Focus on standards

WITH fees in the UK routinely exceeding £2,000 per treatment it’s no wonder dental implantology is the undisputed growth area of restorative dentistry.

In 2007 Merrill Lynch estimated the global dental implant market at £1.37 billion – a 20% increase over 2006. Longterm growth potential is huge as implant dentistry currently accounts for less than 10% of tooth replacements.

Done well, dental implants offer obvious advantages to patients over traditional bridges and removable dentures. Done poorly and the results can be far-reaching and costly for both patients and dentists – and consequently medical defence organisations.

Given this context the recent interim policy statement on implantology by the General Dental Council is hardly surprising. Released in April of this year the statement confirms that dentists practising implant dentistry without relevant additional training are putting their registration at risk.

So what is relevant additional training?

Dental practitioners are urged to refer to guidance published by the Faculty of General Dental Practice (UK) as the “authoritative source” of training standards for implant dentistry in the UK.

In the statement the GDC reiterates: “Dental professionals have an ethical responsibility to limit their scope of practice to what they are trained and competent to do. Any dental professional who carries out work for which they are not trained and competent puts their registration at risk”. The document cites GDC education guidance The First Five Years which states that dental students should “be familiar with dental implants as an option in replacing missing teeth”. But it adds that a “UK-qualified general dental practitioner will not therefore be competent to practise implant dentistry without further training”.

The GDC supports Training Standards in Implant Dentistry for General Dental Practitioners as the gold standard for such training in the UK.

Not a limitation on practice

These standards are the result of a working group convened in 2005 by the GDC and chaired by Michael Martin, then a senior lecturer at the University of Liverpool. The group’s remit was to work independently of any organisation and consider what training standards would be necessary for a GDP practising implant dentistry and to publish these with a commitment to periodic review.

In his preface Mr Martin wrote: “Such standards could be used not only by practitioners but also by the GDC in the consideration of patient complaints against dental practitioners who, allegedly, practise implant dentistry beyond the limits of their competence”.

But he stressed that the intention was “not to limit the practice of implant dentistry” which is seen as an important treatment option for patients. The working group recognised that training in implant dentistry could come from a variety of sources including courses offered by universities, Royal Colleges, hospitals and individuals or industry.

In considering the variety of different techniques and procedures involved in implant dentistry the group saw a distinct division between dentists qualified to place implants only and those doing so with major bone augmentation and/or modification of anatomical structures. Both require that a qualified individual has practised clinical assessment, treatment planning and the placement of implants in the presence of an experienced implant clinician, as part of a course in implant dentistry. But the placement of implants with bone augmentation or modification of anatomical structures demands a higher level of surgical experience with specific training in these techniques and some element of formal assessment.

It was also recognised that some GDPs may have gained expertise in implant dentistry by a variety of means and was recommended that practitioners keep a portfolio of their training, courses attended, any mentoring that they have had, and the implants they have placed.

The standards document states: “It would be expected that the outcome of their implant placement would have been audited. Such portfolios of activity could be used in any dispute as to whether they were competent in implant dentistry, including complaints before the GDC”.

Just at the time of press for this issue of Summons the working group was due to issue an updated standards document. Expected revisions include additional detail on what represents complex implant treatment as compared to more simple cases.

“Whereas before it talked about placement of implants with or without major bone augmentation, the revised standards go into a little more detail of what would constitute more complex implant treatment,” said Dr Anthony Bendkowski, president of the Association of Dental Implantology UK and the ADI representative on the working group.

The new document is also more inclusive in order to take account of new GDC requirements on the registration of DCPs. Said Dr Bendkowski: “It doesn’t just talk about dentists – it talks about the team. So the implication is that technicians and nurses must have appropriate training and experience as well.”

One criticism of the previous document and likely to be levelled at the revised standards is the lack of clarity as to how competencies in implant dentistry should be measured.

“It talks about training standards and what practitioners should be able to do,” said Dr Bendkowski. “But it doesn’t really establish the benchmark for measuring competencies and setting syllabuses. The view of the Chairman – and I support that view – is that we have been tasked to provide an overview rather than detailed course plans at this stage.”

Scope of practice

Another possible factor in the timing of the GDC statement on implantology is the recently closed consultation on the Scope of Practice for members of the dental team. In initiating the consultation the GDC acknowledged that the current approach where dentists are expected to work within the bounds of “training and competence” is too open-ended and vague for both patients and professionals.

In response the GDC set up a working group which drew up lists of skills associated with each category of dental professional. In doing so they considered:

• skills which can be expected of a registrant on qualification
• additional skills which might be developed later in the registrant’s career as part of their professional development
• skills which registrants in a particular group would not develop without becoming a different type of registrant.

Under the category of ‘Dentists’ the sole ‘additional skill’ listed is “providing dental implants”

Ensuring competence

So how does a dentist wishing to develop skills in implantology choose a path that ensures competency? Said Dr Bendkowski: “First it’s important to differentiate between education and training. To be a good, competent, contemporary implant dentist you need both”.

Education can be catered for by meetings, conferences and self-directed learning. GDPs can read books and keep up to date with articles in journals. But education is not enough.

“It’s a bit like reading a book on flying,” said Dr Bendkowski. “You can read a lot but it doesn’t mean to say you can then jump in an aeroplane and fly it.”

Further competence requires a sound foundation in general dentistry including good surgical and restorative skills with the final step being specific training in implant dentistry under the guidance of an experienced mentor. Said Dr Bendkowski: “This is probably the best way to achieve the necessary skills.”

The Association of Dental Implantology offers further guidance on its website (www.adi.org.uk), including a selection of local or commercial courses as well as longer private and academic courses offering postgraduate qualifications and certificates.

Look out for the new edition of Training Standards in Implant Dentistry for General Dental Practitioners on the GDC website.

Jim Killgore is the editor of MDDUS Summons