Risk Management Issues in Implant Dentistry

by Matthew Wilton

Implant dentistry can be profitable and challenging work for dentists. However, this area of dentistry is not without legal risks. Dental regulators across Canada look closely at implant complaints, because they may be concerned that some dentists chose implant dentistry for financial reasons only, without having the necessary skills to practice successfully. Regardless of whether this theory is correct, implant dentistry carries increased and unique special medical-legal risks. Failed implant cases may lead to complications including post-operative infection, implant failure, bone graft failure, paresthesia, sinus involvement, and loss of adjacent teeth, non-restorable implants and fully restored implants.

The most common mistakes that GP dentists make in the surgical phase of implant cases include incorrect placement position, alignment, implants too close to other implants or anatomic hazards, and the use of products not approved by Health Canada. For the prosthetic part of the case, the biggest problems are occlusal overload, or implant design, which make oral hygiene difficult. This increases the risk of plaque accumulation and resultant peri-implantitis. The third area of concern is patient management. Implant cases frequently require long-term monitoring and appropriate hygiene visits to monitor for peri-implant bone loss. Patients must be taught how to clean around their implants, and need to understand the risk of peri-implantitis.

In addition to the potential clinical complications for the patient, there are financial considerations in every implant case. Implants are expensive, and are often a component of a broader prosthetic plan for the patient’s entire mouth. It is a truism that when patients pay larger sums of money, they have increased expectations with respect to the result. This may lead to more regulatory complaints, as patients may be disappointed by the aesthetic outcome, or be upset by painful physical complications.

In Ontario, the RCDS has drafted guidelines entitled “Educational Requirements and Professional Responsibility for Implant Dentistry”. These guidelines should be considered a useful resource for dentists across Canada. The Guidelines divide cases into two categories. Firstly, cases involving straightforward placement and or restoration of implants. These are defined as cases with an easily seen end result with predictable treatment phases. Secondly, complex cases involve complex placement and/or restoration of implants. These are cases where the end result is not easily visualized, where more difficult implant surgery is required and where complications are expected.

The RCDSO Guidelines stress the importance of proper patient evaluation and treatment planning at the outset. The Guidelines provide a useful list of risk reduction measures including the following:

  • Accurate assessment of the level of complexity of the clinical case and of the dentist’s skill level to undertake it – setting reasonable and achievable treatment goals;
  • Careful patient evaluation and treatment planning;
  • Appropriate discussion with the patient regarding the proposed treatment;
  • Excellent communication between all members of the dental implant team;
  • Carefully evaluated and approved dental implant systems and ancillary equipment;
  • Appropriately trained dental staff;
  • Best practices for the procedure; and
  • Best practices checklist for infection prevention and control.

Informed Consent
A different approach is required when obtaining informed consent in an implant case. This is based on the theory that many implant cases will be considered elective treatment. The law recognizes that in assessing the materiality of risks, Courts impose a higher standard of disclosure in relation to elective cosmetic treatments and procedures than in the case of medically or therapeutically necessary treatment. This flows from the reasoning that when non-essential elective treatment is undertaken, any type or level of risk may be that much more material to the patient’s decision to consent. The patient may be presumed to be more likely to not pursue non-essential elective treatments or procedures if they carry with them significant risks of serious consequences. Most implant cases will be elective procedures. In these circumstances, dentists have an enhanced obligation to obtain a fulsome informed consent.

The RCDSO Guidelines provide a useful summary of the requirements to obtain an informed consent in an implant case, which include the following factors:

  • The patient’s diagnosis;
  • The nature and purpose of dental implant treatment as well as the rationale for choosing it in this case; and
  • A clear explanation of the benefits and risks associated with dental implant treatment including the risk of dental implants failing to osseointegrate.

In my experience, the most common negative findings of the RCDSO’s ICRC (hereinafter “the Complaints Committee”) concerning patients’ complaints about implants are firstly, inappropriate case selection, and, secondly, the failure to properly formulate a treatment plan. As indicated above, the more significant the patient’s suffering and financial loss, the more likely that the patient is to complain, or to sue a dentist for malpractice. It is essential that there be effective collaboration between the surgical and restorative dentists in developing a treatment plan. In my experience, if a dentist successfully performs the surgical part of the case, and the restorative component of the case is poorly done by another dentist, the surgical dentist will be criticized for failing to ensure the restorative aspect of a case was adequately treatment planned. Dentists must ensure, at the inception of the case, that there is a thorough patient work up done including necessary imaging and/or a CBCT scan. The dentist should also make a proper assessment of the patient’s ability to maintain oral hygiene once implants are placed.

One of the common concerns identified by the Complaints Committee is that the patient was not a good candidate for implants, most commonly because of bone loss issues or poor oral health. In various complaints I have been involved in, panels have expressed concern that the patient had several risk factors that made them a less than ideal candidate for implant surgery. If risk factors such as the patient being a smoker, or inadequate bone, inadequate ridge height or shallow vestibule are present, then it is incumbent upon the dentist to emphasize these risk factors, to document that the patient was made aware of the risk factors, and that there were discussions specific to the patient’s dental needs. If your College determines that you never should have done the implant work in the first place, then it will be no defence to a complaint to assert that you told the patient that their implants may fail, or that their case was complex. Some treatment should simply not be pursued.

A GP dentist initiating a complicated implant case should be prepared to demonstrate that the dentist told the patient of the option of a referral to a specialist for a second opinion. A recurring theme in patient implant complaints is the patient’s complaint that they did not understand that the GP dentist was not a specialist, and that they were not offered the opportunity of seeing a specialist. It becomes very important for the dentist to record adequate notes of any informed consent discussion, including the option of referring the patient to a specialist for a second opinion or further evaluation.

In Ontario, the Complaints Committee has taken a particular approach to implant complaint cases. Depending on the seriousness of the complications arising from a failed implant case, the Complaints Committee has made orders in the past that include the following components:

  • A one-on-one course in implant dentistry with a focus on implant treatment planning, particularly with respect to comprehensive cases, fixtures and placement of implants, and communication with patients about treatment options, alternatives, risks and benefits of treatment.
  • A Mentorship by a specialist who is approved by the Registrar, who will review implant case selection and treatment planning for all implant cases, including single tooth implants, prior to initiating active treatment.
  • The member must continue to be in contact with the mentor throughout the course of implant treatment, and present the final results of each case to the mentor.
  • The Mentorship will continue until at least 5 multiple implant cases have been successfully completed and the mentor advises the ICRC, in writing, that the Mentorship is no longer necessary, and a panel of the ICR Committee agrees.
  • Practice Monitoring for 24 months.

The approach of the RCDS to require a mentor as a result of a complaint case, creates a layer of expense and inconvenience for the dentist, that may make it difficult for the dentist to successfully continue their implant practice. The approach of using a mentor presumably reflects the concerns of the Ontario College that poorly performed implant cases create significant harm to patients, both financially and physically.

Repeat offenders in Ontario will be subject to strict mentoring requirements which will likely have the effect of dissuading them from doing future implant cases. You must understand that the Complaints Committee will be concerned that dentists have chosen to pursue implant dentistry for financial reasons unconnected to their skill levels. Thus, it becomes vitally important for dentists to be able to demonstrate that, from the outset, they obtained an informed consent from their patient, discussed all treatment options and also discussed the possibility of referring the patient to other dentists for further evaluation. In Ontario, the Complaints Committee of the RCDS will scrupulously apply the written implant Guidelines, often to the dentist’s peril.

Oral Health welcomes this original article.

About the Author

Matthew Wilton is a Toronto litigation lawyer who, for the last 30 years, has been assisting dentists in responding to patient complaints. Matthew’s practice is devoted to the defence of professionals in complaints and discipline matters.

Read more articles from the 2021 Prosthodontics issue!