If you’re not on the list
Implantology and all the issues surrounding one of the fastest-growing areas
of dentistry were brought to the table last month at Scottish Dental magazine’s
first-ever round table evening
Should there be a specialist list for implantology, with implant placement restricted to those on the list? And how should entry to the list be controlled?
These were the opening questions posed to the group, who all have an interest in placing implants, by Sandy Littlejohn of Dental Technology Services, who chaired the event.
Edinburgh periodontist Charlie Maran, who works in private practice and at the Edinburgh Dental Institute, said he didn’t think there should be a specialist list because he felt implantology would eventually form part of the undergraduate training programme.
“I think it’s in the remit of the general dental practitioner and I don’t see any reason why it should be on the specialist register, because it doesn’t come under any speciality,” he said.
George Glover, who works in private practice in Aberdeen, disagreed saying that he believed there should be a specialist list but that the practice of placing implants shouldn’t be restricted just to those on the list. He said: “These things certainly do fall within the remit of general dentistry but, if it was to be made a speciality, it would be unique in that it is partly restorative and partly surgical. It doesn’t make sense for people to go on and advance themselves in terms of the knowledge and getting involved in research, if there is no recognition of that.”
Charlie Maran responded by saying that he believed implantology is not a speciality in itself, as it would form part of a sound understanding of prosthodontics. Duncan Black, GDP working in private practice in Glasgow, then said: “I think if you are going to be an implantologist then you have to bring so many elements from different disciplines. If you are not on the specialist list you can still do ortho, you can still do perio and endodontics. Does there really need to be a specialist list in implantology?”
George Glover countered by saying: “If you have people who spend a long time continuing their education and getting a masters degree, it would be one way of recognising that a group of individuals may be more capable of dealing with more complex cases.”
Edinburgh GDP John Gall asked: “I wonder what a specialist list actually adds. If you have the qualifications and you have the training, what does the list add to that? If you have done the qualification and the training, you are saying that it’s out there. So what the specialist list adds to that, I’m not quite sure.”
On the issue of entry to any potential list, there was general agreement that a base level of qualifications would have to be determined. Stewart Wright, GDP from Greenock, said: “I think to have a specialist register, you have got to have a group of non-specialists. While there is a guy who is happy to place one or two implants every now and again with no sinus involvement, there is another group of people who are going to want to do sinus lifts and the whole thing. Which then takes you onto the point that just putting the implant in just isn’t enough, you do have to have all the occlusion, all the prosthodontics as well as the periodontics.
“What concerns me is who it would be that determines what the entry level would be, where the information comes from so we are getting as wide an input from as many branches as we possibly can.”
George Glover said: “If you are creating a speciality, the amount of training that is required within this very narrow part of dentistry would need to be comparable to the other specialities. If you are creating a speciality, it shouldn’t be an easy speciality to get into, it would have to be a comparable standard.”
The group was divided in their opinions on the benefits of a specialist list with George Glover, an Jacqueline Fergus indicating they were in favour of the principle, and Duncan Black, John Gall, Stewart Wright and Charlie Maran in opposition to the idea.
The group then briefly touched on the question of whether increased funding should be made available to provide implants on the NHS. The consensus of opinion was that it was something of a pipe dream and unlikely to happen any time soon. Charlie Maran said that, even if money were available, it wouldn’t be a good idea: “It would stop dentists from perhaps making the effort they should do to make conventional dentures well. The idea would be that prior to going down the lines of having implants placed, every effort is actually made to make good dentures in the first place.”
And Duncan Black said: “I think it is a pipe dream. But, in an ideal world, for the people that it would be appropriate for, then, yes, it would be wonderful if they could get implants. But I don’t think it’s ever going to happen.”
Sandy Littlejohn asked about the pan-European price discrepancy in implants and the group’s thoughts on implants that are made in the same place but charged differently, depending on the country.
Ted Johnston, former clinical rep for Nobel Biocare in Scotland and now in charge of Procera, pointed out that the prices for implants are not set in the countries themselves, but at the companies’ head office. He argued that the costs for sales reps and so on differ from the UK and countries like Spain and Israel, which in turn affects the overall price. He said: “The price from head office is based on the economy and what that economy can sustain the price at, because they know what we will have to add on.”
The chairman then asked why, when there are so many implant companies out there, are the smaller and cheaper companies not making headway in the market. “Is it a trust thing, is it a price thing? Does it matter?” he asked.
Stewart Wright said: “I don’t think it is a price thing. If you have a system and you feel comfortable with that system and it works for you then you’d be reluctant to change and try a new system.”
Ted Johnston explained that one of the reasons is the comprehensive back-up received from the larger companies, which is the same wherever you are based.
John Gall argued: “I think it’s just down to market forces, like anything else. It’s the same with cars. Unless you get some sort of pan-European pricing legislation that comes along and says it’s got to be the same everywhere, then that will always be the case will it not? With cars and implants and everything else.”
The question was then posed as to whether you could buy implants from other countries at their price to use in the UK. Duncan Black argued that: “What it says on the tin it isn’t necessarily what’s inside. So, if you are sourcing your implants from, say someone in Greece or Hungary, how do you actually know it’s a real implant?”
Stewart Wright seemed to sum up the general mood of the group when he concluded by saying: “At the end of the day, I think that the argument is really not that relevant. Because it is not the price that is determining who you are choosing, it’s the back-up, the name and all the work that has gone on behind it.”
Sandy Littlejohn then brought up the subject of implant warranties and the issue of companies manufacturing on other implant systems. “Is it an issue with anybody? Does it concern anybody?”
Nobel Biocare, explained Ted Johnston, is currently the only company to guarantee situations where, for example, a third-party abutment has been used with their implant system. Although he indicated that he believed the others would follow suit in time.
Jacqueline Fergus, who works with George Glover in Aberdeen, said she didn’t think it was a big issue. “To be fair, if we have any failures in the practice, we don’t actually claim on the implant warranty. We just cover the warranty ourselves out of our own pocket. I don’t know what the other practitioners do?”
John Gall indicated that he does the same in his practice before George Glover said that he believed the manufacturers were not usually at fault for the majority of implant failures: “It is usually the dentist or the patient that influences failures. I’d say it’s more likely factors outwith the manufacturing process. F
or example, zirconia abutments fracturing – in the main, most of the problems are going to be occlusal.”
Stewart Wright said: “I think the significant thing that has happened over the years, to go along with the warranty issue, is that the implant companies have worked so hard at getting a system that is foolproof, that isn’t ‘suck it and see’. If you follow the procedure each time, you know you are going to get the result. Whereas 10 years ago, it was like ‘Oh my god, what are we going to do this time?’ It’s not like that now. So the warranty, I can’t imagine, is an issue. It’s more to do with the quality of the dental work being done, it’s not the implants themselves.”
Charlie Maran agreed and said: “I’m very conservative and I just can’t be attracted at all to the cheaper systems of this world and other less expensive versions of the real thing. I just spend my life fearing ‘What happens if?’ There’s not really any literature behind some of them, no one’s done any scientific research and I’m just not that interested in doing it for them.”
Stewart Wright continued by saying: “Price is important because you need to know that when you put that implant in, it’s going to stay there. And when you put the abutment on it’s going to stay there and it’s going to work. For a £200 saving, you don’t want to try something else. I don’t want to be the dentist sticking it to the patient, saying ‘Well this is a new one, let’s give it a try’. And then it doesn’t work.”
“Well you wouldn’t want to buy a cheap parachute would you?” said Duncan Black.
In the lead up to and in the immediate aftermath of last month’s general election, there seemed to be one certainty no matter who came to power: prepare for sweeping cuts to dentistry and public services in general.
George Glover said he didn’t think much would change in the wake of the ‘new politics’ of Cameron and Clegg: “I would suspect that the status quo will probably exist because the dental budget, as part of the wider budget, is so insignificant. But I certainly don’t expect to see any more funding.”
And Stewart Wright said: “Really what you have to be concerned about more is any cuts. And, at the end of the day, you are just going to have to take them, because we are a small group of professionals who don’t have that ‘ah’ factor. Who gives a damn about the dentists? If they have toothache, then we are very important but then, after that, forget it.”
The conversation then turned quickly to the issue of continuous registration with Duncan Black, Stewart Wright and George Glover agreeing that contentious Scottish Government legislation could lead to many dentists leaving the NHS or cutting down their NHS commitment as a result.
Duncan Black said: “This is going to affect the way that people work. If you have patient that hasn’t seen you for seven, eight years, they are still registered with you and they can still demand to see you within 24 hours. You could find that dentists will become more and more an emergency service – although it’s not going to happen right away – rather than being able to treat patients that regularly turn up every six/eight months or whatever their recall is.”
Stewart Wright agreed: “And, if they are not going to do that, then they are not going to be prepared to sign these people on because they are not going to be prepared to offer that service. It is unrealistic. So they’ll just leave the NHS altogether and become private.
“But that said, continual registration makes it very difficult to cut down your NHS commitment, because once you have signed up that person they are with you until the day you retire. It’s crazy.”
George Glover then said: “What we might see is that all the NHS provision eventually becomes basically itinerant workers. People coming to the UK, working for two of three years and providing the NHS cover. These guys won’t have a problem, because as soon as they leave that practice they leave those registrations. So the practice owners will go private.”
Sandy Littlejohn then tackled the issue of the predicted oversupply of dentists in the next two to five years. He asked the group how, if it occurs, it is going to affect the industry.
Charlie Maran was the first to react, in typically forthright fashion: “There is going to be an oversupply of dentists in the next two-to-five years and they will cut the number of undergraduate places.”
George Glover agreed: “There is going to be a problem. Speaking to people who are involved in vocational training (VT) and know about the manpower models, they expected the influx of Eastern European dentists to be extremely small – insignificant actually in terms of the Scottish market – but you are talking about a dental school’s worth arriving every year.”
“On the other side,” Charlie Maran countered, “we are producing too many. At the moment, Glasgow has got 90 students, Dundee has got 80 and Aberdeen has got 20.”
George Glover pointed out that the oversupply will put a strain on the VT system with Charlie Maran agreeing: “I think there will be a reduction in the number of undergraduate places and I think there will certainly be a squeeze on training places.”
However, John Gall then queried if the oversupply might be a good thing from a practice owner’s point of view: “If there is an oversupply, is it going to drive down associates’ bargaining power? In the past, they could make their demands.”
He continued: “It just seems a bit odd. We have an oversupply of dentists and yet we’ve opened another dental school and are putting too many graduates through. Something has gone wrong somewhere.”
With thanks to Nobel Biocare, DTS International and the Urban Brasserie, Glasgow.