Patient Communication for Dental Implant Treatment

Excellent patient communication is a critical component of successfully managing and completing dental implant cases. Patients must be clear in their understanding of what to expect and the limitations of these prostheses in the oral cavity. When a tooth has been lost or is congenitally missing, there is a disruption in the natural anatomy and native architecture of the associated hard and soft tissues. Achieving harmony through the reconstruction of these tissues and the delivery of the prosthetic elements of the dental implant fixture, abutment, and crown complex can be challenging. In some cases, it can be extremely challenging to reestablish the previously ideal tissue architecture to which the patient was accustomed. Patients must be made aware of these factors and potential limitations. Congenitally missing teeth, teeth lost due to trauma or periodontal disease, or teeth requiring extraction due to fracture, decay, or resorption are among the most common conditions for which patients desire implant-supported restorations; however, patients may be candidates for dental implants for different reasons, and they can be in various stages of their lives.

When any dental treatment is planned, the patient's age must be considered in the sense that dental treatment has a finite lifespan. The treatment plan of an 18-year-old patient may look very different from that of a 75-year-old patient. Younger individuals may need to have their restorative treatments replaced several times over the course of their lifetimes, whereas treatment completed on geriatric patients may last the rest of their lifetimes if executed well. When evaluating patients for the replacement of missing teeth with dental implants, there are specific age-related considerations. The patient's stage of growth and development must be taken into account because dental implants do not have a periodontal ligament and thus do not move with the rest of the dentogingival, periodontal, and alveolar structures in the way that natural teeth do. Placing an implant in a patient who is too young can have either immediate or delayed iatrogenic functional and esthetic consequences. For these younger patients, case management often involves delaying dental implant treatment with alternative approaches, such as delivery of a Maryland bridge in the anterior region, until growth and development stabilizes.

Furthermore, long-term changes can occur as the mandible and maxilla continue to develop throughout the course of a patient's life. The remaining natural dentition may move over time whereas implant restorations will not. For dental implants in anterior segments, this can result in esthetic concerns, such as incisal edge discrepancies, that may require future correction (Figure 1 and Figure 2). In the posterior region, open contacts can form between implant-supported restorations and adjacent teeth. This can lead to food impaction and a lack of patient acceptance. The potential for these and other long-term changes, which are often beyond the dentist's control and may result in the need for re-treatment, should be communicated with patients.

Patients' experiences receiving dental implant treatment can be very different depending on the practitioners and clinical settings involved. In some cases, dental implant treatment involves a multispecialty approach in which a restorative dentist partners with an implant surgeon in a different clinical setting. In others, a single practitioner may execute all aspects of dental implant treatment from the planning phase to the restorative phase. Patient communication should include detailed information about how the different phases of treatment will be managed depending on the approach that will be used. Each dental implant case is unique and will require a different number of billable procedures based on its complexity. The more complex the case, the more procedures, practitioners, and locations may be involved and thus the more robust the patient communication efforts should be in order to clarify all aspects of care.

Efforts to clarify treatment details to patients can utilize a variety of communication tools, including verbal discussions, written explanations, digital photography, digital intraoral scans, and physical guides and models. During the initial treatment planning phase, a comprehensive discussion should be had with the patient regarding the specific set of age-related, financial, timing, and clinical factors for the case. This can also be detailed in writing in the form of a narrative to improve communication. Because dental implant treatment should be prosthetically driven to minimize esthetic and functional compromises, the restorative dentist will typically be the practitioner coordinating the treatment efforts.

Oftentimes, patients do not understand the nature of dental implant treatment and how its results can vary greatly from one case to the next. Practitioners should appreciate that patients only know as much as they have learned through their experiences in life, which makes communication especially important for patients who are receiving implant treatment for the first time. Due to the many steps involved in implant treatment and the complex terminology used, visual aids can often help tremendously in explaining the treatment process. Furthermore, when a multidisciplinary approach is to be followed, patients should understand that each of the multiple practitioners will play a part in achieving the desired outcome.

When planning dental implant treatment that will involve referring patients to specialists, it is important to communicate details regarding any situations, discussions, and decision-making moments that may be encountered. For example, when a patient is referred to a surgeon for tooth extraction, the surgeon will oftentimes recommend that a bone grafting procedure be performed along with the extraction. If patients have no previous knowledge about the need for grafting and did not have a discussion with their restorative dentist about it, they are often dissuaded, perplexed, and frustrated when faced with having to make last-minute decisions about things like adding donor or synthetic bone graft material. Biologic considerations are involved as well as safety questions and concerns about donor bone and the overall cost of grafting. Prior to appointments with specialists, communication efforts should be tailored to prepare patients to be able to make informed decisions in all anticipated situations.

Beyond preparing patients for decision-making in situations involving specialists, it can also be helpful to prepare patients for the personalities of specialists and the nuances of their practices. This can help facilitate smooth integration with an unfamiliar specialist and improve communication, case acceptance, and the overall success of treatment. Oftentimes, patients are conditioned to the practice environment in which they are established—their restorative dentist's practice. To prepare patients, differences that they may encounter when visiting a new specialist practice can be discussed ahead of time, including those involving the specialist's demeanor and methods. Even the office's location and details about parking can be mentioned. This information helps make the patient more aware of what to expect as well as demonstrates empathy and compassion. A simple conversation before a specialist appointment can result in a positive, streamlined experience instead of a confused, frustrated, and disgruntled patient who may lose trust.

It is important to note to patients that all of the aspects of implant treatment are dependent on each other to achieve the desired goals in a predictable fashion. To ensure transparency and provide the best patient experience, patients should be informed of the approximate total treatment time and fees for all of the procedures associated with their selected treatment options. Providing a written timeline can help patients conceptualize the total treatment time involved, which is especially useful when planning and coordinating dental implant treatment for patients with busy schedules. Table 1 presents a sample treatment timeline with patient photographs and overlay drawings that was developed in presentation software and presented to a patient on a tablet computer.

There are many design-related considerations for implant-supported restorations that should be discussed with patients. Perhaps the most relevant with respect to patient management are those that relate to appearance and functional considerations that will impact patients in their daily lives.

Today, many practitioners will choose a screw-retained design, when possible, because this eliminates the need for intraoral cementation. Patient communication should include the advantages of a screw-retained design regarding the prevention of cement-induced implant failure as well as retrievability should there ever be screw loosening, interproximal contact opening, fracturing of porcelain material, or other issues. With a screw-retained design, there will be an obturated screw-access channel somewhere on the implant-supported crown, which may be visible to the patient as a small off-color area on the occlusal surface or result in a difference in surface texture that the patient can feel with his or her tongue. An explanation should be provided to patients prior to crown fabrication that there will be a screw access channel that is filled with composite resin or another restorative material. If this is not discussed ahead of time, the visual esthetics of the screw access channel may be off-putting to some patients who have spent a significant amount of money and time to achieve what they assumed would be a certain appearance. Visual examples of past cases can be utilized for successful communication. When patients are informed ahead of time, those who still find the screw-access channel to be esthetically unsatisfactory may be motivated to choose a cement-retained design. In those cases, the patients should be presented with an explanation regarding compromised retrievability, the fact that the crown could possibly become dislodged over time, and the possibility of cement retention and its related complications.

Another important point to discuss with patients is how the design of implant-supported restorations relates to food impaction. Both changes in the architecture of the native tissue after tooth loss and the shape of the implant components can potentially contribute to issues with increased food impaction around an implant-supported restoration. This becomes a management problem when patients are not expecting food impaction, especially if they have not encountered it previously with their natural dentition. Anecdotally, this is perhaps the most common point of frustration that dental implant patients experience during their daily lives. In order to best manage this issue, up-front patient communication is necessary regarding the possibility of increased food impaction around dental implants. In many cases, extra steps can be taken to manage the soft tissues and develop more ideal emergence profiles for implant-supported crowns. For example, with digital technology, treatment workflows are increasingly improving in their ability to reduce the amount of tissue discrepancy that occurs following tooth extraction. Cone-beam computed tomography (CBCT) scans can be merged with digital intraoral scans to plan guided surgeries along with immediate custom healing abutments and screw-retained provisional restorations that can often be placed at the time of implant placement (Figure 3 and Figure 4). This results in tissue healing that mimics the emergence profile of a natural tooth, which in turn, can help to reduce food impaction and increase patient satisfaction, comfort, and trust.

It is important to communicate to patients that all complex dental work requires follow-up visits as well as maintenance and repairs over time. Patients should also understand that implant-supported restorations, just like natural teeth, require excellent oral hygiene and the management of parafunctional habits, such as bruxism, that may have a detrimental effect on long-term success. Complex full-arch or splinted implant-supported restorations will also require hygiene aids such as small interproximal brushes or enhanced dental floss.

As previously discussed, implant-supported restorations may require revisions and remakes over time. Patients can be brought into the discussion about the short- and long-term prognoses. In addition, patients should be aware that every implant-supported restoration requires parts unique to that particular brand and that, should treatment revision or remakes be needed, those specific parts will be required to execute treatment. Close recordkeeping of the dental implant brands, types, and parts used as well as documentation of the position of the screw access with digital photography helps to inform and streamline any re-treatment that is needed in the future. If a patient leaves the dental practice, these records will need to be transferred to his or her new practice. This can become a challenge when patients live more transient, global lifestyles and move among different cities and countries.

In order to create an excellent patient experience with dental implants, it is important to ensure that treatment options, risks, benefits, limitations, and alternatives are discussed with patients in detail and well-understood prior to starting treatment. Dental implants have arguably been the greatest advancement in modern dentistry, allowing for a tremendous increase in treatment options for patients to rehabilitate their dentition and reestablish esthetic and functional normalcy once teeth have been lost. With proper patient communication and management as well as the setting of reasonable and realistic expectations, dental implant treatment can be rendered that results in a high degree of patient satisfaction and is perceived as an incredible service.

David Wagner, DDS
Private Practice
West Hollywood, California