Mastering Implants


Five Katas That Take Dentists from Beginners to Experts.
Today, patients are more aware of implants than ever before. With the availability of online information, and with social networking making communication easier, patients have access to more education about various dental modalities. Many dental practices have noticed that patients across various demographics are asking about implants.

For dentists, the ability to do implants opens up a whole new set of treatment options, such as implant-retained dentures and tooth replacement that doesn’t require older technologies like bridges. This ability adds another clinical skill set that can help a general practitioner (GP) retain valuable revenue in-house and help patients keep their teeth for a lifetime.

Many young doctors learn about implants, but they usually haven’t had a chance to place any—either in school or in their early years of practice (the first 10 to 15 years). Doctors who have been practicing for several years may want to start placing implants to further enhance their skill set.

What Are The Barriers?
Many GPs are reluctant to do implants for numerous reasons. Often, they’ve been advised to let specialists do them. Yet in many cases, a GP with the skills to place implants is a great service for patients. Most patients are comfortable with their GP and would prefer simply scheduling implant treatment with someone they already trust.

Many of the dentists I meet tell me that they want to learn more about implants, but they are often hesitant to start learning how to place them either because of how much they assume it will cost or because of low self-confidence.
The cost of the armamentarium and the cost of the training can seem like large obstacles for some dentists. For others, the obstacle may be more fear-based than anything else. The question dentists should ask themselves is, ‘What would be best for my patients?’

Here’s an example. A 26-year-old patient comes into the office. He’s had a crown on the upper left first molar. When you take the crown off, you find it’s all decayed underneath. You start endo on it and think you can possibly do a root canal and save it, but as you examine it more closely, you find an extra canal.

You realize that by the time you instrument out the canals, you are going to weaken this tooth. At age 26, the percentage of success over a 10-year period is guarded—meaning there is a 50 to 60 percent chance that the tooth will eventually fail. I truly don’t like those odds.

If the tooth does fail, the treatment requires extracting the tooth, grafting the extraction site, letting it heal, placing an implant, and then putting the crown on. At that point, the patient’s investment is somewhere around $6,000 to $9,000. A typical patient’s response to such a scenario is, “I wish I had known initially that there was a different option. I spent $3,000 on dental work in the first place, and now, less than ten years later, my tooth has broken and I have to start the process all over again.”

Conversely, the survival rate for implants is 90 to 95 percent! When looking for a long-term solution for such a patient, an implant will likely be a better choice. Educating patients on their options is extremely important so they know what the consequences will likely be as a result of either choice.

The situation I just described arose in my practice recently. What did I do? I told the patient that I didn’t feel comfortable with the survival rate on his tooth. I informed him that I would need to do a lot of work to keep the tooth. I explained that I would have to bore out the middle of the tooth and make it like a hollow log to do the root canals—and at some point it would probably break.

Since that patient was relatively young, the tooth would need to be replaced sometime in the future. An implant would definitely last, though (at least the percentage of survival is much higher). When I presented this information to the patient, he made the decision not to keep the tooth.

To get started with implants, dentists must invest in specialized equipment. One of the basics to have is a blood pressure cuff (to check a patient’s blood pressure, which must be checked before any surgery), but that’s not a big cost. For any implant system, an electric motor and a surgical kit are a must.

And of course, you need some implants! I recommend buying and starting out with no more than ten implants for the beginning phase of your learning cycle. For those ten implants, select the ones that are most commonly used and placed in the posterior to bicuspids—the first molar to bicuspids region only.

Beyond this physical equipment, you will need to brush up on your pharmacology, because a lot of implant patients take some kind of prescription medication.

Martial Arts & Implants
In judo and some other Japanese martial arts, participants learn techniques through choreographed patterns of movement called kata. This Japanese word translates into English as “form.” The goal of the technique is to internalize certain movements so that the learner can execute them like a reflex.

Once the movement is automatic, the practitioner can adapt it to different circumstances without thought or hesitation. In this way, students learn to utilize maximum efficiency with minimum effort—a core principle of martial arts. Through mastery of sequential kata, practitioners become adept at martial arts.
Similarly, by following a step-by-step process for implants, dentists can master the basics of implants. This process helps create muscle and mental memory. The kata approach helps doctors achieve a level of confidence that they need to begin or strengthen their ability in placing implants.

Why is muscle and mental memory important? When a new skill becomes second nature, it is due to muscle and mental memory. An automatic response indicates that a doctor has thoroughly mastered the skill. Muscle and mental memory is critical for dentists placing implants and is gained through repeated experience. With this experience, dentists learn what works in placing implants and what to avoid.

Muscle and mental memory is critical even in situations where a dentist thinks he or she has the perfect environment and the perfect case. Occasionally, unexpected circumstances arise that complicate even the best situations.

Consider, for example, a new doctor who starts putting an implant in, does the first diameter bur (which is a small bur), and then puts a guide pin in place. At this point, the doctor typically stops work and takes an x-ray to ensure the angle is correct. The x-ray may reveal that the angle is off. When that happens, instead of disrupting the process, an experienced doctor will know that they’ve simply got to re-angle and re-drill, and things will still be okay. The doctor can save the site without closing it up and starting over again. The muscle and mental memory comes from past experience with similar situations.

First Kata: Basic Proficiency
The best way to learn about implants is to watch the procedure firsthand. Once dentists see how it’s done, they can determine if this is something they want to make a part of their practice. Taking a level I class is an ideal way to make this decision effectively—watch and learn.

The uniqueness of the Dr. Dick Barnes Group is that we offer an Over-the-Shoulder™ program, so dentists actually see implants being done. In the level I course, dentists learn the indications, the reasons for implants, what implants do for their patients, how to diagnose them, how to create treatment plans, and how to educate their patients about implants.

Dentists also get to work on tabletop models so they can start to understand the kinesthetics, or feel, of the implant. By so doing, dentists get a tactile sense of how the implants feel, how the mechanics work, how to orient the implant, and how to ensure that the angles of the implant are correct.

At a minimum, a level I class offers dentists new information so they will be more knowledgeable about implants even if they decide not to do them. Think of the class as an experiment that will help you determine whether you like the potential of implants and whether placing them is something you want to do.

At the end of the two-day seminars, doctors know whether or not they want to start doing implants. Regardless of whether they decide to continue, most doctors appreciate the experience of the level I class. In addition to helping dentists decide whether to continue with implants, the class elevates their existing knowledge so they can communicate better with referring doctors.

Some doctors know they don’t want to place implants but they want an increased understanding of the process. For doctors who have wondered why oral surgeons place implants in a certain place or who have any other questions regarding implant surgery, a level I class can yield some great insights.

At the end of the course, most doctors feel that they can do their job better by giving better guidance to the surgeon. No matter what a doctor decides after the class, he or she will leave a level I course with a superior skill set. To continue the muscle and mental training, more experience and more practice is needed at advanced level training courses.

Second Kata: Advanced Techniques
After learning the basics and practicing several implants on tabletop models, the dentist should be ready to move on to the next kata. At this point, the dentist has experienced some success and is getting into a rhythm of the sequence of events required for basic implants.

To advance to the next stage, dentists should attend advanced training (level II). During level II training with the Dr. Dick Barnes Group, doctors place implants on mannequins. With the mannequins, doctors get the experience of working in the constrained space that is the oral cavity. Also, with the mannequins, doctors can place as many as 16 implants, versus two or three on the tabletop models. Doctors also learn tissue flap design and proper suturing techniques.

Practice, Practice, Practice
After a level I course, if a doctor doesn’t feel comfortable proceeding to level II, he or she can repeat level I training until the understanding is complete. I don’t recommend attending seminars without implementing the training in your practice, however. It’s like learning to play the piano—you have to practice every day. You don’t become proficient at the piano by practicing every two or three months.

To start mastering the new skill, doctors should learn to identify which cases are good cases for implants (see sidebar, right). Once dentists begin to recognize such cases, they will start to get a feel for them after placing about 10 implants.

A “breakthrough” often happens when a dentist is nervous about placing implants, but does so anyway and succeeds. That experience builds the muscle and mental memory—and once a dentist breaks through the nervousness, efficiency and competency naturally follow with additional repetition.

Keep in mind that the timespan in between placing implants is important. I recommend one implant a week to develop proficiency. It’s helpful for dentists to continue developing their skills during this time, too. Consider taking continuing education courses on grafting or other areas of specialty for a deeper understanding of the process.

Another good option that can help dentists master the principles of implants is to volunteer for humanitarian dentistry. On some humanitarian trips, dentists place as many as 10 implants a day—it’s a quick way to develop proficiency!

Third Kata: Team Training
Once a dentist decides to do implants, the next step is to ask an implant representative to visit your office and train the clinical team. The staff needs to be prepared for the new experience. It can quickly become a disaster if the team hasn’t been trained on the ins and outs of the procedure.
The implant sales rep can bring equipment to the practice and stage the procedure so that everyone is on the same page. The rep can also instruct the team on how to properly care for and sterilize the components of the implant surgical kit.

I recommend using only one operatory for implants—meaning that the designated room is of the utmost cleanliness. All the treatment rooms should be extremely clean, but this particular operatory should be ultra clean for all surgeries.

The team needs to practice how to garb (meaning how to drape the patient), and how to make the environment as sterile as possible. Set up sterile areas so your team knows where you need to be cognizant of cross-contamination.

I recommend doing a dry run—a total set-up. I even recommend taking pictures or a video of the set-up. The dentist and team can create training videos of these procedures so that when a team member leaves, the dentist can train the next employee based on the video.

Any time I hire a new clinical chairside, the new team member observes the set-up six times. On the seventh set-up, the new team member starts to do the set-up, usually with another team member who is the most experienced. The experienced team member trains the new employee and ensures that everything is done correctly.

A dry run includes a complete set-up with the water saline bag, the doctor operating the pedals, explanations relating to the buttons on the machine, and the team learning how to set up the machine with the sterile bag and the lines feeding water to the handpiece.

For most dentists, the next barrier is typically around 50 implant cases. At that point, the doctor can experiment with more difficult cases, particularly in the anterior. By 50 cases, the muscle and mental memory is usually there and the third kata has been mastered.

Fourth Kata: Backup Plans
Some doctors use guided stents with implants. However, if there’s an abundance of bone, dentists can place implants using their knowledge of the angles and the depths obtained through clinical evaluation and x-rays (including 3D cone-beam computed tomography scans).

Sometimes when dentists start working on a patient, they discover a perforation in the bone that they didn’t see, or some other unforeseen complication. It’s important to have a “back door” or “bailout plan” for those unexpected situations. All dentists doing implants should have a bailout plan, and that usually involves bone grafting (every dentist placing implants should have grafting material in their armamentarium).

If a dentist extracts a tooth and it has an abscess, I don’t suggest placing the implant on the same day. Instead, clean out everything and then graft the extraction site and place the implant at a subsequent appointment—usually about three to four months later. Grafting helps doctors preserve the bone. At that point, the best thing a doctor can do is to remove the tooth because it’s likely infecting the body, and it’s important to preserve the bone.

With every implant case, I start out by telling the patient, “My goal is to get the implant in today. However, sometimes when I start working, I find something with the bone that’s not conducive to placing an implant. Sometimes the bone anatomy just isn’t the way I’d like it for the best outcome. If that happens today, then I’ll treat that situation and maybe have to graft the area first, and then we will reconvene in about 12 weeks to put the implant in. That gives us a much higher success rate.” It’s important to prepare the patient for any contingencies that might arise during surgery.
Fifth Kata: Observation
The fifth kata involves closely observing the implant over the next four months so you can address any complications that might arise during that time. After an implant and crown have been placed, there are three primary complications that can occur. Keen observation can help catch these complications at an early stage. Here are the three main ones to look for:

1. Cemented crowns vs. screw-retained crowns. Clean out the area thoroughly after cementation! In a large percentage of failures, the cement around a cementable crown is not retrieved or cleaned out and gets stuck subgingivally, creating peri-implantitis.
2. Make sure the occlusion is dialed in. The second most common complication with an implant is occlusion. A dentist must understand occlusion in the teeth and the anatomy of the crown.
3. Patient home care must be impeccable. Peri-implantitis can sometimes occur when the patient just doesn’t maintain adequate home care around the implant. I highly recommend Waterpiks® to all my implant patients, and even to those who have all their natural teeth. Waterpiks®, in conjunction with brushing and flossing, do a wonderful job of maintaining dental hygiene.

Remember that, as with any new skill, practice is key to mastering implant placement. If you want to get better at something—anything—you have to keep at it. Mastering implants is no different. After you have practiced each kata thoroughly and made it part of muscle and mental memory, you’ll get a sense of accomplishment. In addition, you’ll likely feel a sense of contribution, a sense of pride, and a feeling of connection with the work you have just accomplished. With it comes the understanding that you’re not in the tooth business, you’re in the life-changing business, and implants can offer just that for your patients.

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Dr. Jim Downs received his DMD degree from Tufts University School of Dental Medicine in Boston, MA. His post-dental education includes numerous prestigious institutes in advanced restorative fields, such as dental implants, temporomandibular dysfunction and occlusion, full mouth rehabilitation, cosmetic dentistry, lasers, office management, and leadership training/mentorship. Dr. Downs has placed more than a thousand implants since 1989 and has restored numerous full mouth cases. Dr. Downs’ extensive knowledge includes many modalities of dentistry, and he intertwines such principles with a down-to-earth, caring sensibility. Dr. Downs has lectured extensively in the U.S.A. and abroad and has published many articles on dentistry. He is currently the clinical head instructor for the Dr. Dick Barnes Group in Salt Lake City, UT, and practices dentistry at Denver Dream Dentistry in Denver, CO.


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