How to avoid problems in implant placement and/or restoration

Nov 4, 2022

Dental implants are the gold standard to replace missing teeth. For many patients, they provide a more comfortable and well-fitting alternative to dentures and bridgework. Their durability also means they provide a secure anchor for restorations and/or dentures for many years.

The success rate is high, but because implant dentistry can take many months, and involve several invasive procedures as well as high costs for the patient, dentists are at risk of litigation if things go wrong. Not all patients are suitable candidates, and a small percentage of dental implants do fail.

The most common pitfalls that lead to complaints and claims are related to consent, planning and treatment execution. This article looks at how such problems can be avoided.

Gain appropriate training

To perform implant dentistry safely and ethically, dentists must complete further training. Different training routes are available, allowing dentists to provide implant treatment within general practice or to specialise in implant surgery or prosthodontics.

The College of General Dentistry (CGDent) guidance, Training standards in implant dentistry, explains the required training and the standards that must be met by training courses. Note that this guidance is also a reference point for the General Dental Council (GDC) when considering patient complaints about the competence of dentists providing implant treatment.

Following completion of an appropriate training course, dentists are expected to be mentored by an experienced clinician. The complementary Mentoring in Implant Dentistry: Good Practice Guidelines explains the requirements.

Follow GDC standards

Dentists performing implant treatment should follow the GDC’s Standards for the Dental Team, with particular attention to:

Working ‘within their knowledge, skills, professional competence and skills’.

• Any practitioner without the appropriate training should refer patients requiring implant dentistry to somebody who is trained and competent; this may be a specialist in oral surgery or restorative or prosthodontic treatment.

Communicating effectively with patients and obtaining valid consent.

• The patient should receive a treatment plan, with sufficient information about the treatment options, benefits, risks, likely prognosis, and costs, in a format that they can understand.
• Dentists must seek consent for every stage of the implant process, so it is important that they continue to discuss with the patient the progress of ongoing treatment and record this meticulously in the notes.
• Dentists should also spend time with the patient to ensure they understand and agree to any post-procedure advice (for example, diet, analgesics, and good oral hygiene), since non-adherence to the advice could increase the risk of complications or dissatisfaction.

Work with colleagues in a way that serves the interests of patients.

• Implant dentistry often involves a multidisciplinary team, so communication between colleagues is fundamental to success. All the involved team members may be liable to some extent if a claim is made.
• If different practitioners perform the surgical and prosthodontic aspects of implant treatment, they must agree on the treatment plan and document who is responsible for each aspect of treatment.

Keep complete and accurate patient records.

• Diligent record keeping is essential and helps if problems occur that subsequently lead to complaints or litigation. Maintain a record of all discussions with patients and colleagues regarding dental implant treatment, as well as any imaging, models, and documentation. It is highly recommended to have photographic records as well.

Perform a thorough patient assessment

The initial patient assessment is crucial to identify and record conditions that could complicate treatment. Successful treatment also depends on the patient’s bone to allow osseointegration of the implant which cannot be predicted, thus discussions must be recorded in the notes as well as ensuring the patient has copies of the consent process and all information related to treatment. Any failure to do so could be a cause for litigation if complications occur.

Assessment should include:

• Relevant health conditions and patient factors that are associated with increased risk of implant failure, including: smoking, diabetes, untreated caries or periodontitis, bruxism, age, chemotherapy or radiotherapy, and therapy with bisphosphonates or corticosteroids. These cases require caution and alternatives to dental implants may be preferable.
• Bone and soft-tissue condition: deficiencies may need to be addressed before implant surgery. Bone structure determines many aspects of treatment, from selection of the implant design to the surgical approach, type of reconstruction, the need for bone grafts, and the healing time between stages of treatment.
• Retained roots at the implant site: these usually need to be removed before implant surgery. More complex cases may require invasive surgery under sedation or general anaesthetic, and potential complications include injury to the adjacent teeth, bone or nerves. This makes implant treatment a longer and more complex process, so it is essential to discuss the risks and benefits with the patient.
• Testing for implant allergy or sensitivity.

Agree a plan for treatment

To maximise the chance of long-term treatment success, and reduce the risk of complaints, dentists should prepare a comprehensive treatment plan based on the patient assessment and treatment goals. This should be in writing and agreed with the patient and any other practitioners involved in their treatment.

The plan should include any pre-implant treatments (such as bone augmentation or treatment of existing oral health conditions), all stages of implant surgery and prosthetic placement, healing times, the design and positioning of the implant and selected prosthesis, and post-procedure care.

Use of imaging and wax-ups can assist the treatment planning and help the patient to understand how the prosthesis will look, giving them a chance to discuss any concerns before treatment starts.

Know how to manage complications

Most dental implants are successful, and many complications are minor and easily treated. For example, patients should be advised how to treat any minor swelling, bruising, pain, and bleeding that may occur in the first few days after treatment.

However, dentists who provide implant treatment must also be appropriately trained to manage less common, but potentially serious complications. These include implant site infection, peri-implantitis, failure of osseointegration, mechanical or technical failures, nerve damage, and sinusitis.

At Dental Defence Society, we offer indemnity packages covering implant dentistry and 24/7 dento-legal support. If you provide dental implant treatments, please contact us to discuss your needs.