Interview: Good practice guidelines for implant dentistry

Dental Tribune UK & Ireland: Prof. Ucer, what is the level of implant dentistry in the UK at the moment?
Prof. Cemal Ucer: From what I can see, the standard of dentistry in this country is maintained at a very high level. There are some very well-structured courses and seven or eight MSc programmes throughout the country providing education and training at a high postgraduate level. As we are still behind our European neighbours in market penetration of implants in the UK, it is expected that the numbers will keep rising, with increasing opportunities for training in this field.

Implantology is very complex and requires skills from all across dentistry, including restorative dentistry, oral surgery, periodontology, orthodontics and endodontics. It is also becoming increasingly team-oriented, requiring the services of highly trained dentists, dental technicians, dental hygienists and dental nurses with a special interest in dental implants. Finally, the recent advances in digital dentistry and surgical navigation are revolutionising the delivery of implant treatment while improving precision, efficiency and safety.

How did you become involved in the preparation of the new implant dentistry guidelines?
In 2006, the FGDP(UK) published the TSID, which is used by the General Dental Council to define the training that should be undertaken to carry out implant dentistry in the UK and the standards that should be met by training courses. One of the requirements of the document is that dentists wishing to provide implant treatment in the UK have to undergo structured and supervised training in this field. Another requirement is that dentists need to audit their implant cases annually. Most of the training programmes in this country have responded positively to the TSID and have improved the structure and content of their courses. For example, mentoring to help with clinical skills development under supervision has now become widely available. Implantology requires a variety of clinical skills, which can only be developed practically and clinically, so mentoring has been a huge advantage to dentists training to incorporate implantology into their practices. By the way, the contribution of TSID has also been recognised worldwide.

I was invited by the current Dean of the FGDP(UK) to lead the development of the new guidelines. Given my previous work in helping to develop other such documents in the UK and in Europe, this was already an area of special interest to me. My remit is to develop evidence-based best practice standards in line with a framework known as AGREE II. There are six domains that are required to make this process rigorous, including editorial independence, well-defined scope and specific objectives, and stakeholder involvement. Drs Simon Wright and Andrew Shelley are my co-authors developing the document; however, there will be widespread stakeholder consultation before the standards are finalised.

When did you begin, and what is the current state of the document?
We started last May and, so far, we have written about 40,000 words. It is a huge workload, as implant dentistry covers a wide spectrum of the science of dentistry. The manuscript is now in its first draft and the next step is to condense and consolidate it. It will then go to internal review first in the FGDP(UK). After this, it also has to go through an outside review process and we will invite all stakeholders in the UK to have a look and give their comments so that we can respond to any concerns and eventually modify the document. It will certainly see a couple of changes over the next few months. The aim is not to exclude any one group from the process and we will certainly circulate it to the Association of Dental Implantology and other organisations that might have a stakeholder interest in implant dentistry.

What are the basic principles behind the document?
Delivery of satisfactory dental implant treatment and its long-term success and maintenance require complex and invasive surgical and restorative procedures using a variety of highly specialised products, biomaterials and equipment. Patients expect that the members of the dental team have the right skills and that the products they use are safe and proven. Furthermore, patients are entitled to have adequate information and advice on the alternative techniques and products, as well as the risks and outcomes, before autonomously deciding to commence treatment.

The overall objective of Standards in Implant Dentistry is to set out a framework of knowledge and skills that the dental team must possess in order to provide safe and successful treatment that can meet the long-term expectations of patients who seek the restoration of their dental function and aesthetics with dental implant-supported prostheses.

The document is divided into two main domains: clinical and non-clinical. These cover the subdomains of professionalism, patient information and communication, application of knowledge and skills, safety, consent, human factors, audit, teamwork and management, governance and regulations, and so on. It is a dynamic document that will evolve with the changing evidence base and knowledge in the years to come. These are intended to be good practice guidelines that will improve the clinical standards rather than prescriptive regulations that could hamper best treatment of patients.

What challenges have you faced in compiling the guidelines?
The greatest criticism of any guidelines is that they could work against the clinician, who might find them impossible to fulfil if the standards are clinically unachievable. The standards are written using a grading system of “recommended”, “essential” and “unacceptable” or “conditional”. These are a framework of structured domains that describe the best practices, yet they allow for individual autonomy and variation. Clinicians therefore need to refer to the document and justify their clinical decision-making protocols with special reference to the best current evidence.

For example, in the patient communication domain, we do not specify what should be in the treatment plan. What we do say is that a good treatment plan should involve description of the patient’s problem, a diagnosis, what the treatment options and risk management factors are, and what a satisfactory outcome should be. The document provides a broad prescription, but then it has to be fitted with the patient’s individual requirements and desires and the current evidence supporting clinical decisions.

When will the guidelines be available?
The hard work has been done in producing the main manuscript. However, there is still a great deal to be achieved when the document goes out for the internal and external review processes. I am hoping that this could be accomplished by March/April. We should then be in the position to publish the standards towards the end of the year.

Thank you very much for the interview.

Editorial note: Ucer is also one of the directors of the Implant Centres of Excellence Postgraduate Dental Institute and Hospital in Manchester, as well as an academic lead for the MSc in Dental Implantology at Edge Hill University in Ormskirk near Liverpool.