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WHY DIDN'T I DO THIS SOONER Timothy F. Kosinski, DDS

A recent editorial in the November 2001 issue of the Journal of the California Dental Association states, "Dental implants are the preferred method for tooth replacement in many situations that were formerly the province of traditional prosthodontics." For the general practice dentist this means the standard of care has been redefined and implants must be offered as the preferred option for many crown and bridge and denture patients. Why is this important? Incorporating dental implants into treatment plans for patients who have lost teeth results in many benefits such as maintenance of bone, elimination of preparing vital abutment teeth and even improved esthetics. With the principles of smile design and emergence profile becoming so prominent in dentistry today, the manufacturers have provided us excellent components that simplify the restorative process and allow for outstanding esthetics.

Most consumers are still not aware of the benefits that implant dentistry can provide. A consumer awareness survey conducted by the Institute for Dental Implants and reported in their "Health Letter," published in 2000, found that only 36% of the respondents knew bone loss resulted from tooth loss, even though the survey respondents had either bridges, partials or dentures or were considering these treatment options to replace missing teeth. Forty-five percent of the respondents who were aware of implants knew about bone loss and 75% of the respondents with bridges, partials or dentures would have changed their minds if they had known about bone loss. Today it is incumbent on the general practitioner to educate and instruct their patients on the options available today, including the benefits of dental implants and the consequences of long term tooth loss.

Twenty years ago dental implants were introduced by Branemark to North America, which started an entirely new phase for implants in this country. While the early Branemark clinical reports were on totally edentulous mandibular patients, it was not long before the focus changed to partially edentulous cases. Today the vast majority of patients receiving dental implants are partially edentulous and most of the partially edentulous group are single tooth replacements. This information sets the tone for dental implants in this country and naturally has defined the direction for the evolution of dental implant systems.

Before summarizing some of the product innovations that have made implant dentistry simpler for dentists restoring implants and easier for patients receiving implant therapy, a few comments about the size of the dental implant market are appropriate. After all, the potential market for dental implants for partially and totally edentulous patients is very large and growing rapidly. It is critical general dentists out there, the gate keepers of dental therapy, get involved and provide information and treatment where appropriate.

The Centers for Disease Control and Prevention reports that by age 17, 7% of people in the United States have lost at least one permanent tooth because of decay. Cavities and periodontal disease are the main reasons for tooth loss and among adults from 35 to 44 years old, 69% have lost at least one permanent tooth. By the age of 50, Americans have lost an average of 12 teeth, including their wisdom teeth, and among adults 65 to 74, 26% are totally edentulous. These statistics confirm the huge pool of patients that could benefit from dental implants and the challenge for general dentists who chose to treat them.

The dental implant industry is aware of the opportunity, but they also realize the need to simplify surgical and restorative procedures so that implant dentistry becomes more like conventional dentistry. In the past, a practitioner may elect to perform an implant case. It may have been a little more complicated than anticipated and he or she may have even lost money on the case. This is fine the first time around because it is rather exciting to perform a new procedure. The practitioner may attempt a second case and break even. But experience indicates the dentist will not promote a third case if he or she is not able to show a profit. Most dentists feel comfortable providing the treatment they feel they do best. When you throw in the concept of reimbursement, the dentist may choose the more conventional approach and not discuss dental implants, even if implants may be a more conservative approach. This is a mistake. Dental implants provide an outstanding alternative to conventional restorative techniques and we owe it to our patients to explain the options. Let the patient make the final decision understanding the benefits and risks of all the choices.

Recent trends indicate that cemented restorations are the procedure of choice. In many cases the implant surgeon, who may be an oral surgeon, a periodontist, a prothodontist or a general dentist, may even place the abutment so that the restorative dentist can prepare the abutment as necessary, make an impression and cement on the crown that is fabricated by the dental laboratory. Other trends include immediate placement of an implant after tooth extraction when bone is adequate and there is no sign of infection, and immediate loading of certain types of implants. All of these innovations make implant dentistry more attractive to both patients and the restoring dentist. The key trends toward simplification and cemented restorations allow general dentists to become proficient in dental implants in a much shorter period of time. Depending on the level of involvement the practitioner chooses, the initial investment is manageable. A surgical setup with appropriate equipment and an inventory of different size implants may involve an initial investment of $10,000. This is reasonable considering the cost of many of our innovations in our practices. If one chooses to only restore the cases, the investment is much less, around $800-1000 for the prosthetic kit and a small inventory of abutments and laboratory components. The laboratory cost for implants cases is slightly higher than normal, possibly as much as 20% more. This percentage cost increase should be passed onto the patient.

Dr. Kosinski’s office in Bingham Farms, Michigan
Dental implants are also seeing greater acceptance because of the continued publication of long term success rates. The first Branemark implants now have more than 30 years of history and are still performing well. Most publications report success rates in the 95% ranges but cases that require bone grafting, sinus augmentations and guided tissue regeneration may have lower success rates. Long term statistics from the insurance industry now indicate that implant restorations will outlast the conventional crown and bridge restorations.

While there are many reasons for a general dentist to become proficient in dental implants and make them the restorative option of choice for many patients, there continues to be some issues that have not been resolved. For example, insurance coverage for dental implant procedures is spotty at best and implants become a fee- for-service therapy. Many practitioners choose to make implants and their cosmetic therapies fee-for-service procedures. The next issue is cost. Many dental implant procedures are costly and patients must be willing to pay out of their own pockets. Many patients feel that they cannot afford them, but when they better understand the value and benefits of implant treatment, they are willing to accept the financial responsibility. Presenting the benefits, such as maintenance of bone, facial structures and preservation of adjacent teeth help the patient make a decision that is right for them.

Even the issue of calculating fees to be sure that profitability for the restorative dentist is preserved has been addressed. It is important that the practitioner work closely with a qualified implant lab. Certainly they can help formulate laboratory costs. Working with the dental manufacturers can also simplify the process. Time spent on esthetics and the dentists’ competence and confidence is the third part of the fee process. The entire dental team must become comfortable with presenting and providing implant therapy. If any one of the links is broken, implants will not become viable in the office.

I have presented some of the pros and cons about the current state of dental implants in the United States. There is a large potential population for dental implants, the procedures have been simplified and predictable and there are definite benefits to our patients. Training, cost, lack of insurance coverage and concerns about the profitability of implant cases are potential drawbacks. These concerns should be addressed and can become insignificant as each general dentist becomes proficient in implant therapy. The overriding issue becomes the extremely high degree of satisfaction expressed by many implant patients. Their only regret is that they did not do the procedure sooner. DT
Dr. Kosinski is a Diplomate of the American Board of Oral Implantology/Implant Dentistry, the International Congress of Oral Implantologists and the American Society of Osseointegration. He is a Fellow of the American Academy of Implant Dentistry and the Academy of General Dentistry, and a member of the American Prosthodontic Society. He has been inducted into both the American and International College of Dentists. Dr. Kosinski practices general and implant dentistry in Bingham Farms, MI, and is an Adjunct Assistant Clinical Professor at the University of Detroit Mercy School of Dentistry. He has published numerous articles on the surgical and prosthetic phases of implant dentistry, and is a contributor to Principles and Practice of Implant Dentistry.

Dr. Kosinski can be reached by calling 248-646-8651 or by writing him at: 31000 Telegraph Rd., Ste. 170, Bingham Farms, MI 48025
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