Why a new Dental Implant Specialty is Needed.

Despite all the opposition expressed to this new specialty, there is nothing more needed in dentistry than this change. Much of this opposition is based on misinformation and deceit, and it is my intention to clarify as much of this as possible.

I have been licensed to practice dentistry in the Commonwealth since 1977. I graduated from MCV under the guidance of dean John DiBiaggio, one of the greatest educators in the world. Dean DiBiaggio was the individual who inspired me to want to become the best dentist I could be. I placed my first implant in 1983. Today, 35 years later, my practice is dedicated completely to dental implant treatment. As a result of recent Federal Court decisions, if my practice was located in Texas, Florida, California, New Jersey, or Massachusetts, I would be permitted to market myself as a dental implant specialist.  It was for this reason and because too many patients in Virginia have been mistreated and harmed, that the Virginia Board of Dentistry was petitioned to make a change to allow qualified doctors to call themselves dental implant specialists. All the comments that have been made in opposition to this measure were the same ones made in the other states where it is now legal for Diplomates of the American Board of Oral Implantology/Implant Dentistry to advertise themselves and specialists, and in the end the impartial courts agreed that we are Implant Specialists, despite all the opposing rhetoric.

American Academy of Implant Dentistry

The AAID is the oldest dental implant organization in the United States, it was founded in 1951, it was organized to promote dental implant teatment and education, and is composed of Oral Surgeons, Periodontists, Prosthodontists, and General Dentists. The Academy is the sponsor of the ABOI and all the efforts to develop this new specialty and one of the founding organizations that established the American Board of Dental Specialties. This organization was founded to remove the bias and collusion of the ADA which has prevented any new dental specialties unless they were not in competition with the existing surgical specialites. The Academy has been the leader in comprehensive dental implant education and has made this education available to any doctor with a desire to learn. It’s certifications are based on valid and verifiable testing criterion, not a system of pay the money and get a certificate with no verifiable measure of the candidates knowledge and understanding. There are many other organizations promoting excellent implant education and provide certificates of participation that appear impressive, but lack any valid testing criterion of the doctors knowledge and understanding. I joined the AAID and have been a member since 1983. Over the many years of my involvement with the Academy there has been one unchanging goal, that has been seeing that dental implant treatment becomes a recognized dental specialty.

Over the last 30 years the Academy petitioned the American Dental Association, a biased trade organization, on two separate occasins, years apart, to accept and allow development of a dental implant specialty. These petitions were accepted and studied at the ADA, and the ADA’s own council on education recommended acceptance of the measures to the House of Delegates citing the public need for this specialty. Each time the petitions came up for a vote they were turned down by the members of the House of Delegates. Because the House of Delegates was composed of a majority of surgeon specialists it was believed that these voting members did not believe a new competeing surgical specialty was in their best interest and that was why the measure was not accepted.

The Court Decisions

It was this very real and ongoing problem at the ADA, common within similar commercial trade groups, that led Diplomates of the American Board of Oral Implantology/Implant dentistry (www.aboi.org/) to sue the Boards of Dentistry in California, Florida, and Texas, in the Federal Courts. The dental boards of the states mentioned had threatened to revoke the licenses of the doctors in those states because they were accused of advertising themselves as dental implant specialists. In each of these states the same reasons for opposing this specialty were made and in all three decisions, the courts, found for the plaintiffs saying they were truthful in their declarations and that their certifications were based upon valid and Bona Fide testing criteria. They determined that the ADA’s, restrictions and opposition to any new specialty applications was an unfair restriction of trade, and against the law. They ruled that that the doctors certified as Diplomates of the ABOI should not be restricted from declaring themselves as specialists just because the ADA, a biased trade organization, had not recognized Implant Dentistry as a specialty. This led to the formation of the American Board of Dental Specialties, an organization similar to those in medicine, where the bias of the AMA, another trade organization would not have influence. The American Board of Dental Specialties is composed of the American Board of Oral Implantology, the American Board of Oral Medicine, The American Board of Orofacial Pain, and The American Dental Board of Anesthesiology. See www.dentalspecialties.org/. The ABOI examination process is open to any qualified doctor desiring to take the examination. Diplomates of the ABOI include oral surgeons, periodontists, prosthodontists, and general dentists.

Winning in the Federal Courts was the only way to effect a change in ADA opposition policy. After the court decisions came down the Federal Trade Commission approached the ADA’s surgeon leadership. These individuals were taken to task for their collusion to prevent a competing surgical specialty in Implant Dentistry. They were told if they continued to oppose this new specialty they could be personally held accountable. A new specialty in Implant Dentistry has been sorely needed to better serve the public for many years. The leadership in the ADA house of Delegates had previously turned down two petitions by the American Academy of Implant Dentistry, (AAID) over the past 30 years to allow implant dentistry, the most complex and demanding practice in dentistry, to become a specialty. The specialty applications were turned back in the House of Delegates despite the ADA’s own councils recommending approval because there was clearly a need and benefit for the public. All three of the Federal Court cases found in favor of allowing Certified, Diplomates of the American Board of Oral Implantology/Implant Dentistry to advertise themselves as specialists. This was only possible after the courts determined that the candidates receiving certification from the Board's testing procedures were indeed valid and Bona Fide, and similar to the Board's testing candidates in other specialties. Court cases in California, Florida, Texas, resulted with damages that awarded to the American Academy of Implant Dentistry in the amount of $15,000,000. Since then, other states have already adopted regulations similar to the one now prepared to be enacted in the Commonwealth. New Jersey, Massachusetts, Indiana, and Ohio have changed their regulations to allow or not interfere with Diplomates advertising as Implant Specialists, or they are currently in the process of change now.

An Implant Specialty Would Establish a Standard of Care

 A new specialty is not to say implants should not be placed by anyone except specialist, but without a specialty there is no Standard of Care, no rules.

I have seen existing ADA recognized specialists say they are surgical implant specialists, but before the recent changes in the ADA’s definition of ethical behavior, they were restricted to the surgical phase only. Today, as a result of the ABOI court decisions and FTC interventions at the ADA, recognized ADA surgical specialists are no longer considered unethical when they perform prosthetic procedures, even with little prosthetic training and experience. Likewise, ADA recognized prosthodontic specialists are not considered unethical when they perform implant or other surgical procedures. Implant dentistry is a prosthetic discipline with a surgical component, the prosthetics determine the surgical component. Modern specialist training in the ADA recognized surgical residencies have only a small portion of their training devoted to dental implants and then only the surgical components, yet is that to be considered sufficient to be an implant specialist when implant dentistry is primarily a prosthetic discipline? Who is more qualified as the implant specialist, an ADA recognized specialist with limited experience in prosthetics or a GP with thousands of Implant specific CE hours and 35 years of clinical experience in all aspects of implant dentistry? Proper treatment planning, providing patients with all options of implant care, based upon the patient’s prognosis is sorely missing in the majority of implant treatment provided today. Today the vast majority of dental implant treatment plans are based upon what the patient thinks they want or what the doctor’s knowledge and ability can offer. In both of these situations the treatment plans offered are typically lacking needed decision-making information, patient education and understanding of what the future holds for them.

An Implant Specialty Would Improve Treatment Plans and Patient Prognosis

Personally, I have treated thousands of patients using all types of dental implant techniques, and materials. I have placed blade implants, subperiosteal implants, root form implants, buried implants and immediately loaded implants. I have performed sinus augmentation procedures, and treated the complications associated with those procedures when needed. I’ve performed mandibular nerve transpositions, to allow implant placement when required. I have recognized soft tissue complications associated with implant treatment and provided soft tissue grafting procedures to obtain the tissue required to maintain long term implant stability. I have recognized and treated occlusal load complications that left unrecognized and without preventive treatment would have led to eventual painless implant failure. For the last few years my practice has been devoted to implant treatment focusing on full mouth implant restorations, “All on 4” or more implant cases, and the long-term management of these cases. I have provided years of post-treatment maintenance of implant cases recognizing potential problems before they led to case failure and treated them accordingly to prevent failure. Many failing implant cases result because of prosthetic problems not surgical problems. I have a 35-year perspective looking back at implant patients and what happened after their implant treatment was completed. My perspective is very different today from what it was ten or fifteen years ago, this is only because I have seen what happens with patients after the implants and prosthetics have been placed and paid for. A specialty in Implant dentistry would go a long way in helping inexperienced dentists placing implants avoid many of the problems they will face in the future. Without an understanding of what the future will bring to the patient and the treating doctor, a set of problems that will not benefit the doctor or patient. Not understanding the prognosis and explaining to the patient what will most likely be encountered, can set the doctor and patient up for costly future problems that could have been avoided with proper initial treatment planning and patient education. This is something that for the most part is not being considered by many doctors today placing dental implants. Understanding proper treatment planning and prognosis is the single most important factor with any dental implant treatment plan, it is something that would be elucidated with a dental implant specialty, and something missing in most of the treatment being provided today.

An Implant Specialty Will Better Serve Dentistry and The Public.

Suffice it to say I do not treat patients today the same way I did 35 years ago, I have made all the mistakes possible because I did not know what I did not understand then. I see patients today asking for second opinions or corrective treatment that are shocked when they learn what is required and the associated cost. Such problems are the result of little or no understanding of implant treatment and lack of patient education. Because of the problems associated with such treatment errors I have explained to patients that the doctors providing their previous treatment were doing the best they could at the time, but for many patients harmed by implant treatment gone wrong and determined to sue there is little anyone can do. These cases are not limited to general practitioners but from more often than not, ADA recognized specialists providing less than ideal treatment. Today I see patients come in for 2nd opinions who were treated by GP’s and specialists, who only have a rudimentary knowledge of implant dentistry. They have been taught by manufactures reps and bone salesmen, who want to sell them products. Today bone grafting techniques are so overdone and promoted to inexperienced doctors “as required” by bone salesmen when all these grafts do is add unnecessary cost to patients and slow down treatment time. I’ve seen cases where nothing but greed, was the motivating factor behind the treatment plan. A patient was treated by a surgeon who attempted to put as many implants in place as humanly possible, placed them so close together that failure was the only possible outcome. It was obvious that the surgeons fee was based on the maximum number of implants that could be placed, implants that were placed in the pterygoid plate that were so far out of position to make them unrestorable, but which still generated a surgeon’s fee. Once the implants were placed the restorative doctor was told that he had a wonderful foundation to build anything the patient wanted as a prosthesis which was far from the truth.

I have another patient who was told by his general dentist that he needed a sinus graft for implant placement when in fact the proposed treatment could have been accomplished with no graft at all. His general dentist referred him to another general dentist who was supposed to be a dentist experienced with sinus augmentations. The patient went as recommended to this general dentist sinus expert, but who had no credentials at all, and had the procedure. The procedure failed, and the sinus opened up as it failed. The patient went back to the doctor who told him he would need a rescue procedure and the patient agreed, and paid again, only to have the mismanaged rescue procedure fail too. By the time I saw the patient most of the damage had been done. The lateral wall of the maxillary sinus was gone, leaving a huge defect with a patent opening into the patient’s nose. Every time he drank something it went into his nose. I spoke with the doctor who performed these surgeries. He claimed to have done many of these surgeries without a problem and would take no responsibility for what went wrong with this patient. I tried to get him to settle with the patient out of court, but he refused, and now the case is going to the courts. All this because these doctors were unskilled in their treatment plans and diagnostic abilities.

I could go on with many more examples, but the fact of the matter is that recognized specialists and GP’s are at fault equally. This problem is a result of no separate recognized dental implant specialty where standards of care could be developed that would give all doctors involved in implant treatment some guidelines. Today there are no guidelines, no standard of care that would be in the patient’s and the profession’s best interest. Today, implant dentistry is being damaged in the eyes of the public because of the internecine turf battles and the ADA’s previous focus on what has been good for surgeons and damn the public welfare. Treatment planning is the most important aspect of any implant case, but often it turns out to be an afterthought. I’ve seen one implant placed into an arch of periodontally involved teeth destined for failure, where no prognosis for the patient’s overall need in the future was even considered. Too often the public sees this lack of honesty as a stain on the profession, sometimes from a doctor’s ignorance but more often out of greed. This affects all of us and our standing in the community and would be discussed and dealt with properly if there was an implant specialty established that could be depended upon for guidance.

Opposition to an Implant Specialty                  

I have read the comments of those opposing an implant specialty and most have a common thread, the lack of education, not CODA approved, a threat to the public, real specialists have years of residency training, lack of experience, and on and on. Adding a specialty will do nothing to limit the numbers of patients seeking care, or the opportunity for practitioners to provide it. But it will improve the nature of the treatment and magnify the benefits of implant treatment in the eyes of the public and profession. Today that’s not the case, today implant treatment in general is developing a negative connotation, primarily because there is no specialty. Any new developing specialty needs growth and development, but it needs to be declared a specialty before that can happen. The problems with implant treatment as practiced in general today are hurting the public and the profession. I and many others have devoted their dental careers to fostering implant dentistry, I am confident that I have more complete dental implant experience than anyone commenting on this forum. Today my practice is devoted to implant treatment, and associate care based around dental implants. I consider myself a specialist in Implant dentistry despite what anybody else thinks or believes. I provide all aspects of dental implant treatment, from diagnosis and treatment planning to long term follow up maintenance. I have 35 years of implant specific experience and a Credential from the ABOI that has been thoroughly examined, tested, and upheld in the Federal Courts, against opposing state dental boards across the country. Doctors like myself had to turn to the courts when biased factions within organized dentistry determined they would not support such a move. They had their own reasons for their opposition, and the public interest and welfare was not one of them. The Virginia Board of Dentistry has the obligation to protect the public from harm and by permitting Certified doctors to advertise themselves accordingly will do exactly that.

Rodney S. Mayberry DDS

Diplomate, American Board of Oral Implantology/Implant Dentistry