Continuing Education

Implant Dentistry Education for the Practicing Dentist

Nicholas Caplanis, DMD, MS; Joseph Y.K. Kan, DDS, MS; Jaime L. Lozada, DDS

Copyright 2001 Journal of the California Dental Association.

Contemporary standards of care, as well as ethical and legal issues, dictate the incorporation of dental implants into the general dental practice. Given the simplicity of current implant systems, most general dentists already possess the clinical expertise necessary to provide basic implant restorative services to their patients. However, due to the restricted manner in which dental implant training was propagated in the United States, and perhaps due to its foreign origins, many competent dentists seem unaware of this greatly beneficial innovation. There are a variety of educational resources available for the uninitiated dentist to gain proficiency in basic implant dentistry. The ideal education in implant dentistry provides supervised hands-on clinical training on live patients as well as didactic instruction by recognized teachers in implant dentistry. Such education may or may not be devoid of commercial bias. This paper will describe many of these opportunities.

The original, or Brånemark, concept of the "team approach" to implant dentistry promoted the notion that implants be placed exclusively by oral and maxillofacial surgeons and restored by prosthodontists. This model was understandably helpful in the past, given the complexity of the surgical and prosthodontic procedures of earlier implant systems. This exclusive and elitist orientation has impeded the pervasiveness of implant dentistry in general practice by restricting education to a privileged few. However, it did allow the science of implant dentistry to be extensively studied, documented, and perfected.^1-4 Regardless of its restricted availability and foreign origins, implant dentistry has flourished into what is today an extremely predictable treatment for edentulism. Dental implants have become an appropriate part of the general as well as specialty dental practice.

Implant-supported dentistry has proven to be extraordinarily successful when compared with more-traditional methods of dental treatment. Long-term success rates of dental implants have been reported as high as 97 percent for single-tooth replacements and 94 percent for implant-supported fixed partial dentures.^5-9 Given long-term reported failure rates of 10 percent for fixed partial dentures,¹⁰ 19 percent for resin bonded bridges,¹¹ 13 percent for hemisection and root amputation,¹² 15 percent for endodontic therapy,¹³ and 34 percent for endodontic retreatment,^14-15 implant therapy may now be regarded as a more predictably successful method of restoring the dentition than the conventional means with which California dentists have been treating failing teeth.

Today, oral and maxillofacial surgeons and periodontists perform the vast majority of dental implant surgeries.¹⁶ General dentists perform the majority of simple implant restorations while prosthodontists treat more-complex oral rehabilitation.¹⁷ Periodontists have gained, at minimum, equal credibility as qualified implant surgeons during the past two decades. This should be of no surprise to the dental community given its unique background in comprehensive treatment planning, soft- and hard-tissue management, and meticulous attention to detail, as well as its vital role in oral health maintenance. With the simplicity of current implant systems,¹⁸ particularly those with cemented final restorations, many general dentists are providing implant restorative treatment to their patients in a similar manner to traditional crowns. This article is directed to dentists of little or no experience in dental implantology who are desirous of providing this most beneficial of new technologies to their patients.

There are a variety of educational resources available from which California dentists can gain proficiency in basic implant dentistry. These programs can be grouped into five basic categories:

* University programs;

* Private programs;

* National/international implant organizations;

* Manufacturer-sponsored educational programs; and

* Local study clubs.

The ideal education in implant dentistry will provide supervised hands-on clinical training on live patients as well as a broad didactic education by recognized teachers in implant dentistry, devoid of commercial bias. Unfortunately, there are very few programs that can offer all these ideals in one neat package. Therefore, dentists should consider pursuing several programs to achieve proficiency.

University Programs

Loma Linda University

The Implant Dentistry Center at Loma Linda University provides the perfect example of the ideal educational resource center for implant dentistry in Southern California (Figure 1). The late Dr. Robert A. James established the residency program in 1976. The residency is a three-year full-time program admitting qualified general dentists and offering an extensive education in complex oral diagnosis and treatment planning. Clinical training includes implant surgery, implant prosthodontics, and advanced surgical techniques including immediate implant placement, immediate implant loading, sinus grafting, autogenous bone harvesting techniques, ridge augmentation, nerve lateralization, and distraction osteogenesis.¹⁹ Advanced postgraduate education in biomedical science, anatomy, pathology, radiology, statistics, and nutrition complement the didactic training, which also includes extensive literature reviews in current and historic implant dentistry, removable and fixed prosthodontics, periodontics, and occlusion. Advanced procedures are supervised by attending faculty members who are experts in implant dentistry and specialists in the fields of prosthodontics, periodontics, and oral and maxillofacial surgery as well as general dentists with extensive backgrounds in implantology. Residents also obtain extensive laboratory training and upon completion of the program have achieved competency in all facets of implant dentistry laboratory techniques. In addition to a Certificate in Implant Dentistry, the program confers a master’s of science in implantology with the successful defense of a master’s thesis in addition to completing the educational curriculum. Up to three residents per year are admitted to this prestigious program, which attracts general dentists from around the world (Figure 2).

General dentists in private practice who are unable to return to full-time postgraduate study can enhance their backgrounds in implant dentistry by enrolling in the Preceptorship Program in the LLU Implant Dentistry Center. The Preceptorship Program can be tailored to fulfill a dentist’s specific needs and schedule. Preceptors are exposed to both the didactic instruction as well as hand-on clinical training. The majority of clinical exposure is gained through assisting the implant dentistry residents with patient care. Given the extensive volume of procedures performed in the center, preceptors obtain a diverse and extensive clinical exposure to all facets of implant dentistry. Preceptors can attend the training one to five days per week for three months or longer depending on their needs and desires. Obviously, the greatest opportunity to maximize education, training, and experience will be through increased and consistent participation.

Through the Continuing Education Department, the LLU Implant Dentistry Center offers a program for general dentists and specialists called Clinical Experience in Implant Dentistry. After proving minimum proficiency in implant dentistry, for example through the completion of the preceptorship program or a specialty residency, general dentists and specialists are permitted to bring their own implant patients to the center and render treatment under the direct supervision of attending staff. This allows the dentist to perfect his or her clinical skills. Patient care can be geared toward implant prosthodontics, implant surgery, or both (Figure 3).

The fellowship program for specialists is a one-year full-time program designed to complement the specialist’s education in his or her respective discipline. Periodontists and oral and maxillofacial surgeons can enroll in the program to gain additional expertise in advanced surgical techniques related to implant dentistry. These include sinus lift and grafting, intra- and extraoral autogenous bone harvest, ridge augmentation, distraction osteogenesis, and the use of cutting edge as well as experimental materials such as platelet-rich plasma. Prosthodontists enrolled in the fellowship program perform only complex implant prosthodontics, including laboratory procedures.

Through the Department of Continuing Education, the LLU Implant Dentistry Center also offers a study club one evening a week (usually on Wednesdays from 5 to 10 p.m.) that provides basic didactic education through lecture presentations and hands-on training in the laboratory. In addition, live surgery is performed and projected on a screen for study club participants, which leads to informal treatment discussions in a small-group setting (Figure 4). Loma Linda University also hosts an Implant Dentistry Symposium held approximately every five years with the world’s premier experts in implant dentistry as invited speakers.

Recently, the Implant Dentistry Center has begun offering educational programs through the Internet. A number of courses are available. Topics include problem-based learning in implant dentistry and immediate loading. Live Web conferencing is available once a month with a lecture given by Dr. Jaime Lozada, professor and director of the Implant Dentistry Program. Topics range from the basics of diagnosis and treatment planning to advanced surgical and prosthetic concepts in implant dentistry. These Internet programs offer C.E. credit and allow dentists to attend a course or lecture from the comforts of their own homes and/or offices thereby eliminating travel and lodging expenses. These programs can be accessed through the Loma Linda University home page at http://www.llu.edu. The LLU Implant Dentistry Center can also provide further information on the residency, preceptor or fellowship programs, and the Department of Continuing Education can provide further information on the study club, implant symposium, or online courses.

The University of California at Los Angeles

UCLA is in the process of establishing an implant dentistry teaching program, according to Dr. Sascha Jovanovic, research associate and director of preceptorship studies, and Dr. Earl Freymiller, chair of oral and maxillofacial surgery at UCLA. Although plans are not finalized, it is anticipated that a teaching program will be available soon for general dentists and specialists. The UCLA Dental and Maxillofacial Implant Center may be in operation by the end of this year.

At present, UCLA offers a mini-residency in implant dentistry directed by Dr. George Perri, lecturer in the Section of Advanced Prosthodontics, and Dr. Jovanovic. The program runs from October to May and meets one Monday per month from 8 a.m. to 5 p.m. The mini-residency incorporates lectures, hands-on laboratory instruction in implant prosthodontics, hands-on surgical experience on animal jaws, and live surgery demonstrations to teach dentists the basics of implant surgery. The small group setting of approximately 20 to 25 residents per year is ideal for personalized instruction (Figure 5).

UCLA offers several preceptorship programs for general dentists. Preceptors are exposed to didactic instruction and observe implant surgery and implant restorative procedures performed by faculty and postgraduate students. The preceptorship programs are full-time programs of three or more months in duration. However, there is some flexibility in the number of days attended, depending on an individual’s needs and desires. Once again, the more days spent in the program, the better the training.

UCLA also offers fellowship programs specifically designed for the periodontist, oral maxillofacial surgeon, or prosthodontist to gain advanced training in his or her specialty area. These fellowships are one-year full-time programs offered by the graduate prosthodontics and periodontics programs. Dr. Perri can provide further information on the mini-residency in Implant Dentistry and staff at the graduate programs in prosthodontics and periodontics have further information on the preceptorship and fellowship programs.

University of the Pacific

The University of the Pacific offers a hands-on implant program through its Department of Continuing Education. According to Dr. Belinda Gregory-Head, prosthodontist and director of dental implants at the University of the Pacific, this program is designed for general dentists seeking to increase their level of expertise in implant dentistry. The course consists of two weekend sessions that combine lectures with clinical demonstration on live patients and hands-on laboratory training. The program follows several patients through treatment, from the initial consultation and examination, to implant surgery and final restoration. Each day of the course includes a lecture followed by hands-on laboratory training or live patient demonstration (Figure 6). The Department of Continuing Education at the University of the Pacific can provide more information.

Private Educational Programs

Many well-known and respected practitioners in the field of implant dentistry promote their own educational programs. A university or an implant organization such as the American Academy of Implant Dentistry may sponsor or endorse some of these programs. The main advantage of these programs is the personal exposure to the expert who sponsors the program as well as the informal, small-group learning environment. These programs may be somewhat biased, however, by that individual’s training, experience, opinions, and interpretations of implant dentistry. For example, programs by implant surgeons may not offer implant prosthodontic training. As a general rule, the more respected and well-known the expert is, the better the program should be. Some of these programs offer hands-on training in addition to lecture presentations. Topics range from basic implant dentistry to advanced implant prosthodontics and implant surgery. Many of these programs are excellent ways to get started in implant dentistry as well as to expand proficiency. Programs offering both surgical and prosthetic education in implant dentistry are listed in Table 1.

Implant Organizations

All dentists involved in implant dentistry should be a member of at least one national implant organization. The benefits to membership are overwhelming. These groups offer their members national and international meetings and symposia that are exclusively devoted to implant dentistry. They also provide educational programs for office staff members, hygienists, and laboratory technicians that encourage better communication to enhance implant dentistry success. In addition, members are eligible to receive the respective organizations journals containing the latest information on implant dentistry in order to keep current (Table 2).

The American Academy of Implant Dentistry is the world’s oldest professional organization dedicated to the advancement of implant dentistry. Established in 1951, the organization boasts more than 2,000 members across the globe. It is also the only organization that offers court-protected credentials in some states, including California. AAID maintains a peer-reviewed credentialing process that awards the statuses of associate fellow and fellow. AAID is also the sponsoring organization of the American Board of Oral Implantology/Implant Dentistry, which confers diplomate status to eligible implant dentists following successful completion of written and oral case defense examinations. AAID’s membership includes nondentists, general dentists, periodontists, oral surgeons, and prosthodontists. The Academy’s goal is to maintain the highest standards of practice and education by supporting research and maintaining a forum for the exchange of comprehensive implant knowledge. Membership to AAID includes a subscription to the Journal of Oral Implantology, which is published six times per year.

The Academy of Osseointegration is the fastest-growing professional organization dedicated to advancement of the art and science of osseointegration. It is arguably the premier organization at this time, as demonstrated by the quality of presentations and participation at its annual meetings. The first annual meeting of AO was held in Chicago in April 1986. Since that time, membership has grown to more than 4,200 in 70 countries. Academy members share the common goal of moving the field of osseointegrated implants forward through clinical and evidence-based research and education. AO is the sponsoring organization for The International Journal of Oral & Maxillofacial Implants, the leading dental implant journal in the United States and possibly the world. Members of AO receive a subscription to the Journal, which is published six times per year.

The International Congress of Oral Implantologists is the world’s largest oral implantology/implant dentistry organization. It has more than 50 component or affiliated societies representing more than 20,000 members in more than 70 countries. ICOI is dedicated to education, research, communication, membership recognition, and fraternity. The organization publishes a quarterly journal, Implant Dentistry, for its members with summary translations in Spanish, German, Japanese, and Portuguese. ICOI administers an international fellowship and diplomate recognition program for its members and sponsors a world implant congress annually.

Manufacturer Programs

It is difficult to keep up with all the dental implant manufacturers and their educational programs. As new companies emerge, others file for bankruptcy, merge, or consolidate. The noteworthy dental implant manufacturers include Nobel Biocare (Brånemark and Steri-Oss implants), Straumann dental (ITI dental implant system), Sulzer/Medica, Lifecore Biomedical, Friadent, 3I (Implant Innovations), and Astra. Manufacturer-sponsored educational programs can be extremely informative, especially when the company sponsors a nationally recognized speaker. The only disadvantage with these forums is the obvious commercial bias. Manufacturer who sponsor programs want participants to buy their products. Hence, it should be obvious that nothing negative will be said regarding their product lines. Therefore, one should attend educational programs from only those companies that have valid scientific research published in peer-reviewed journals to support the successful use of their implants and prosthetic components. These include companies such as Nobel Biocare and Straumann, which also sponsor annual symposia.

Study Clubs

Local study clubs present an excellent venue for dentists to obtain knowledge in implant dentistry. Study clubs have recently become an increasingly popular method of continuing education. These clubs are commonly established by specialists to increase the quality and level of dental care in their areas and to facilitate communication between their referring offices, as well as to market their practices to their community. The benefits of a study club include small group size, personable and informal presentations, and member influence on programming. These groups also offer excellent opportunities to meet and fraternize with colleagues in a local area. In addition, meetings are extremely convenient since travel, lodging, and extensive time away from the family and office is eliminated. Some study clubs offer hands-on laboratory training with the support of various dental implant manufacturers in addition to lectures and treatment-planning sessions.

Worthy of mention is the Seattle Study Club. The Seattle Study Club is a large network of local study clubs across the United States, Canada, and Australia with approximately 150 chapters and more than 4,000 members. Each club provides clinical treatment-planning sessions designed to increase total case management incorporating the use of dental implants. Meetings include problem-solving sessions, a network of specialists, and dedication to comprehensive treatment planning. National lecturers are showcased in small-group settings, allowing intimate sharing of state-of-the-art treatment for patients. Members of this unique network receive a quarterly interdisciplinary treatment-planning journal, as well newsletters, and are eligible to participate in the national meetings and symposia. There are approximately 17 chapters in California (Table 3). For additional information on the Seattle Study Club network, one can visit their Web site at http://www.seattlestudyclub.com.

Conclusion

Patients suffering from partial or complete edentulism must comprehend the benefits of implant dentistry. Dentists have moral, ethical, and legal obligations to educate partially and completely edentulous patients about the benefits of implant dentistry. Given extremely successful long-term treatment outcomes as well as the simplicity of current implant dentistry techniques, every dentist has the opportunity to provide basic implant dentistry services within his or her practice. There are a number of educational resources within as well as outside the universities for the dentist who wants to increase his or her level of expertise in implant dentistry. When treatment complexity exceeds a dentist’s level of training and expertise, appropriate referral to an experienced implant surgeon and prosthodontist should be made.

Authors

Nicholas Caplanis, DMD, MS, is an assistant professor in the Graduate Program in Implant Dentistry at Loma Linda University. He also maintains a private practice in Mission Viejo, Calif., that is limited to periodontics and implant dentistry.

Joseph Y.K. Kan, DDS, MS, is an associate professor in the Graduate Program in Implant Dentistry at Loma Linda.

Jaime L. Lozada, DDS, is a professor and the program director of the Graduate Program in Implant Dentistry at Loma Linda.

References

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19. Caplanis N, Kan J, Lozada JL, Osseointegration: contemporary concepts and treatment. J Cal Dent Assoc 25(12):843-51, 1997.

Legends

Figure 1. The Loma Linda University School of Dentistry.

Figure 2. The Advanced Education Program in Implant Dentistry, Loma Linda University.

Figure 3. Implant dentistry residents, preceptors, and fellows perform surgery in state-of-the-art operating rooms in the Implant Dentistry Center at Loma Linda University.

Figure 4. Dr. Jaime Lozada lectures to the study club participants at Loma Linda University.

Figure 5. Dr. George Perri reviews an implant case in the laboratory with a student of the implant dentistry mini-residency program at the University of California at Los Angeles.

Figure 6. Dr. Belinda Gregory-Head discusses the progress of an implant case with students at the University of the Pacific. Photo by Warren Hsu.

To request a printed copy of this article, please contact/ Nicholas Caplanis, DMD, MS, La Paz Medical Dental Center, 26302 La Paz Road, Suite 207, Mission Viejo, CA 92691, or Nick@DrCaplanis.com