Who are we?
By Dr. Paul A. Fugazzotto, Academy News Editorial Consultant
When introducing the Model T, Henry Ford was asked what colors the vehicle would come in. He famously replied, “Black, and black.” If one wished to avail himself (it was inconceivable that a woman would drive!) of this technology, he would buy what was available and not complain. One type of vehicle would have to meet all needs. Clinicians (including women, of course) wishing to treat their patients with osseointegrating implants in the early 1980s faced a similar dilemma. Implant materials and designs, as well as restorative components, were essentially “one size fits all.”
When introducing the Model T, Henry Ford was asked what colors the vehicle would come in. He famously replied, “Black, and black.” If one wished to avail himself (it was inconceivable that a woman would drive!) of this technology, he would buy what was available and not complain. One type of vehicle would have to meet all needs.
Clinicians (including women, of course) wishing to treat their patients with osseointegrating implants in the early 1980s faced a similar dilemma. Implant materials and designs, as well as restorative components, were essentially “one size fits all.”
Much like the automobile industry, the field of implant therapies has changed rapidly. The triad of conceptual evolutions, material development, and technical advancement has made implantology an integral, and in truth, indispensable part of comprehensive patient care.
As automobile use became more widespread and technological advances resulted in faster, more powerful vehicles, mishaps became more commonplace, even in such bastions of cautious driving as Boston. The result was the development of the industry of auto repair and acceptance of the fact that one’s automobile would not last the driver’s lifetime.
Unfortunately, a similar mindset is gaining ground in dentistry in general, and implantology in particular.
The all too often reckless placement of implants in clinical practice has led to an increase in implant complications and failures. Programs at scientific meetings include an ever-increasing number of presentations discussing “treatment of peri-implantitis,” “saving the failing implant,” “establishing healthy hard and soft tissues around compromised implant,” etc. Our refereed journals abound with articles documenting implant failures, and techniques for “salvaging” compromised implants.
We cannot even agree upon an appropriate definition of implant success, forcing us to speak of “implant survival.” Discussion of treatment outcomes in terms of implant survival is an actuarial exercise fraught with danger, and is a disservice to all but our most elderly patients. Cited publications speak of an implant survival rate of 92-95 percent. Equating survival with success, which is generous to the extreme, even a 95 percent success rate would be unacceptable in today’s clinical practice. If you have a reasonable size clinical practice, and place 1,000 implants per year, you would be faced with 50 failures. Unacceptable!
Would Drs. Danny Buser, Urs Belser, Burt Langer, Michael Norton, Anthony Dickinson or Dean Morton (to name a few our our “elder guard”), or Stephen Chen, Will Martin, Laureen Langer, Clark Stanford or Ed Lorenzana (to cite a few “youngsters”) accept such treatment outcomes? Of course not.
Esteemed speakers caution we need to expect to replace implants multiple times during a patient’s lifetime, depending upon the age of the patient when treatment is initially performed.
This fatalistic approach has infected our field like a cancer, and is threatening to metastasize.
While speaking at a corporate gathering a few years ago, I stated that, following appropriate examination, insightful diagnosis, interdisciplinary treatment planning, performance of comprehensive care with the highest quality materials and appropriate long-term follow-up, implant failure after 10 years in function should be less than 1 percent. I was met with silence. I turned to Dean Morton and asked if he agreed. The response: absolutely!
When I repeat this claim at consensus conferences or in small groups, I uniformly encounter incredulity at best and disbelief at worst. I am told that such claims are unrealistic, and not what clinicians are experiencing.
The fault is ours as the treating clinicians. As technological advances have resulted in narrower implants of sufficient strength to stand alone following restoration, as newer, cheaper, “just as good” implants and regenerative materials flood the market, we are regaled with unfounded claims of success. One or two-year results are quoted; follow-up and true documentation are nonexistent; and our patients suffer.
Fortunately, as educators and clinicians who can call upon committee corporate partners dedicated to research and responsible product development, we are uniquely suited to meet this challenge.
- Continue to stress the need for appropriate diagnosis and comprehensive care at all levels of therapeutic complexity;
- Provide appropriate education in both the fundamentals and advanced therapies;
- Present unbiased assessments of materials and treatment modalities; and
- Continue to penetrate dental schools to help train future dentists; dental societies to assist developing dentists; and refereed journals to inform all dentists;
- Continue to test and challenge the efficacy of all technological advances;
- Formulate clinically based treatment protocols for integration of newer materials and therapies into everyday treatment armamentaria;
- Develop a realistic definition of success.
In the absence of a more comprehensive definition of biologic (not esthetic) implant success, I use the following criteria, both in clinical practice and when compiling statistics for publication:
The criteria of Albrektsson, et al;
All implants are bone sounded buccally and palatally/lingually;
Every measurement is taken by me or my co-authors.
As our profession becomes intoxicated with new treatment options, simplification of therapy, and greater financial reward, we must not lose sight of the basic tenets of successful clinical practice: treating patient needs, while fulfilling patient desires, in as predictable a manner as possible.
To those who say such a goal is nothing more than a chimera, I repeat the words of my mentor, Dr. Gerald Kramer:
Our definition of success is limited by our perception of possibilities.
Who are we?