IMPLANT INSIGHT: The importance of clinical guidelines

AO Immediate Past President Dr. Stephen L. Wheeler discusses some timely information for clinicians to apply in their practices

As dental implants become more mainstream, proper training and standards are more important than ever. It’s important that specialists and general dentists involved in implant dentistry work together to represent the field in the best light possible.

The Academy of Osseointegration (AO) seeks to ensure that those offering implant reconstruction to their patients have the training and background to provide excellence in their care. It is critical to follow evidence-based clinical guidelines focused on achieving the best possible patient outcomes.

AO clinical guidelines

In 2008, AO published its first set of clinical guidelines focused on dental implants. The purpose of the guidelines was to establish guidance based on the provision of patient care and the results of AO’s 2006 Consensus Conference on the State of the Science on Implant Dentistry.

In 2010, AO updated the guidelines to provide an update and expansion of its recommendations for safe and effective implant dentistry. The Academy’s “Guide-lines for the Provision of Dental Implants and Associated Patient Care,” which were published in The International Journal of Oral & Maxillofacial Implants (JOMI), are available to download in their entirety via AO’s home page at www.osseo.org.

HighlightsofAO’sguidelinesinclude:

Training: Whether a specialist or general dentist, AO is determined to underscore the importance of adequate training in the surgical and/or prosthodontic aspects of implant dentistry. Training pathways now exist through monospecialty training programs, as well as a wide variety of courses offered through institutions both in the United States and abroad, and by private individuals and companies.

Training must be comprehensive enough to not only meet legal standards of care, but also to ensure optimal patient outcomes and maintain a positive public image of implant dentistry. At minimum, clinicians who place, restore and/or maintain dental implants should be well-versed in implant dentistry techniques, technologies, and best practices for basic to complex cases; diagnosis and clinical care plans; patient selection and education; surgical protocols; minimizing risk and treating complications; ethical considerations; and maintenance and long-term management. In addition, because the field of implant dentistry is always advancing and changing, clinicians must be committed to ongoing training and education.

Legalstandard: The law holds that any practitioner (generalist or specialist) undertaking any surgical and/or prosthodontic procedure, particularly one deemed to be of a complex nature, should do so to the same standard of care expected of a specialist; or in the case of a specialist, to a standard equal to a reasonable body of his/her peers. In particular, the ability of a practitioner to predict, recognize, and treat complications arising from treatment is of paramount importance.

Therapeuticgoal: Implant dentistry should be a restoratively driven therapy whereby the therapeutic goal determines the treatment plan and subsequent surgical placement of dental implants. Assisting in the ongoing maintenance of the remaining intraoral and perioral structures and tissues remains part of the therapeutic goal.

Pretreatmentconsiderations: It is important to emphasize that the need for a dental implant is a prosthodontic diagnosis and the prescription of a dental implant is part of a restorative treatment plan. This will involve a number of stages, which can be distilled into the following headings:

• Appropriate medical and dental history
• Thorough intra- and extraoral examination
• Appropriate radiographic examination and any other relevant investigations
• Provision of a comprehensive report, treatment plan (including schedule), and estimate of treatment cost

Diagnostics: The following aids are recommended for use in reaching a presurgical diagnosis to assist in determining the complexity of the case as well as the number, location, type, and angulation of the implants and abutments to be placed:

• Mounted diagnostic casts
• Imaging techniques
• Radiographic guides and templates
• Computerized planning software

Theat-riskpatient: Possible contra-indications to implant therapy and risk factors for implant failure include smoking, diabetes, periodontal disease, osteoporosis, and certain types of radiotherapy.

Implantplacement:
The surgical approach should be based on the pretreatment evaluation and the type of implants and/or graft procedure to be utilized. The surgical risk should be assessed and classified according to the Surgical Classification System (scale 1 to 4) as set out in the “Parameters of Patient Care” document of the American Association of Oral and Maxillofacial Surgeons (AAOMS).

Graftingprocedures:
For the purposes of classification, grafting can be categorized as dentoalveolar or anatomical.

Postoperativemanagement: It is a central requirement in all patient care documents that a patient be provided appropriate instructions for postoperative care. These instructions may be verbal, but a written, individualized instruction sheet is recommended with information on bleeding, pain control, swelling, the need for antibiotics, the use of chlorhexidine or similar mouthwashes, etc.

Prosthodonticconsiderations: Im-plant dentistry is a restoratively driven therapy, and as such, the prescription of implants will have been taken in light of all other prosthetic considerations — including an evaluation of the pre-existing condition of teeth adjacent to edentulous spans, alternative methods of tooth replacement, and the condition of the soft tissues, which may be critical to the anticipated results.

Managementofimplantandperi-implanttissues:
Periodic evaluation of implants is a requisite component of patient care. The responsibility to perform this evaluation falls on the providing clinician(s). In the case of a team approach, an agreement should be in place as to whether one or both members of the team (i.e., surgeon and/or prosthodontist or general dentist) will follow the patient.

Recallappointments: The appointment should involve a careful examination of the suprastructure, the surrounding peri-implant tissues, and an assessment made of the patient’s oral hygiene. Considerations recommended by the American Academy of Periodontology (AAP) in the evaluation of implants at recall follow:

• Oral hygiene status
• Clinical appearance of peri-implant tissues
• Bleeding on probing and/or presence of exudate
• Pocket probing depths and alveolar bone level
• Radiographic appearance of implant, peri-implant bone, and alveolar bone levels relative to the implant abutment junction
• Stability of prostheses and assessment of occlusal screws or cement
• Assessment of veneering material for presence of fractures
• Occlusal assessment
• Patient comfort and function
• Assessment of appropriate maintenance intervals

Outcomesassessment: The desired outcome of successful implant therapy is not only the achievement of the therapeutic goal, but also the maintenance of a stable, functional, and esthetically acceptable tooth replacement for the patient.

While AO’s guidelines provide information and recommendations, they are not intended to be all-inclusive. Clinicians also should consider recommendations set out in comparable documents offered by other specialist bodies and organizations.

As with any specialty, new studies and recommendations regarding implant dentistry are always evolving. As such, AO constantly evaluates emerging research, technology and techniques to ensure its members have the most important and timely information to apply in their practices.