the practitioner to be competent.'
In addition, the guidelines make specific recommendations about more advanced treatment modalities involving bone grafts:
'Before progressing onto this type of advanced surgery a person must be competent and experienced in the placement of implants as described above. 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 individual. The person must have attended courses which specifically train in these techniques and include an element of formal assessment. The person must be competent to deal with immediate and long-term complications of the treatment provided.'
It is proposed that these guidelines will be reviewed and updated in line with developments in implant dentistry education and clinical activity within the UK.
Examination and Diagnosis
It is absolutely essential that patients undergo a comprehensive history and examination to determine their main complaints and to avoid missing important diagnoses that will have a bearing on their dental management. Even common conditions such as caries and periodontitis can be missed when the dentist is focusing on the evaluation and provision of the more exciting aspects of dental implants. Although implants may be immune to dental caries they are susceptible to the ravages caused by inflammation, smoking and parafunction (Table 1). Implants placed in subjects with untreated periodontitis or close to periapical lesions are associated with higher failure rates.
Table 1: The main risk factors associated with increased implant failure:
Tobacco smoking (especially high dose/duration)
Endodontic lesions (e.g. apical granuloma)
Parafunction (e.g. bruxism)
Poor bone quality
Surgical after-care and complications
Localised infection at an implant site can arise from poor surgical technique, necrosis or contamination due to failure to reduce the bacterial count in the surgical field. Smoking, uncontrolled diabetes and periodontal disease are risk factors. Very rarely severe or persistent infections could arise for no apparent reason. There is some evidence that this may be due to activation of dormant foci of infections within the bone, which are impossible to identify in radiographs.
Damage to Inferior Alveolar Nerve
This can occur as a result of implant placement in close proximity of the inferior alveolar nerve, and particularly in case of poor surgical planning and/or technique. Any report of paraesthesia or altered sensation occurring to the teeth, lip or the gum should be investigated urgently and the signs and symptoms should be recorded.
Premature Membrane Exposure
Higher incidence of membrane exposure has been reported with the use of non-resorbable or highly cross-linked collagen membranes, as these do not readily integrate with the wound through rapid transmembraneous vascularisation. In these cases, the removal of the exposed membrane is advocated to reduce the risk of infection. With resorbable membranes such as natural collagen, wound infection is not a common feature, even if the membrane becomes exposed during healing, as these natural products have been shown to become rapidly vascularized through transmembranous infiltration of the microcirculation.
Maxillary Sinus Complications
Maxillary sinus can be involved either as part of the planned surgical procedure (closed or open sinus lift/grafting) simultaneously, or in 2-stage procedure when placing implants. In healthy individuals the success of bone regenerative procedures within the maxillary sinus cavity has been demonstrated to be safe and reliable. Severe complications, however, can arise due to poor surgical technique, infections and wound break down. Patient factors such as pre-existing sinus pathology, immunosuppression, medication, uncontrolled diabetes and periodontal disease also increase the risk of complications. An infected sinus graft should be treated rapidly, preferably through a referral to a specialist or more experienced clinician.
Displacement of Implants into Maxillary Sinuses
This is being reported with increasing frequency. The retrieval of the implant, preferably by endoscopic surgery, is indicated to prevent the migration of the implant or the damage to the sinus cavity.
Being aware of where the risks lie in implant dentistry will enable practitioners to make sure that their skillset covers not just the placing of the implants but also the complications that might arise, and thereby offer better care to their patients.