Interview: "The term 'implantologist' is ill-defined and often misleading"

Dental Tribune ONLINE: Dental implants have gained a negative image recently in countries like Japan. Is this perception due to portrayal by the media, or to some extent to the lack of education and skills in placing dental implants?
Dr Nikos Mattheos: It is true that a wave of negative publicity recently affected the whole of implant dentistry in Japan. A few high-profile cases of complications after the placement of dental implants were picked up by the daily press and blown out of proportion, with the help of some negative statistics. This had a direct and drastic impact, as the number of treatments with dental implants dropped dramatically within a short period.

It is unfortunate that as a result of this negative publicity many patients who could benefit from implant treatment significantly are becoming increasingly hesitant to seek or accept implant treatment. But it also an opportunity for us all to stop for a minute and reflect on the way implant dentistry is being practised today. In the case of Japan, it is true that the way the media chose to present the topic might have contributed to the sudden burst of negative publicity, but it is also true that implant dentistry is not always carried out to the highest standards, and Japan is no different to the rest of the world in this regard.

After more than 30 years of research and development, implant dentistry has today achieved the technology and protocols that can ensure highly predictable and sustainable treatment outcomes applicable to a wide portion of the population. At the same time, we are witnessing an increasing trend of compromising the standards that have led to this highly predictable success, possibly owing to pressure from market forces and the need to reduce costs or simply a lack of adequate education. This compromise can take many forms: it can be compromise in the education and skills of the operator, compromise in the selection of patients, compromise in the protocols followed or, frequently, compromise in the quality of the material and the devices used.

Such a compromise is a ticking bomb not only for implant dentistry, but also for the dental profession as a whole. Dental hospitals and specialist clinics are often the final recipients of complications with dental implants, as patients are referred there after failed implant treatments. At this point, I can already say that the number of complications we see in referral clinics is much higher than what one would expect based on published research. Therefore, it is imperative to ensure quality education and strict adherence to evidence-based protocols for all practitioners of implant dentistry. Otherwise, the risks are high and will affect us all. As demonstrated in Japan, patients’ trust is our most precious investment and it does not take much to jeopardise it.

According to some studies, including recommendations of the first workshop on dental implant education in Europe that you co-ordinated in 2008, there is a wide discrepancy in undergraduate education regarding implant dentistry training. Would you agree with that statement, and what are the consequences for the quality of implant placement?
To be more precise, there is discrepancy between what a general dentist is expected to know/perform in implant dentistry and what the current education in most schools is teaching. Nowadays, a general practitioner should be able to discuss with his or her patients the treatment option of dental implants when indicated, regardless of whether he or she will be undertaking the placement himself or herself or just the restoration of the implants.

Moreover, a general practitioner must be able to maintain patients with dental implants and prevent or diagnose biological and technical complications early. There is an increasing number of patients with dental implants and the general practitioner has a key role in maintaining long-term health. Unfortunately, most dental curricula have not developed to the point where the graduates have the skills and competencies in implant dentistry that are necessary for modern practice.

In addition, there is great diversity in the knowledge and skills that universities provide in their undergraduate programmes. Our latest research in preparation for the second consensus workshop in Budapest this summer has shown that this diversity still persists among European schools, although significant improvement steps have been taken since the previous workshop held in Prague in 2008. All dental schools have increased the amount of teaching in the area of implant dentistry in the past five years and in many cases preclinical and clinical education components have been introduced. However, it is clear that there is still room for improvement.

Several initiatives to standardise norms and guidelines in implant education already exist. What are the main obstacles to implementing them?
In 2008 in Prague, we managed to come up with a consensus on the knowledge and competencies a general dentist today must possess in implant dentistry. It is without a doubt that general practitioners must have a thorough understanding and certain skills, regardless of whether he or she will choose to place or restore dental implants.

What we realised in 2013 however is that although it is relatively easy to identify what a general practitioner needs to know it has proven to be a very difficult exercise to implement this knowledge in the dental curriculum for most dental schools. The lack of time in the curriculum, lack of resources or staff, as well as departmental fragmentation, make the implementation of implant dentistry a challenging task for dental schools. Progress has been achieved nevertheless.

Virtual implant planning and guided implantology have the potential to enhance implant treatment outcomes significantly. Are these technologies of benefit to dental implant education or do they make it more challenging?
Technology has offered many solutions to clinical problems, and computer-aided planning in combination with CAD/CAM technology has opened up possibilities for effective and quick treatment of rather complex cases. Although such technologies are certainly promising, there are still challenges related to their application. Many clinicians mistakenly see such technologies as compensating for a lack of clinical experience, as they are often led to believe that with the help of guided surgery even a relatively inexperienced clinician can undertake complex treatments with safety and this is a dangerous illusion.

Another limitation is the high cost of such technology, which makes the investment worth while only when undertaking relatively large reconstructions. However, there is no doubt that in the hands of an adequately trained clinician computer-guided surgery combined with CAD/CAM technology can improve the quality of service offered to the patient and introduce many new possibilities.

The Dental Council of Ireland currently does not recognise the term “implant specialist”. Does dental implantology need to be an independent specialty?
This is a very hot topic, which was also extensively debated in the latest consensus workshop in Budapest. Indeed, the Irish dental council is not alone in this, as the vast majority of dental boards have not recognised implantology as an independent dental specialty. The American Dental Association, for example, has repeatedly rejected applications by various bodies to recognise implantology as a new specialty.

The consensus workshop has also adopted this position and does not see any need for implantology as a new specialty. I cannot reveal any details, as the detailed position paper will be published in early 2014, but the consensus is that implant dentistry is a multidisciplinary treatment modality that at present does not fulfil many critical requirements for recognition as an independent specialty.

Unfortunately, the truth is that many clinicians and societies are self-proclaimed implantologists or implant specialists, thus implying a specialist status. An established specialist, for example a periodontist, is someone who has completed an accredited three-year full-time programme, has achieved specific knowledge and competencies as defined by the respective scientific and government bodies, and can perform an array of treatments, for which he or she has undergone adequate training.

However, the term “implantologist” is ill-defined and often misleading, as there is no widely accepted description as to what an implantologist is (competencies, scope of practice, etc.), nor any structured educational pathway defined for someone to reach such a status. So I think the consensus among university lecturers of implant dentistry will agree with the Irish dental council and will discourage the use of the terms “implant specialist” and “implantologist” in any context.

Thank you very much for the interview.