In the face of growing public complaints over flawed dental implant surgeries, the Oklahoma Board of Dentistry and the Oregon Board of Dentistry are instituting rule changes for minimal levels of education related to dental implant surgery (not restorative implant prosthetic placement). Unfortunately, most clinical dentists have witnessed cases related to implant surgery and implant case design, which fail to meet the standard of care.
Liability carriers are also mindful of alleged negligence related to implant surgery. Alleged malpractice concerning dental implants is the third leading cause for malpractice claims and accounts for approximately 11% of patient claims.
Patients have suffered needless chronic sinusitis from implant perforations into the maxillary sinus. Others have sustained inferior alveolar nerve damage from perforations into the mandibular canal. Damaging perforations also occur at sites of compromised buccal plate bone into fenestrations, dehiscences, as well as internal bony defects.
Implant fixtures are sited too frequently at severe off-set angulations, which predispose case failures with chronic screw loosening, screw fractures, implant body fractures due to metal fatigue, and peri-implant bone loss. Little attention may be paid to bone quality and quantity, or the benefit of adequate bone grafting.
Patients are harmed by clinicians failing to employ CBCT scans as a diagnostic tool with more complicated surgeries. Patients may also be damaged by a failure of the implant surgeon to appropriately plan for the level of biomechanical loading forces. This too often results in chronic fractures and mechanical failures not only of implant components, but the restorative prosthesis. Surgical guides may be habitually not exploited when such service would be of value to case outcomes.
Something akin to a dental cult movement has developed in which narrow-diameter implants are grossly over deployed, in cases not ideally suited for this treatment modality. The answer to peri-implantitis and crestal bone loss around narrow-diameter implants is apparently limited to placing additional narrow-diameter implants.
“The More, the Merrier” is a 1940s romantic comedy film and should not exist as a philosophy of dental care.
The Oklahoma State Legislature passed Senate Bill 754 in their initial session of 2023.
This bill specifically addresses state statues related to the practice of dentistry. Concerns over the quality of care associated with implant placement was one focus.
- Beginning May 1, 2025, a dentist placing implants must have an implant designation included on his or her license. Between the effective date of this act and May 1, 2025, every dentist shall provide proof of a minimum of eighty (80) hours of continuing education or a certification program specific to implants.
- Specialists licensed in oral and maxillofacial surgery, periodontics, prosthodontics, and endodontics are exempted from the requirement in paragraph 1 of this subsection.
- Current certification as an associate fellow, fellow, or diplomate of the American Academy of Implant Dentistry (AAID) or the American Board of Oral Implantology (ABOI) shall be automatically granted an implant designation.
- The Board may begin adding a designation to a dentist that meets the educational requirements as of the effective date of this act.
Changes to the Oklahoma dental practice act ensure general practice dentists would be permitted to surgically place implants, but only after proof of significant continuing education. The new codes also tacitly acknowledge modern endodontic residency programs have a curriculum in implant placement, which has long been established in oral maxillofacial surgery and periodontal specialty programs. Likewise, one of dentistry’s newest specialties, oral implantology, is also recognized.
The Oregon Board of Dentistry (OBD) voted for rule changes at its June 17, 2022 meeting, impacting requirements to place dental surgical implants. Effective January 1, 2024, Oregon dentists will be required to complete 56 hours of hands-on clinical implant course(s), at an appropriate postgraduate level, prior to surgically placing dental implants.
“Graduates of specialty training programs in Oral and Maxillofacial Surgery, Periodontics, and Prosthodontics that comply with CODA standard 4 curriculum guidelines (or similar educational requirements) who have been trained to competency in surgical implant placement may qualify to surgically place implants with documentation of completing the required training.”
No mention was made related to the specialties of oral implantology, or orthodontics, which may utilize implants as an anchoring device in facilitation of tooth movement.
“Additionally, beginning January 1, 2024, Oregon dentists will be required to complete seven hours of continuing education related to the placement and/or restoration of dental implants each licensure renewal period.”
The rationale for the rules changes by the Oregon Board of Dentistry (OBD) mirror problematic substandard implant placements seen nationally.
“The OBD investigated 82 dental implants cases between February 2014 and August 2017. Of those cases, 41% resulted in Disciplinary Action, which was equally distributed between specialists and general practitioners.”
“During Strategic Planning in 2016, the OBD identified dental implant complications and the subsequent complaints as a significant problem in Oregon. Dental implant safety was codified in the OBD’s 2017-2020 Strategic Plan as a priority issue, and it has remained an ongoing safety concern of the Board through the present.”
“At the April 21, 2017, Board Meeting, in order to effectively protect the public, and per ORS 679.280, the OBD established an ad hoc Committee named the “Dental Implant Safety Workgroup” to research, review, and discuss dental implants, implant complications, and the resulting investigations. The Workgroup’s ultimate goal was to advise the OBD on the most effective actions to protect the public and educate dentists regarding dental implants. The Workgroup included OBD Board Members, OBD Staff and Licensees (both specialists and general practitioners).”
“The Workgroup’s recommendations to the OBD, some of which have already been implemented, and some of which continue to undergo additional refinement
- Require a written informed consent form for dental implant placement. The level of detail that should be included in such a form remains under debate.
- Develop the educational requirements/prerequisites for dentists who wish to place implants.
- Develop a plan for “grandfathering in” licensees with a great deal of experience and success placing and restoring dental implants.
- Require a certain amount of CE pertaining to dental implants be required of licensees practicing implant dentistry for each renewal cycle.
- Determine whether all licensed dentists will be required to complete a certain amount of CE pertaining to dental implants each renewal cycle.
- Communicate with the Oregon Dental Association regarding developing a set of specific “guidelines” for Oregon licensed dentists practicing implant dentistry.
- Develop a requirement for how important information related to the implant (such as type/ manufacturer) is properly documented and provided to the patient.”
There was not unanimous consensus on rule changes by all members on the OBD’s Workgroup. In an exclusive statement for Dentistry Today, Cyrus Javadi, DDS, who also serves as Oregon’s House District 32 Representative, presented the following dissenting view.
“I respectfully express my concerns about the proposed regulations by the Oregon Dental Board. While it is important to continuously improve patient outcomes, mandating 56 hours of hands-on continuing education without evidence of its efficacy is questionable.”
Javadi continued, “Additionally, the fact that this requirement is not in place in other states raises concerns about its necessity. I have faith in the training and expertise of dental professionals to make informed decisions and provide quality care for their patients. Perhaps a more evidence-based approach, rather than overly restrictive regulations, would better serve the dental community and patients.”
AMERICAN COLLEGE OF PROSTHODONTISTS
The American College of Prosthodontists (ACP) issued a position statement, “Dental Implants,” in 2014, which has since been updated and revised (current copyright 2022).
The initial sentence of their professional position paper reads, “Placement of dental implants is a procedure, not a National Certifying Boards for Dental Specialists (NCRDSCB) recognized Dental Specialty.”
“Implant therapy is a prosthodontic procedure with radiographic and surgical components. Using dental implants to replace missing teeth is dictated by individual patient needs as determined by their dentist. An implant is a medical device approved and regulated by the US Food and Drug Administration, which can provide support for a single missing tooth, multiple missing teeth, or all teeth in the mouth. The prosthodontic and the surgical part of implant care can each range from straightforward to complex.”
“Restorative dentists are experienced in restorative procedures, and many have been trained and know requirements for providing dental implant restorations. A restorative dentist trained to place and restore implants may be the appropriate practitioner to provide care using dental implant procedures. This will vary depending on an individual clinician’s amount of training and experience. However, the dentist should know when care should be referred to a specialist (a prosthodontist, a periodontist, or an oral and maxillofacial surgeon).”
“Orthodontists may place and use implants to enable enhanced tooth movement. Some endodontists may place an implant when a tooth can’t be successfully treated using endodontic therapy. Maxillofacial prosthodontists may place special implants or refer for placement when facial tissues are missing, and implants are needed to retain a prosthesis.”
“If a patient’s implant surgical procedure is beyond the usual practice of a dentist, this part of the care should be referred to another dentist that is competent in placement of implants. The referring dentist should effectively communicate and provide specific instructions and any necessary surgical template(s) for appropriate care.”
“It is the position of the American College of Prosthodontists that the procedures dentists perform should meet the standard of care for that procedure. A dentist should refer to a specialist those implant procedures they are not experienced and trained to do. Dental specialists also vary in their level of experience and training relative to the use of dental implants and should not perform procedures they are not experienced and trained to do.”
The ACP clearly differentiates an array of implant surgical services from relatively routine to highly complex. The ACP emphasizes the critical component of appropriate referral when a procedure is beyond a clinician’s level of experience and competence. This applies to both specialists and general practitioners.
The American Dental Association’s “Principles of Ethics and Code of Professional Conduct” parallels the stance of the ACP. In Section 2.B., CONSULTATION AND REFERRAL, it reads, “Dentists shall be obliged to seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience.”
Two state dental boards, Oklahoma and Oregon, have taken steps to require additional educational requisites upon dentists engaged in the service of surgical implant placement. Obviously, these actions were initiated in response to excessive and increasing problems with implant surgeries outside standard of care. Violators include both general dentists and specialists.
Seemingly unfairly punished will be doctors who elect to surgically place implants limited to relatively straight-forward cases. Orthodontists may place implants which are not designed in the scope of a long-term restorative outcome, but as an interim anchoring mechanism to facilitate tooth movement.
The ADA Principles and Code also states, “The dentist’s primary obligations include keeping knowledge and skills current, knowing one’s own limitations and when to refer to a specialist or other professional…” One may question if these states’ mandatory rule changes on the front-end with additional education will generate the desired results on the back-end, of beneficial service to patients.
If a practitioner is placing other interests above their patient’s welfare through greed, apathy, servicing a disease of addiction or mental unwellness, financial debt servitude (i.e., student loan debt), and/or an employer’s manipulation (employment visa status, debt, etc.), no degree of educational mandates will generate desired optimal results in patient care.
Would more value to the public welfare be gained by stiffening dental board penalties to professional violators? Perhaps dental boards might adjudicate complaints and potentially deviant providers in a far timelier manner (months not years)?
Should both front-end directives for education and testing be combined with enhanced punitive consequences for non-compliant doctors and doctors practicing below standard of care? Should unlicensed corporate entities which are tacitly influencing and directing a doctor’s clinical treatment face regulatory oversight and enforcement?
Regardless, expect more state dental regulatory boards to enhance educational requirements related to dental implant surgical placement. Oklahoma and Oregon are only the start.
ABOUT THE AUTHOR
Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation. Davis also currently chairs the Santa Fe District Dental Society Peer Review Committee.
He can be reached at MWDavisDDS@Comcast.net.
FEATURED IMAGE CREDIT: Iurii Kachkovskyi/shutterstock.com.