A Brief Report on Standard of Care in Implant Dentistry

By

Kavitha P. Das, BDS, MPH, MS

Feb 2011

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Background

The term "standard" in medicine has multiple interpretations1 and a fixed accepted standard of care does not exist in medicine or dentistry. However, there are conditions for which standards of care have been established and are constantly evolving, and they can be referred to for specific cases or scenarios.

The Institute of Medicine reports that standards are set by combinations of regulation, self assessment and norms established by health professionals.2 Standard of care is multifactorial and can be specific to a procedure at a specific time, level of expertise and technology available.3 It can vary by regulation- at the regional and national level.4 Standard of care is often described in the context of negligence, but this does not give clarity to the dentist on specific norms or guidelines in the context of dental procedures.

The American Dental Association describes standards as those that are intended to be applied rigidly and carry the expectation that they be applied in all cases and any deviation from them would be difficult to justify.5 A standard of care indicates that measurable criteria are present and these criteria shall be used in order to arrive at a given level of outcome.

The recommendation of specific procedures as standard of care impacts the treatment options provided by individual clinicians and institutions, and has broader legal implications.

Standard of Care and Dental Implants

An independent report published by the Millennium Research Group states that the use of dental implants in the United States of America is growing rapidly. 6 The history of modern dental implants and their impact in the context of various prostheses is well documented. 7-15 Published data focus on merits and demerits of procedures in the context of dental implants.16, 17 The longevity and efficacy of dental implants has been reported by numerous authors and it has been estimated that there is over 90% success rate with dental implant.18, 19 Emphasis has been on the preservation of natural tooth structure over tooth replacement with dental implants,20-22 but these recommendation are considered on a case by case context. The final treatment outcome is based on taking multiple factors into considerationesthetics, function, costs and longevity of each procedure.20

The field of dental implants is constantly evolving and the trend is towards minimally invasive procedures with a focus on immediate function and esthetics. Dental implant treatment has been effectively included in the curriculum of most dental schools 23-25 and most recent dental graduates in the US have had some experience restoring dental implant supported prostheses. Despite marked scientific developments, new treatment options and change in dental school curriculum to include implant dentistry, there is uncertainty on quality of care provided.26

Various authors have made recommendations for establishing standards of care for the single implant procedures27 and the two implant retained mandibular overdenture. 10, 28 The response to the standard of care for two implant retained mandibular overdenture has been well accepted and has been recommended as the first choice standard of care for the edentulous mandible.29, 30 Experts in the field placed emphasis on sound scientific evidence, randomized clinical trials and evidence-based dentistry before publishing the McGill Consensus statement on the first choice standard of care for the edentulous mandible.10 Studies that originated 4

from the team at McGill University, systematically produced evidence to support the recommendation of the two implant support mandibular overdenture as the first choice standard of care. The York consensus statement on the first choice standard of care for the edentulous mandible reinforced the McGill consensus statement. 28

As with most prostheses, dental implant supported prostheses are not free from complications. 31, 32 Many studies have reported over 90% success rate with many implant supported procedures16, 33, 34 However, there are not many independent studies that compare variations in success rate between various implant manufacturing companies30 even though there are numerous articles that report the efficacy of specific procedures, techniques and technology.

Technology in dental implants is constantly evolving.35 Implant dentistry is expected to play an important role in the future of dental prosthetics and replacement of missing teeth. Dental implant procedures are increasingly becoming digitalized and will bring on new challenges,36-38 which will require new guidelines, regulations and standards.

Thus, there is a need for comprehensive studies to assess and make recommendations for procedures in implant dentistry and evaluate the possibility of creating standards that will be acceptable within the scientific community.

Conclusion

The American College of Medical Quality defines the standard of care as a case and time specific analytical process in medical decision making, reflecting a clinical benchmark of acceptable quality medical care. The standard of care must reflect the art (consensus of opinion of clinical judgment) and science (published peer reviewed literature) of medicine and must be uniform for all health care personnel whether they are providing direct clinical care or reviewing the medical necessity of past, present or future medical care.39 5

Based on the above definition, it is crucial that clinicians and stakeholders take action to create an environment that encourages systematic creations of standards for specific prosthesis and procedures that can be all encompassing and can be utilized to provide the highest possible standard of care to the patient.

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