In this month’s Charting Progress, Dr. Rick Valachovic looks at the debate over teaching the placement of dental implants in predoctoral and specialty curricula.
This past summer, the Commission on Dental Accreditation (CODA) adopted revised accreditation standards for advanced education programs in prosthodontics, ending one of the longest and most contentious standard review processes in recent memory.
At issue was the inclusion of standards related to dental implant placement. Although historically the surgical procedure has not been associated with prosthodontics, prosthodontists began placing implants in the early 1980s. A decade later, prosthodontics programs were lengthened to accommodate the introduction of implant therapy.
“Prosthodontics used to be defined as, ‘You do dentures; you do crowns,’” says Lily Garcia, D.D.S., M.S., FACP, Associate Dean for Education at the The University of Iowa College of Dentistry & Dental Clinics and Immediate Past Chair of the ADEA Board of Directors. “No,” she responds on behalf of her specialty, “we treat and restore patients based on a diagnosis of their conditions.”
Lily says 2003 was pivotal for prosthodontics. That is the year when the American College of Prosthodontists adopted a new definition—one that made clear that implant placement, as well as implant restoration, fell within the specialty’s scope. A 2013 survey showed that 90% of prosthodontics residency programs were already training residents in implant placement. The new CODA standards go a step further: They ensure accountability by making the training a requirement for all advanced programs in the specialty.
Given that the standards largely ratified the on-the-ground reality, why did their adoption take so long to approve? Since researchers at the 1982 Toronto Osseointegration Conference in Clinical Dentistry validated the placement of implants as a long-term alternative to bridges and dentures, many dental specialties have laid claim to one part or another of implant dentistry.
“Periodontists and oral surgeons took on placing implants, prosthodontists took on restoring implants, orthodontists use a type of implant for anchoring, endodontists are placing implants and want to include this as part of their specialty, and periodontists want to include the name ‘implant dentist’ in their specialty’s name in the near future. The public is confused about who should be doing this.” That’s the assessment of John Da Silva, D.M.D., M.P.H., Sc.M., Vice Dean of the Harvard School of Dental Medicine and President of the American Academy of Implant Dentistry (AAID), which offers a 300-credit-hour certification program. John has limited patience with what he calls the “underlying battle going on among all the specialties about who should own implant dentistry.” His association represents 5,000 general dentists and specialists, and he says that general dentists appear to be placing more implants than are specialists.
“Some general dentists refer out to specialists, and some don’t have access to specialists in their communities. Those folks tend to go out and learn how to do implant dentistry, and many of them do it well,” he told me.
“I think a motivated and well-trained general dentist is ideal for implant placement,” says Mark Latta, D.M.D., M.S., Dean at Creighton University School of Dentistry. Creighton does not have advanced education programs, so Mark feels passionately that implant dentistry should be a core competency for general dentists—not just the treatment planning, but understanding the concepts involved in the surgery and hands-on knowledge of the restoration.
“What we’re trying to articulate to our students is that the restoring dentist has to be at least an equal partner with the dentist who places the implant to achieve the best success,” Mark told me. So is it feasible in Mark’s view to include implant placement in the predoctoral curriculum?
“If we followed the IOM [Institute of Medicine] recommendation that the dental doctoral degree be a five-year degree,” Mark responded, “then in that fifth year, there would be an opportunity to teach more complicated dental therapies, including implant surgery. But the reality is, we have so many areas in which we have to get our graduates to minimal competency, that implant placement is probably a bridge too far.”
Many would agree with Mark, but not everyone. How much dental students should learn about implant placement, what is more appropriate for residency training and which specialties should be involved remain open questions and the source of considerable debate. Implants have become the first choice of care for a majority of patients with missing teeth, and it’s not clear if dentistry will be able to meet future demand for this treatment if implant placement remains a strictly advanced-level competency.
Leila Jahangiri, B.D.S., D.M.D., M.M.Sc., Clinical Professor and Chair of Prosthodontics at New York University College of Dentistry, has dedicated the last 14 years of her career to seeing that implant dentistry becomes integrated in the predoctoral curriculum. In her view, “No dental student should graduate in 2015 only knowing theoretical aspects of implant dentistry.”
At the direction of her former Dean, Mike Alfano, D.M.D., Ph.D., and with the support of her current Dean, Charles Bertolami, D.D.S., D.M.Sc., Leila has taken the lead in developing the implant dentistry curriculum at NYU for the past decade. She has also trained faculty at 48 schools in the United States and abroad, helping them establish their own implant curriculum.
Leila feels strongly that dental schools should take responsibility for educating their students and alumni in this area rather than leaving implant training to implant manufacturers, and she advocates starting at the predoctoral level because, she says, “There aren’t enough specialists in the country to handle the load.”
Leila’s views have been challenged by others who perform surgical procedures, who argue that today’s graduating dental students are not as well surgically trained as their peers were 20 years ago, and are therefore unprepared to learn implant placement. All students do not necessarily have the same experiences in periodontal surgery or flap surgery for extractions, her surgeon colleagues tell her. “I agree with that,” she responds, and she offers as a solution putting more surgical training in the curriculum.
Another objection also dogs proponents of predoctoral education in implant placement: the potential for competition between advanced dental education and predoctoral programs when it comes to finding patients. To get a handle on this issue, I called Mike Reddy, D.M.D., D.M.Sc., Dean at the University of Alabama at Birmingham School of Dentistry. Mike has researched bone regeneration, implant site development and abutments, and he considers implants one of the major health care innovations of the last 30 years.
“Where some schools may struggle,” he told me, “is in finding the volume of patients, but at UAB, access to patients hasn’t been a problem. We are seeing tremendous demand for implants from complex patients who come to us for our expertise.”
Dr. Jahangiri also thinks that fears about access to adequate numbers of patients are misplaced. She points out that 40% of Americans over the age of 65 are edentulous in at least one arch, and she says 120 articles discuss the beneficial impact of a simple two-implant overdenture for the lower jaw on the general health of older adult patients.
“The medical community and insurers don’t know about the value of this,” she told me, “that this procedure can reduce the cost of care to the elderly.”
Once these benefits are more widely known, Leila believes this patient population—along with others—will supply more than enough training opportunities for dental schools. In her view, there are bigger issues. These include the high cost of implants—which are covered by some private, but no public, insurers—and outmoded educational requirements that inappropriately influence which prosthodontic care choices students recommend.
“The students need to ask, ‘What is the best option for the patient?’ That’s what should determine the treatment, and in an academic dental setting, the cost of bridgework and implants should be made equal so treatment cost is not a deciding factor for the patient.”
Meanwhile, the biggest hurdle of all, Leila says, is the need for faculty training. She recommends a combination of the following before faculty attempt implant placement themselves:
- Didactic education that can be accessed online
- Opportunities for independent simulation learning (so faculty can take all the time they need with the instrumentation and materials without pressure from their colleagues)
- Multiple side-by-side surgical observations with a trained expert
She also advocates for annual reviews of problems that have occurred to give faculty an opportunity to reflect, discuss challenges and refresh their skills
At least in the academic dentistry community, there seems to be a consensus that dentists of all stripes can and will continue to be engaged in implant dentistry, and that all dentists must learn to collaborate in this endeavor for the sake of their patients. A 2015 survey published in the Journal of Dental Education confirmed that more than 90% of dental schools are teaching restorative procedures related to implants, most often in the third year.
Mike Reddy would like to see the implant curriculum integrated earlier on. “Implants should be taught with treatment planning, perio, prosthodontics and oral surgery, not just in a separate course. It makes for better treatment planning if students start thinking about it from the time they come in.”
While John Da Silva does not advocate the categorical exclusion of general dentists or specific specialty groups from implant placement, he is concerned that everyone who practices implant dentistry be thoroughly trained and that the field has the opportunity to evolve and mature. To encourage progress in these areas, he and his fellow AAID members are working toward creating an implant dentistry specialty through the American Board of Dental Specialties. John says a separate specialty would allow dental schools to establish formal implant dentistry programs, which would build a critical mass of dentists who understand the full scope of implant treatment—including ancillary surgical procedures.
“A specialty would create a group of people who can go beyond the routine and simple things and become a resource for the dental community. To me, that’s how you move a profession forward—by having experts you can rely on to drive the frontier further,” he says.
John anticipates resistance to AAID’s proposal, and his worries may be well founded. But within academic dentistry, there appears to be considerable common ground. Leila told me that she would like to see all predoctoral students educated in implant dentistry, but she added, “I don’t see this as an opportunity for general dentists to do it all. I see this as an opportunity to sift through the cases and identify the ones that are simpler to treat versus those that require interdisciplinary care by specialists.”
Similarly, in reflecting on her specialty’s recent experience with the revision of its advanced education program standards, Lily asked, “Should an isolated clinical procedure be used to define boundaries between specialty and general dentistry? Are we truly at odds, or can we learn something from this about working better together, capitalizing on our strengths for the patients we all serve?”
I have no doubt we can, and that the dental education community will show the way in doing so.