A referring dentist called my treatment coordinator recently and made a comment to her that I thought was both complimentary but also insightful. I want to share here the process I and my team go through in our creation of a successful dental implant practice.
He said that he was, “envious of our practice and the way we educated our patients, how we treated them and how we made the process of implant dentistry rather seamless.”
This got me to thinking about what we do to get patients to accept treatment and leave our practice satisfied, which leads to promoting us to their family and friends, and referring dentists.
Jan, our highly-effective receptionist, who we hired for her exceptional people skills rather than for dental experience.
Many things have changed over my 33 years of practice in the field of implant dentistry. When I first started, being mentored by a prominent implant dentist in our community, implants were rather special. Many called them “experimental.” The processes were rather complicated and required a certain amount of clinical skill.
I was trained to visualize the case finished before I ever start, but this is certainly an art that is achieved over time and with experience. This has been my mantra during my entire dental implant career. Patients came to us to restore missing teeth, to stabilize a removable denture or partial or somehow improve their quality of life with better function and esthetics. There was vague understanding of dental implant procedures.
Several items have changed implant dentistry over the years. First the Internet provides a space for patients to get information about the benefits and risks of dental implants. The information provided there is often not completely correct, but it does get the patient to come to our offices with questions. It is common for someone to Google search, “missing tooth, tooth hurts, I hate my partial, my denture is loose.” What comes up in this engine search is DENTAL IMPLANTS.
Information is all over the Internet today. It is our job as professionals to educate and instruct our patients on the benefits and risks of this type of treatment.
To provide this service we must educate ourselves to a high degree. There is much more to implant placement then simply drilling a hole in the bone and threading in a screw. As general dentists, we certainly are the gate keepers of our patient’s oral health. We often see dental problems that need to be addressed, such as nonrestorable or missing teeth.
Our patients trust us and want us to provide the proper treatment for them, and skip the referral to a specialist. My suggestion is always to continue our education. I am a big advocate of the Academy of General Dentistry and the outstanding educational programs they provide. Many of these courses are not only lecture-based, but hands-on participation courses. There are also several high-quality dental implant training programs available, including the Engel Institute dental implant training program held in Charlotte, NC and Detroit. This program specifically introduces the dentist to the “recipe” to achieve predictable functional and esthetic results using dental implants, while advocating knowing our limits in treatment. The training course provides actual patients where the attendees will place implants under a strict protocol under direct supervision of one of the mentor dentists. What a wonderful way to learn!
Dr. Kosinski with patients.
Education does not stop with learning the surgical protocols though. We must understand vital anatomy and tooth position. In today’s environment we try to achieve outstanding esthetics. We teach a “tooth down” visualization in our surgical placement, meaning that it is no longer acceptable to simply place dental implants in available bone and restore with the thought that the patient should be satisfied with any result. We try to achieve emergence profile and esthetic design of our implant restorations.
Patients want their teeth back to as normal a look as possible. This can be a challenge and thus comes the part where we need to clearly and concisely educate our patients.
Where does our education to our patients begin? Well, we already mentioned that Internet searches are one important resource. Once a patient does some research on where to be treated, they call the office.
The patient’s first introduction to our practice is with my receptionist, Jan, who we hired away from Macy’s. She had no dental experience but had exceptional people skills. Having a pleasant, empathetic voice she is able to present our practice in a positive and compassionate way. She attempts to accommodate new patients in a professional manner, respecting the fact that the patient’s time is the most valuable asset.
Lorry discussing treatment with patient.
Most of our pre-consultation paperwork like health histories and desires are done online to be reviewed before the patient presents him/herself.
When the patient arrives, they are greeted by Jan in a friendly tone and a hardy handshake. She smiles and welcomes the patient to our practice and assures them that they are in good hands and that the experience will be pleasant. Jan sets the tone for the way we try to treat all our patients, as if they were family. Family that we like.
The patient is then taken back to our operatory and the appropriate radiographs are made, including a CBCT if appropriate. The team member will do a brief interview of their concerns and take a blood pressure reading. The team member will then present her findings to me and the patient’s primary concerns.
I then walk into the room and introduce myself. Now with the advent of the Internet, the patients often check me out before they ever schedule. A proper and professional website that represents the tone of your practice is essential in today’s environment. My websites www.smilecreator.net and website www.michiganimplantdentist.com (my dental implant site) represent my thoughts and mode of practice. They introduce me and the facilities as well as my entire team. Common questions are addressed and answered, and many before and after photographs are included.
The patient is always sitting upright as I sit next to them so that our eyes are at the same level. Spouses or family members are invited to sit in during our consultation.
I always introduce myself briefly explaining where I’ve studied and that I’ve been practicing for over 33 years. I also tell them that I did my initial implant training at the Harvard Seminars in Boston and that I have placed well over 13,000 dental implants in my career.
(I think telling our patients our experiences is important in gaining confidence in their eyes). I mention that I speak extensively around the country and have authored many articles on dental implants. One of the most important things I tell them is that, “I am very good at what I do.” Now this may sound a bit conceded, but I believe patients are seeking someone who can meet their expectations.
I try to address the patient’s major concern during this first visit. This means that if they are missing one tooth and heard about these dental implant things to fill the gap, I will focus on that initial concern. In my practice I found that overwhelming the patients at their first visit with total comprehensive full mouth rehabilitation only leads to a patient who leaves the practice without accepting treatment.
So here’s what works for me. I will use the "car and an oil change" analogy. You’ve probably gotten a coupon in the mail for a reduced fee on an oil change. Once you get to the dealership you are told that you need new brakes, tires, transmission etc. You may indeed need all those things done on your car, but all you really wanted to have done that day was an oil change. The salesperson, if he is good, will explain why you need all those other repairs on your car, and that the dealership will be there for you when you are ready to proceed. This creates a positive experience where the patient does not feel railroaded into extensive therapy and in control.
In my practice, we eventually finish a full mouth evaluation. Once a patient has allowed me to surgically place and implant and they have a positive experience, with little discomfort, they certainly gain confidence in my abilities. Then they typically will continue treatment over time. In my full mouth evaluations I will create a plan with the patient. This can be a five-year plan if necessary. As long as the patient is aware of what is required and the consequences of postponing or rejecting treatment, we have done a good job of educating.
Everyone is on a budget today. Different people have different budgets to work with, so after my evaluation of their immediate concern, they will be moved to our consultation room to discuss specific treatment and fees. We will discuss that a bit later.
So, after briefly introducing myself and my credentials, I discuss dental implants, the procedures, what to expect, and the risks and benefits.
Dental implants are simply small "spark plug shaped" screws that are threaded into the jawbone and simulate the root of a tooth. They are biocompatible, a big word that simply means that the bone will grow into it. The implant becomes a permanent part of the jaw and allows us to attach something to it. It can be one tooth, several teeth, all the teeth or as a support for a removable denture. I mention this because even though the patient may just want one space filled with an implant retained crown, they may have a friend or family member who has other issues that can be addressed.
There are two basic criteria for those who want implants. First you must be relatively healthy, meaning no uncontrolled medical problems, like uncontrolled diabetes, uncontrolled hypertension or immunosuppressive diseases such as AIDS. If the patient is a good healer, they will normally heal well. Slow healers will heal more slowly.
The second criteria is that there must be enough bone present to place an implant. This is often determined using our two dimensional conventional radiographs, or more recently a CBCT. The CBCT analysis allows us to see the bone contour in the sagittal or cross sectional view, allowing us to see the width and height of bone available. With the proper software we can also virtually place the implant and even design the final crown prior to any surgical intervention. This tool makes the procedure more predictable and our procedures less complicated. It is an outstanding teaching tool that really helps explain to the patient what the end result will look like.
Even though my initial consultations are at no fee, the CBCT is charged out nominally, but the amount is credited back towards treatment if the patient elects to move forward in my practice. This is a no-risk consultation and the patient feels no pressure to continue, feels in control of their decisions. I do not sell implant procedures, rather I educate and instruct on what is possible.
It is important to realize that modern implant dentistry is a tooth down procedure, meaning we will visualize the final prosthetic design before surgical placement of the implant. Thus we maximize the positioning of the implant, eliminating potential esthetic or functional concerns after placement.
I tell our patients that bone is alive in the body and changes over time. For example, if you break your arm, you are placed in a cast for 6 weeks or so, and the injury heals itself. The same is true for our dental implants. Once placed into the jawbone, the body’s cells will first attack the implant area (we know these as osteoclasts) and then other cells will lay down new bone (we know these as osteoblasts.) The entire event is a process, as the bone needs to heal around the dental implant.
The surgical placement of the implant itself is not complicated. We will numb (anesthetize) the soft tissue in the area. We do not need to block our dental implants because bone itself is not innervated. Nerves run through the bone, for example the mandibular nerve and mental nerve, but bone itself does not hurt. Therefore, all we need to do is numb the soft tissue. Eliminating the nerve block also aids us in placement of the implant away from the mandibular canal.
We simply make an opening in the bone and then widen the site with different surgical burs. The implant is then threaded into place. Sometimes there is a feeling of pressure, but certainly no pain.
If necessary, I may need to reflect the tissue to see the available hard tissue for implant placement. If that is the case, the patient will have sutures that will need to be removed in a week. When we do a “flapless” procedure, no sutures are needed, but I still like to see my patients in one week for an evaluation.
Digital radiographs also changed the way we place implants as we are now easily able to verify position and angulation in a short amount of time.
Our modern implants are very successful, but there are times when implants simply do not integrate to our satisfaction. We are dealing with the human body and sometimes we cannot predict integration.
Implants do not heal for a number of reasons; inability or unwillingness to keep the site clean (so we must design the case so the patient is able to maintain), engineering is critical. I tell my patients that I use a high-quality, warranted implants – ones that I would feel comfortable placing in a family member. Cigarette and cigar smoking intuitively can affect the healing around a freshly placed implant. Smoke, tar and nicotine can seep into the surgical site and affect the way the bone heals around the implant. If I chose to place an implant in a smoker, I will always bury the implant under the tissue.
Smoking decreases circulation of the tissue around the implant also.
Finally, some implants, a very small percentage, don’t heal properly and I don’t know why. It could be the implant itself, my surgical techniques, changes in body chemistry or hormonal changes. However, if an implant does not integrate today, we normally know it during our initial 3-4 months of healing. If there are problems I have always warranted my work (I can’t guarantee anything), but I do have a written policy that states that I am 100% responsible for any problems with any of my dental work during the first year. Over the next years, my responsibility decreases by 20% per year.
Once my specific consultation is complete, I will refer the patient to our treatment coordinator and financial planner. We physically move the patient to a private consultation room, where Lorry or Jessica can privately discuss the procedure one more time. They can show video demonstrations of the procedures and further answer any questions the patient may have.
Financial planning is an important part of this process, and the patient is provided options for payment including several of the credit companies.
Although these companies will charge me a merchant fee, it is worthwhile because I get immediate payment.
Most patients experience little discomfort following our dental implant procedures taking only 600mg Ibuprofen. Antibiotic regimens are only indicated if there is any sign of active infection at the time of surgery.
Finally, all surgical patients are contacted by me personally by phone the evening of surgery. They are very appreciative of our empathy and professionalism.
There really is no mystery to our high conversation rate of patients. The most valuable asset our patients have today is their time, so making the procedure appear seamless and respecting them and their time is imperative.
Dental implant therapy is definitely in the realm of the general practitioner. Continuous proper education is paramount to understanding the intricacies of what we provide. Our patients are requesting these implant procedures from us. Dental implants are certainly one of the most profitable dental procedures we provide. I challenge the general dentist to get involved in both the surgical and prosthetic aspects of implant dentistry. The professional rewards are immense.
Dr. Timothy Kosinski is an Affiliated Adjunct Clinical Professor at the University of Detroit Mercy School of Dentistry and serves on the editorial review board of Michigan Dental Association Journal and is Associate Editor of the AGD Journals. He is a Diplomat of the American Board of Oral Implantology/Implant Dentistry, the International Congress of Oral Implantologists and the American Society of Osseointegration. Dr. Kosinski has published over 190 articles on the surgical and prosthetic phases of implant dentistry. You can reach Dr. Kosinski at: drkosin@aol.com or 248 646-8651. www.smilecreator.net.
