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MyView: Surgical and prosthetic implant treatment

July 13, 2015

By Dennis Flanagan, D.D.S.

Dennis Flanagan, D.D.S.
Recently a retrospective research study entitled “Outcomes of Implants and Restorations Placed in General Dental Practices” was published in the Journal of the American Dental Association.

This was funded by the National Institute of Dental and Craniofacial Research and was performed and written by Dr. John DaSilva and coworkers (1). There has been much discussion about this work. Much of the discussion apparently has been misunderstood.

Dr. DaSilva’s work entailed a retrospective analysis of the “success rates” of implant-supported fixed crowns and partial dentures placed by general dentists as compared to treatment by academics and specialists.

A retrospective is a lower level of evidence credibility. It is not a double-blinded randomized controlled trial, the highest level of credibility. Nevertheless, this article does point out the need for extensive education and training for any clinician who endeavors to perform implant treatment.

It is very likely that the majority of practicing dental specialists and academic clinicians practicing today were educated in dental implants in the exact same manner as general dentists, that is, through continuing education courses. Formal education has only recently been instituted in dental schools.

A subsequent article appeared by Dr. P. Papaspyridakos in Evidence-Based Dental Practice evaluated Dr. DaSilva’s article (2). He considered the work and made a commentary of three key points. First a “formal post-doctoral education in oral Implantology is necessary to achieve high success rates.”

Second, the distinct difference between success and survival needs to be made. Success means the implant is in place with appropriate bone loss. Whereas, a surviving implant is in place irrespective of the remaining osseous level (3). Third, Dr. DaSilva’s work is a low level of credibility. Dr. Papaspyridakos also importantly points out that treatment by skilled specialists and academics may not be realistic in the “real world” of dental practice.

These articles point to the importance of training and education. The American Academy of Implant Dentistry has an education and credentialing process. The AAID and American Board of Oral Implantology/Implant Dentistry have processes that enable dentists to be educated, trained and then to demonstrate a proficiency in oral implantology. The AAID Associate and Fellow credentials indicate a level of education, training and expertise. Advanced education in immunology or other basic sciences that many specialists receive are certainly advantageous but doubtfully primarily useful in clinical oral Implantology.

As Dr. Papaspyridakos points out, when comparing university-based formal education and extensive continuing education, the skills developed by the clinician may be more related to the quality of the clinician than the program attended. For example, the degree of site debridement may be a variable that may be reflective of an astute clinician irrespective of where or how the clinician was trained.

It appears that general dentists are placing and restoring an increasing number of implant cases. This will probably continue. Effective training and education is important to ensure that the patients treated are treated efficaciously. Thus, it may be important for implant treatment to be taught to undergraduate dental students and not only to specialty residents.

Inevitably there will be surgical and prosthetic complications which will need to be addressed (3). A controversy can arise. The “team approach” is where the patient is referred to different surgical and prosthetic specialists for treatment. In these cases with complications, the question arises as to which clinician “owns” these cases, especially in those with late complications (4, 5). Questions arise such as what is the cause of the complication and is there a fee for treatment. Thus it may be better that a single clinician performs both the surgical implant placement and restoration of these cases. Patients may be better served by one responsible well-educated and well-trained dentist.

The need for formal education and training is evident. Therefore it is time for the American Dental Association to approve oral Implantology as a recognized dental specialty. Dental schools should begin training in this arena. Dental implant treatment has become a viable modality that benefits our society. It is time for our beloved profession to make this important change.

1 Da Silva JD, Kazimiroff J, Papas A, et al. Outcomes of implants and restorations placed in general dental practices: a retrospective study by the Practitioners Engaged in Applied Research and Learning (PEARL) Network. JADA. 2014;145(7):704-713.
2 Papaspyridakos P. Implant success rates for single crowns and fixed partial dentures in general dental practices may be lower than those achieved in well-controlled university or specialty settings (published online ahead of print December 15, 2014). J Evid Based Dent Pract. 2015;15(1):30-32.
3 Papaspyridakos, P, Chen CJ, Singh M, Weber HP, Gallucci GO. Success criteria in implant dentistry: a systematic review (published online ahead of print December 8, 2011). J Dent Res. 2012;91(3):242-248.
4 Barr, BK. Whose implant is it, anyway? Academy News. 2013;23(2):3.
5 Schmitz JP. Clearing the air about managing implant complications in implant surgery (editorial). Academy News. 2009;20(2):14.

Editor’s note: Dr. James M. Boyle, chair of the Council on Dental Education and Licensure, explains that a specialty is an area of dentistry that has been formally recognized by the American Dental Association as meeting the Requirements for Recognition of Dental Specialties which can be found on by clicking on “Education and Careers,” then “Careers in Dentistry,” then “Dental Specialties.”  

Dental specialties are recognized in those areas where advanced knowledge and skills are essential to maintain or restore oral health. A sponsoring organization must submit a formal application to the Council on Dental Education and Licensure that demonstrates compliance with all the requirements for specialty recognition. The council then submits its recommendation for approval or denial of request for recognition of the proposed specialty to the Association’s House of Delegates. In 1993, the American Academy of Implant Dentistry’s application for recognition as a dental specialty was denied when the council recommended and the ADA House of Delegates agreed that the requirements for specialty recognition were not met.  

The ADA believes that the public is best served if the profession is oriented primarily to general practice. However, the public and profession benefit substantially when interest areas are developed and advanced through education, practice and research.

Today’s rapidly emerging technologies and science are providing more sophisticated and complex solutions to problems encountered in general dentistry. The advances are changing and enhancing the dental practice environment. Recognizing this, the 2010 ADA House of Delegates adopted “Criteria for Recognition of Interest Areas in General Dentistry,” which can be found on by clicking on “Education and Careers,” “Careers in Dentistry” then “General Dentistry.”

The council also has developed a process to consider requests for recognizing interest areas in general dentistry. Such a request would be submitted to the council and ultimately acted on by the ADA House of Delegates. This is a new recognition program offered by the ADA.

Perhaps in the future a sponsoring organization for implantology will consider pursuing recognition by the ADA. The council stands ready to receive applications.