A 30-year perspective on implant dentistry

A conversation with Dr. David DiGiallorenzo

How did you become involved with dentistry?

My father was a prosthodontist, and my uncle was one of seven lab technicians. Growing up in this dental environment, I had the privilege of witnessing the incredible talent of numerous academics and clinicians in the Philadelphia dental community. I eagerly took the opportunity to shadow many of them, which solidified my passion for the field.

How did you alter the traditional paradigm of dentistry?

Having a mother who advocated for health in the integrative space, I developed an understanding of environmental health, organic approaches, holistic, and alternative therapies as means to take control of one’s health. In my practice, we integrate reflexology during treatment, acupuncture, aromatherapy, massage, along with Biohealth IV and fat-soluble supplementation.

Furthermore, I aimed to improve efficiency and reduce treatment timelines for patients referred to our practice. We wanted them to return to their referring doctors as quickly as possible. Financial considerations also played a role, as my father used to say that when he received his patients back from the periodontist, they were tired and broke.

To adapt to these challenges, we performed minimal scaling in the practice and primarily focused on comprehensive full-mouth periodontal procedures under sedation. This approach was not common on the East Coast, but rather an evidence-based approach more prevalent on the West Coast. Single-visit conversions to implants and immediate implant placement were also key priorities early on in my practice. We established a daily practice of emergency immediate total tooth replacement.

How did you evolve your career and practice?

During my specialty program, I had the opportunity to practice general dentistry two evenings a week and on Saturdays. This allowed me to apply my advanced education to my patient population, which was incredibly beneficial. In 1989, I met my wife, who happened to be the daughter of an oral surgeon. She also had experience working within the field of dentistry.

After completing the periodontal program in 1995, we decided to open two offices in Pennsylvania focused on periodontics and implants. I briefly taught at Penn and then started working closely with several implant and periodontal therapeutic companies, providing education globally. I also had the opportunity to lecture at numerous society meetings and study clubs.

Therefore, my focus was primarily on private practice and education. The first 15 years of my practice coincided with the golden age of implant dentistry and periodontics. During that time, most dentists had never restored implants, so we educated them on periodontal medicine, alveolar health, implant reconstruction, overdenture diagnosis and treatment, and the systemic manifestations of oral disease, occlusion, and diagnosis. Over the years, implants began to be treatment planned in general dentistry offices, which was a significant shift in the field.

How did you respond to this market shift?

In response to the market shift, we decided to start marketing directly to consumers. We recognized an unmet need to save or replace teeth, and as periodontal specialists, we were well-positioned to deliver that message. Other providers were also actively doing direct-to-consumer marketing focused on implants to help educate consumers about this option.

Some practitioners were upset about the emergence of direct-to-consumer marketing, but we viewed it as an opportunity to increase overall awareness. Our goal was to position ourselves in the pipeline to direct these consumers to our practice through radio, TV, and the internet. We aimed to bridge the gap and ensure that we all spoke the same language, despite the competing needs and interests within the field.

How do you feel about specialist training?

The unique aspect of specialty education is that it allows you to spend 10,000 hours becoming an expert in your chosen specialty. It not only develops your clinical expertise but also equips you with the ability to handle adverse outcomes and diagnose and treat patients at a more sophisticated level. Specialty education still offers viable options, whether in academic or clinical settings, and consumers will continue to seek specialized care. While the cost of advanced education may be prohibitive, the return on investment is still significant.

How did implant dentistry evolve?

At that time, we still lacked crucial diagnostic information that would come later. We began recognizing challenges in the implant-to-implant relationship when placed in thin biotypes. Defining the microgap and understanding the biologic width around implants were ongoing areas of study. The clinical datasets and advancements in these areas would come later with Team Atlanta and Dr. Dennis Tarnow. It was truly a golden age of innovation in implant technology.

What is genuinely new in implant dentistry today?

Most of the advancements we see today, such as platform-switching designs, All-on-4 treatment planning, scanners, and CT scanning, have been with us for decades. However, these advancements have undergone generational improvements and refinements over time.

How has implantology changed over the past 30 years?

Over the past 3 decades, we have witnessed significant advancements in medical and dental imaging, guided surgery, digital planning, milling, and the use of adjunctive therapies like growth factors. These tools have become essential components of our toolbox, allowing us to provide better care once we have a proper diagnosis. However, the most notable change has been in the patients and the marketplace.

In my practice, the key to determining the best treatment options for each patient lies in comprehensive dental and medical diagnostics. Every patient receives a tailored approach based on their unique diagnosis. What has truly changed is our ability to deliver therapeutic options in a more timely and simplified manner. For instance, we can now often provide a full-arch fixed All-on-6 solution in just four visits. This highlights the integral role of specialists in delivering predictable and efficient results. It’s important to remember that we are all held to the standard of care for our respective specialties.

Are we better off than before?

Presently, peri-implantitis affects approximately 50% of all implants, which has become a significant disease entity and a common concern in periodontal practices. Therefore, it is important to consider the maintenance of natural teeth as a viable option. Thus, the question arises — are we truly better off than before?

Currently, we are facing a crisis in commercialized dentistry with patients being sold treatment plans that do not meet acceptable diagnostic standards. Some practices and doctors are placing implants and undertaking complex treatment plans that exceed their skill set, resulting in poor outcomes. Patients who experience such negative outcomes share their dissatisfaction with others, distorting the perception of implant dentistry. Money and volume-driven paradigms have contributed to numerous adverse outcomes.

How has diagnosis changed in the past 30 years?

Dr. Morton Amsterdam always emphasized, “There can be only one diagnosis, but many treatment options. If we miss the diagnosis, our therapeutic endeavors become more prone to failure.” This statement remains critical today. While practitioners spend a significant amount of time refining techniques, it is essential to remember that expertise in a specific area requires approximately 10,000 hours. During specialty training, we spend 3 years studying and applying knowledge for around 60 hours per week.

However, the key to success still lies in proper diagnosis. Our literature has continuously evolved over the decades, providing critical information that must be firmly ingrained in our minds. In my approach, I start by examining the patient from the outside and work my way down to the dental level. Understanding the patient’s past dental history is crucial to avoid repeating past mistakes. Patient narratives also offer valuable insights for diagnosis. Additionally, we consider the medical history, vitamin D levels, inflammatory mediators, and sometimes conduct sensitivity testing for known materials.

We evaluate occlusion, angle classification, skeletal profile, periodontal health, caries, esthetics, phonetics, smile reveal, tissue biotype, previous failures, patient expectations, bone density, sinus health, joint health, alveolar health, endodontic diagnosis, and interproximal bone levels. We classify cases as perio, caries, or a combination thereof, as well as assess occlusion and neuromusculature. Patients with a history of cancer, Lyme disease, and other inflammatory conditions are candidates for zirconium implants, as metals can complicate the body’s electrical circuitry and induce inflammation.

Diagnosis is currently suffering in the implant world. There is a trend of edentulating patients and providing them with prosthetic periodontal biotypes. The idea that everyone is a candidate for All-on-4 treatment is questionable, especially when considering guided surgery. Mutilating a healthy gingival scaffolding and reducing the anterior maxilla’s healthy interproximal bone is not suitable for everyone. We have a higher responsibility to our patients.

How has the consumer marketplace changed over the past 30 years?

Over the past 3 decades, there have been notable changes in the consumer marketplace, largely influenced by the widespread use of the internet and digital technology. Patients now have easy access to information through search engines, leading to second opinions, misinformation, and a lack of loyalty to healthcare providers. Additionally, patients today prefer comprehensive solutions provided in a single location and have a strong desire for immediate results. They often seek treatment from commercialized vendors with varying levels of expertise, creating opportunities but also the need for careful evaluation when comparing different providers. It is crucial for dental professionals to resist an economic-based philosophy and avoid compromising on quality and patient care.

What are the largest differences between today’s patients and patients of 30 years ago?

One significant difference between today’s patients and those from 3 decades ago is the increased prevalence of medically compromised individuals. Chronic diseases such as diabetes, heart disease, Lyme disease, and immune disorders like lupus often coexist with periodontal disease and advanced caries in these patients. Furthermore, contemporary patients face higher levels of environmental cellular toxicity, endocrine disruptors, and metabolic disturbances. Circulating inflammatory mediators and cortisol levels are also elevated, which can negatively impact efficient healing and long-term homeostasis. Deficiencies in vitamins, trace minerals, micronutrients, and hormones further complicate the healing process, even in otherwise healthy individuals.

In light of the rampant occurrence of peri-implantitis and various health conditions, it is becoming increasingly common to recommend fixed perio-prostheses as an alternative to edentulation and implant-supported restorations. Traditional periodontal prosthesis and crown-and-bridge solutions regain relevance as a bail-out strategy when anterior implants fail in the esthetic zone. These fixed restorations offer a broader scope of treatment that helps control many variables contributing to functional and esthetic implant failures.

Are you concerned about the increasing presence of Dental Service Organizations (DSOs) in the dental market?

Yes, I am concerned about the widespread influence of general DSOs that prioritize high volume, low-cost implantology, and the use of mini-implants without proper consideration for patient care. What is particularly worrisome is that practitioners in these environments may lack the necessary expertise, often being recent graduates who are trained by sales representatives in a corporate setting.

One significant concern is the undue pressure placed on younger doctors to perform as many procedures as feasible within a limited timeframe. It is important to recognize that one cannot be an expert in all facets of dentistry. That’s why the specialty model remains crucial for our patients. By focusing on specialties, we ensure that patients receive the specialized care they require. This desire for specialists to grow and thrive was a contributing factor in my decision to join Specialty1 Partners.

Can you elaborate on the importance of expertise and experience in implant dentistry?

While we can teach anyone to perform a procedure, it is essential to understand that the diagnosis and management of complications come through expertise and experience. Only then can we effectively apply the technology and techniques available to us. It is the combination of knowledge, skill, and understanding that leads to successful outcomes in implant dentistry.

Are there any positive developments within the DSO landscape that you find promising?

I am genuinely excited about the emergence of specialty-focused partnership organizations, particularly partnerships that value the clinical autonomy of specialists and prioritize collaboration and partnership among their members. For specialists considering selling their practices, specialty-focused partnerships offer a more robust option that allows them to continue delivering specialized care while benefiting from the resources and support of a larger organization and, within some organizations such as Specialty1 Partners, retaining equity in the larger scalable entity. By working together and emphasizing the importance of specialized care, we can continue to provide the best possible outcomes for our patients.