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Thu 10 Jul 2008 04:00 AM

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Code of prosthetics

Implantology may seem like a quick path to profit, but mastering the art of osseointegration can be a long road.

Implantology may seem like a quick path to profit, but mastering the art of osseointegration can be a long road.

From its humble start as a niche corner of restorative dentistry, implantology has come a long way. The technique was pioneered in the 1980s, but it is recent advances in technology and reliability that have spurred implants into a prime role in dental offices.

The procedure is now so widespread that the American Dental Association recently proposed that bridges be replaced by implants, as a better and more durable solution.

In the past we would often be working with a margin of 1mm... now that number is closer to 0.1mm.

From a financial perspective, the future certainly looks rosy for the implant industry. But for dentists hoping to add an osseointegration string to their practice's bow, making the move successfully can take a lot of hard work and some sizeable investment.

Implanting seeds

Training is the biggest hurdle for any would-be implantologist. And the first difficulty is in picking a course. Very few are recognised by official dental bodies, such as the General Dental Council or American Dental Association, making it hard to prize one curriculum over another.

A good match, suggest experts, is usually found in a course backed by evidence-based clinical practice that realistically reflects the dentist's skill level. In short, know your weaknesses and plan around them.

Implant dentistry is also unavoidably tied to the implant industry, courtesy of the more than 200 different systems in use. The subtle design differences between systems means most implant firms offer short courses on their proprietary methods.

For an experienced implantologist, these sessions can work as a conversion course from one system to another. For general dentists, they offer a taster of the implant methods on offer and can even flag up gaps in their restorative or surgical know-how.

But what these - typically two-day - courses won't do, is adequately prep general dentists for a job switch. As Dr Bill Blatchford, a dental business coach in the US, stresses: "To [operate] as an implant dentist, you must take a year-long course. Because of the complexity of implants, some dentists actually take the full course twice."

Dr Cedric Coucke of the Dental Art Clinic, Dubai, advises general dentists to brace themselves for ongoing training. Despite claiming to have placed 5,000 implants since qualifying from Loeven University, Belgium as an oral surgeon, Coucke still devotes an hour a night to brushing up on the latest techniques.

He is currently in the process of finishing two masters' certificates at the University of California, Los Angeles, most of which has been done remotely to fit around his practice. "Even though I don't need it, I still find it very helpful," he says.

The discipline has become far more accessible since Coucke started out in the early 1990s. "Back then, people would recoil with amazement when you talked about sinus lifting," he recalls.

Yet nowadays it is an essential skill in the implantologist's armoury. Still, Coucke is careful not to equate the procedures newfound accessibility with ease. "Implantology is not something you learn in 14 days and then go and implement it in your clinic," he insists.

Someone to watch over me

Mentoring is more prevalent in implantology than almost any other field of dentistry. Both the UK and American Associations of Dental Implantology credit mentoring as a key part of a rounded training programme. Much of the success in this approach lies in having a wiser, more experienced implantologist hone your skills and hand-hold you through more complex cases.

Dr Rabih Abi Nader, oral surgeon and implantology specialist at the Dubai Sky Clinic, ranks a mentor system as a must for newly qualified implantologists. "I have been operating for 10 years and I still have to deal with the unexpected," he admits. "What does someone who does not have my experience do when he encounters a problem?"

"When you experience a complication that can be rare, sharing it with others can prevent them having the same problems when trying to solve the issue."

Mentoring programmes are standard in the US and the UK, but have largely failed to get off the ground in the Middle East. In his role as the vice-president and executive director of the Implant Study Group UAE, Dr Coucke tried to establish a mentor system but failed to get government support.

The group was originally designed to help dentists introduce implants into their clinic in, what Coucke describes as, the "the correct way". These days it is a low key, online affair. "The problem in Dubai is if you don't get the backing of the ministry you are nowhere," he sighs.

"We tried to set up a mentoring system in Dubai about five years ago. Unfortunately the government did not see the mileage in it."

In the few meetings that took place, attendance swelled to 50 dentists, but eventually the lack of support from the Department of Health and Medical Services (DoHMS) took it toll. Coucke is optimistic, however, that with DoHMS' recent attempts to standardise implantology training a mentorship scheme would now receive a warmer welcome.

"I would be very open to try mentorship again," he says. "Back in Belgium and when I first came to Dubai, people would pay to come to my clinic or for me to go to them."

"I would place the first implant and they would place the second under my supervision. It's one of the best ways of learning the different techniques."

Close to the bone

One of the most significant advances in the implant industry has been the development of computer guided implant systems. According to data and analysis firm Millennium Research, by 2012, a quarter of implant cases will incorporate guided surgery.

While these systems are not foolproof, they are helping to remove much of the uncertainty for both patients and dentists. Guided implant systems are built around 3D cone beam tomography and simulation software that allows the dentist to gauge the extent of bone platform available to work from and virtually ‘place' the implants pre-operation.

Once the implant locations are mapped, the images are sent to a manufacturer-sponsored lab and an intraoral drilling guide is produced to enable the dentists to place and load the implants in one sitting.

"Not only does this technique allow the patient to walk away with implants after one surgery, but it enables dentists to be a lot more flexible with the treatments they can offer," explains the Sky Clinic's Dr Nader.

The technology can dramatically reduce the margin of error associated with implantology. "But the computer doesn't do all the work," Nader is quick to add. "The dentist still needs to know what he is doing to place the implants, but it means that there are no surprises at surgery time."

"In the past we would be working with a margin of error of about 1mm," Coucke explains. "Now we are talking about closer to 0.1mm. We are getting more and more precise and there are times when you cannot work without [computer guided implants]."

Coucke is excited by the prospect of what it means for the future of the discipline. "If you start your career using guided implants, I think you have the best opportunity to get very proficient very quickly," he muses.

The cost of success

Guided implant systems do not come cheap. The price of the 3D tomography machine and imaging software starts at around US$270,000. In fact, even the basic equipment for traditional implantology can mean an investment of between $13,000 and $30,000.

As the price tags suggest, implantology is not a quick path to added profit. "When I see the amount of time and money I have put into my education for implants, I don't think it such a lucrative business," warns Coucke. "It is an ok business."

Coucke estimates that a comprehensive basic training program will cost a dentist up to $27,000, including flights, hotels and materials. Once training is complete, standard practice is to operate with two assistants, one sterile and one non-sterile.

They too need to be educated in techniques vital to the discipline, which can mean costs of up to $8000 per assistant.

After all this outlay, geographical location can play a large role in dictating the amount of return a dentist can expect. Remuneration varies greatly between countries.

A single tooth implant with crown typically costs around $5,450 in the UK. In the US, implants average around $2500, in addition to the cost of the crown and abutment. In countries such as Turkey and Egypt, they start at about $700, while in Iraq, single implants can cost as little as $250.

Money aside, dentists must be confident they will receive enough business to keep their implant skills in shape. To maintain the required level of expertise Coucke suggests a dentist should be placing a minimum of 50 implants a year.

"You have to be able to feel the bone, where you are going to place the implants, at what speed, at what level and what pressure," he explains. "If you are not getting this quota then I think it would be wise to put the case into the hands of experienced people."

Implantology can take its toll on both a dentist's time and wallet but for those who wish to be challenged, and who have a penchant for the surgical side of the job, then it is well worth the investment.

"Implantology can be hard, but rewarding work," Coucke advises. "But it is not for dentists with short term vision."

MED TIPS: Counting the cost

A commercial two-day 'taster' course:US$677

Certificate in oral implantology (1 year):US$27,255

Advanced implantology and bone graft surgery (1 year):US$22,578

Masters degree in implant dentistry (3 years - minimum):US$59,500

Basic implantology training for dental nurses (five months):US$885

Commercial foundation course for implant technicians:US$4,320

Estimated cost of basic start-up equipment and materials:US$30,000

Total:US$145,215

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