Ethics in Dental Implant Practice: Patient Care over Rat Race

​(This is a part of the ‘Implant Dentistry– Updated Yet Simplified Series’ by prosthodontist & implantologist Dr Nupur Shrirao)

Ethics in dental implant practice is a crucial aspect that shapes the patient experience and the reputation of dental professionals. Understanding ethical guidelines is essential for practitioners to maintain trust and uphold the integrity of their practice. This article explores key ethical considerations in dental implantology, highlighting how they impact both patients and practitioners.

​Implant dentistry has made remarkable strides over the years. Innovations such as digital workflows, guided surgery, full-arch immediacy, as well as remote anchorage techniques, have transformed patient care. However, with advancements comes the responsibility to uphold the ethical standards that define our profession.

Importance of Informed Consent

Informed consent is the cornerstone of ethical implant practice. Dentists must ensure that patients fully understand the procedure, risks, benefits, and alternatives. This involves clear communication and providing enough information for patients to make informed decisions about their treatment. Informed consent respects the autonomy of patients, ensuring they are active participants in their healthcare.

A signed informed consent sheet with detailed explanations, along with verbal discussions in a language the patient fully understands, is not only ethical, but also a legal responsibility of the implant surgeon.

Transparency and Honesty

Transparency is vital in establishing trust with patients. This includes honesty about potential outcomes, costs, and any complications that may arise during or after the procedure. This is especially true when dealing with cases in the esthetic zone, or medically compromised patients, or plans to perform immediate placement, loading or temporisation.

(Learn about current concepts of immediate placement and loading or temporisation here).

Ethical practitioners do not overpromise results and remain truthful about their expertise and the limitations of the procedure. Such openness helps build long-term relationships with patients based on trust and respect.

Continuing Education and Competence

Staying updated with the latest advancements and techniques is an ethical responsibility for dental implant practitioners. Continuous education ensures that dentists offer the highest standard of care, which is in the best interest of the patient. Practitioners must actively seek training opportunities and be aware of new research and technologies in implant dentistry.

For example, placing an implant in maxillary incisor region, or immediately after extraction or in a full mouth, requires a certain amount of clinical skill which comes only with rigorous training and experience, and must not be ethically attempted at the beginner stage.

Patient-Centred care

Providing patient-centered care is a fundamental ethical principle. This involves considering the individual needs, preferences, and values of each patient by:

• Addressing concerns promptly
• Empathizing with patient experiences
• Ensuring comfort throughout the treatment process

​Reports of clinicians inappropriately extracting treatable teeth to place implants — often driven by speed or profitability rather than patient-centered care — are increasingly surfacing. A CBS article titled, ‘Dentists are pulling healthy and treatable teeth to profit from implants, experts warn’ recently highlighted this issue. Extracting 10 healthy teeth to place 4 implants to support a complete arch restoration, must pose an ethical dilemma to the implant surgeon.

The Periodontal & Endodontic Perspective

‘Biologically Guided Implant Therapy’ places emphasis on a comprehensive evaluation from a periodontal perspective including periodontal grading as a foundation for treatment decisions. For patients with manageable periodontal disease, treatable dental caries, or endodontic infections, retaining and restoring natural teeth is often the preferred approach – NOT implantology!

​A patient in tremendous pain usually requests tooth removal. It it the dentist here, who must guide the patient into the right direction by taking into account the clinical factors. Preserving natural dentition, when possible, is not only a cornerstone of ethical practice, but is associated with better long-term outcomes. The risks and benefits associated with treatment options need to be weighed and clearly explained to patients.

Accountability and professionalism

Maintaining professionalism and accountability is essential in dental implant practice. This includes adhering to regulatory standards, following best practices, and being willing to address any issues that arise comprehensively and transparently. Being accountable for actions and outcomes not only benefits the patient but also upholds the standing of the profession.

​Aggressive marketing tactics, corporate pressures, and the commodification of dentistry are contributing to unnecessary over-treatment, raising ethical concerns.

Full Arch Implant Cases Are Unique

​Full-arch implant rehabilitation has a vital role in addressing complex dental needs, but it must never become a one-size-fits-all solution. Patients deserve a comprehensive diagnostic approach that prioritizes preservation as the first option.

​It is important to scrutinize the messaging within some full-arch training courses. While the advantages of digital workflows and immediate solutions are undeniable, overly simplistic or profit-driven narratives promote a mindset that prioritizes speed over thoughtful, ethical care. The clinician must carefully evaluate and inform the patient the periodontal condition as well as restorability of these teeth prior to treatment, and also the complications, which are an inherent risk of surgical treatment.

Confidentiality and Privacy

Protecting patient confidentiality and privacy is a legal and ethical obligation. Practitioners must secure patient records and personal information, ensuring it is accessed only by authorized personnel. This fundamental respect for privacy reinforces patient trust and complies with ethical standards.

Make Friends with Removable Prosthesis

​Today, the treatment plan is often driven by the phrase ‘faster, easier, and cheaper.’ It is faster, easier, and cheaper to use the existing bone volumes, rather than perform bone grafting later. It is faster, easier, and cheaper to extract healthy teeth and place an implant with a cantilevered prosthesis.

But let us examine the phrase ‘faster, easier, and cheaper’ from a scientific and ethical compass. Most often, the cheapest treatment in dentistry is not an implant prosthesis but rather a removable partial or complete denture. It is also the fastest and easiest treatment option. Implant dentistry is almost never faster, easier, or cheaper than many other treatment options!

Sometimes, an implant supported removable denture (called as RP-4 or RP-5) is the best option for the patient’s clinical conditions. For example:

• ​RP-4 or RP-5 prosthesis is a better option in cases with an increased inter-arch distance due to intensive bone resorption
• RP-4 rather than fixed prosthesis may be considered in edentulous patients to reduce nocturnal parafunctional forces
• RP-5 prosthesis may be considered to permit the soft tissue to share the occlusal force
• ​​RP-4 or RP-5 may be considered in patients with on-off control over their blood sugar levels or those with poor hygiene levels.

After Care – Handling Complications Ethically

When complications occur, ethical handling is crucial. This involves being transparent about what went wrong, discussing possible solutions, and taking immediate action to resolve any issues.

Practitioners should be prepared to refer patients to specialists if necessary, prioritizing patient safety and well-being above all.

Conclusion

Ethics in dental implant practice is a multifaceted subject that requires ongoing commitment from practitioners to uphold the values of transparency, competence, and patient-centered care. By adhering to ethical principles, dental professionals can foster trust, achieve favorable outcomes, and enhance the patient experience. Dental practitioners must continually reflect on their ethical responsibilities to build a robust and trustworthy practice.

References

1. 1. Misch, Carl E. BS, DDS, MDS, PhD. A Current Dental Ethics Dilemma. Implant Dentistry 21(3):p 161, June 2012. | DOI: 10.1097/ID.0b013e318258ec5d
2. ​Kelman B, Werner A, KFF CBS News. Dentists are pulling healthy and treatable teeth to profit from implants, experts warn. KFF Health News. November 2024.
3. Ramanauskaite A, Galarraga-Vinueza ME, Obreja K, Sader R, Schwarz F. Prevalence of Peri-implant Diseases in Patients with Full-Arch Implant-Supported Restorations: A Systematic Review. Int J Prosthodont. 2021 Suppl;34:s27-s45. doi: 10.11607/ijp.6488. PMID: 33571325
4. Greenwell H, Wang HL, Kornman KS, Tonetti MS. Biologically guided implant therapy: A diagnostic and therapeutic strategy of conservation and preservation based on periodontal staging and grading. J Periodontol. 2019 May;90(5):441-444. doi: 10.1002/JPER.18-0495. Epub 2018 Dec 7. PMID: 30461019.
5. Sarafidou K, Lazaridi I, Gotsis S, Kirmanidou Y, Vasilaki D, Hirayama H, Michalakis K. Tooth preservation vs. extraction and implant placement in periodontally compromised patients: A systematic review and analysis of studies. J Prosthodont. 2022 Oct;31(8):e87-e99. doi: 10.1111/jopr.13560. Epub 2022 Aug 2. PMID: 35794083.
6. ​Bach Le, DDS, MD; and Hom-Lay Wang. Prioritizing Ethics in the Age of Full-Arch Implant Dentistry. Editorial, AO CONNECT,UP FRONT.