The Changing Role of GP’s in Implant Dentistry

His comments would imply that the general dentist has done appropriate treatment planning such as imaging or perhaps CT scans before "writing the prescription" The role of the surgeon is far more than being a technician. A solid working relationship between the surgeon and restorative dentist overcomes all of the concerns detailed in this inappropriate article

The comments imply that GP's are willing to advance their education to parity with their specialist colleagues. Further, he implication is that GP's are ready to take responsibility for treatment planning options for their implant cases. I find these assumptions to be less than valid. While it is important to have a prosthetically driven team, I see no advantage to driving implant surgery from the surgical specialist to a general practitioner. My general practice colleague do not routinely read professional journals, attend advanced training courses in surgical technique, and have little or no advanced training with respect to managing post-operative surgical complications. Until recently implant dentistry is not taught at our undergraduate dental schools. I do not feel that a week-end course qualifies a dentist to make surgical decisions necessary during placement of implants. The paradigm should not be shifting toward mediocrity.

While Dr. Kaplowitz's comments encourage a more active role for the GP's, implications are not valid as already pointed out by the first two posters. Also, documenting the reasons why a "prescription" was not followed by the surgeon is already too late. A constructive team approach means that the GP and the surgeon work together BEFORE the treatment is done. There needs to be a treatment plan agreed on by the GP, surgeon, and the patient.

PROSTHODONTICS is the specialty of dentistry, sanctioned by the American Dental Association, that is devoted to proper treatment planning and execution of advanced dental procedures, including the planning and restoration of dental implants. Many PROSTHODONTIC programs also offer proper implant surgical training. It is up to the surgical specialist and the general dentist to seek proper guidance in complex cases from a PROSTHODONTIST, a person who has the proper training in the subject. Let's shift the paradigm towards the specialists who took the time, and incredible effort to accquire the proper Post-Graduate education on the subject. Contrary to the Academy of General Dentistry, accumulating weekend course credits does not substitute for a proper Post-Graduate education in PROSTHODONTICS!

I am a GP who has surgically placed and restored hundreds of implants since the mid '80s. Only on a handful of cases have I had to use angled or custom abutments because I place the implants where they should be for an optimal prosthetic outcome. If there is not enough bone present to do this, I graft it. I cannot say that I am seeing the same care taken by the "surgical specialist" in my area. I urge any GP interested in implant dentistry to educate themselves and provide both surgical and prosthetic phases to their patients. In my and my patients' opinions it is much easier for them when they are treated in one office. For instance, if the implant is stable enough at the time of placement for immediate provisionalization this can be done to create perfect tissue contour for proper emergence profile of the final restoration. About 98% of the implants I now place are temporized at the time of placement. However, most of the surgeons in my area are still practicing the "ancient art" of two stage surgery.

with all due respect to the author of this article, his comments are very UNREALISTIC, and he clearly lives in LA-LA land. There is a proven fact that "numbers don't Lie", and Statistics always prevail. Just show us how many ethical General dentists are "really" caring enough and dedicated enough to educate themselves and their staff, take and pay for long term hands-on courses,(NOT the over-the-weekend IMPLANT MOTIVATION COURSE!!) and really come back and try to "communicate" those knowledge with their surgeons, and patients. Yes, you may find very few respectable people , like this last guy who wrote the last posting, but not too many!. The other important factor missing from the author's arguement in "quest for perfection, by absolute IMPERFECT GP'S", is the "patient" and their financial flexibility. Don't you think that all the surgeons would love to have all the soft and hard tissue grafts and get paid for them prior to implants in order to get perfect results??. I strongly encourage that next time if you want to put an article up there, or send it to us in email, atleast interview someone who has a real degree, real certification, and REALISTIC goal, not just a bunch of wishful dreams (that he would like to see !) being presented as "DYNAMICS or CHANGING TRENDS".

It's very interesting to see the strong responses here from some specialists. It would seem that those that feel threatened are not actually looking to the future. Their reponses merely rehash current affairs in the dental community. The fact is that big, big money is being invested by the implant companies in new implant designs, technology, and education so that the GP will be able to place implants successfully. It is in fact in the implant companies best financial interest that more implants are placed, more quickly, and more easily. As this new technology gets implemented (and marketed) in the next 5-10 years, there will be a significant change in the way the GP and Specialists interact during implant treatment. Let me close by saying, that nobody is saying that specialists are not vital for implant treatment, but the fact is that their role is going to change and they will quite frankly have to become "More Specialized".

i am somewhat surprised at the acerbic tone to which much of the commentary has gravitated.....that being said, the singular aspect which surprised me re the article under review is the encouragement to document abdication of liability in a patient's progress note should the implant surgeon fail to meet the exact expectation of the referring restorative dentist.....should the failure of a fixture to maintain integration frighten us to the point of finger pointing we should stay away from this modality et. al.......the fact remains that inorganic materials may at times disappoint our expectations in an organic environment no matter how many letters we choose to aquire behind our names, and no matter in which fashion we choose to further enhance our knowledge and skills...perhaps a usable guideline for all of us to consider when surgically placing implants as GP or MS is to evaluate how comfortable we are in handling the eventual surgical complication.....patients fail around our implants as well....

Most implant continuing education courses are geared to general practitioners. The lab can wax up study models and prepare surgical stents to guide implant implacement. Most labs have a dental consultant on staff to supervise the work and help with treatment planning. And contrary to what some of these specialists claim, many of us GPs attend courses, read journals and belong to study clubs. Would you want somebody treatment planning an implant bridge for you who has not placed a bridge since dental school?

Perhaps the real paradigm shift is towards CT-based planning. This increases understanding and collaboration between all members of the implant team – surgical, restorative, and laboratory. Even patient understanding is increased with 3D images and models, leading to better acceptance and compliance. We all benefit from the growing availability of cone beam scanners such as i-CAT (www.imagingsciences.com) and NewTom (www.aperioservices.com), stereolithography BioDental models (www.biomodel.com), and simulation software packages such as I-Dent, Simplant, and Implant3D. These tools facilitate optimum implant placement taking into account BOTH surgical needs and prosthetic goals.

While CT scans and models created from them are a good adjunct to the diagnostic aids we now have, they are by no means necessary. Good panoramic images, periapicals, bone sounding when necessary, a thorough knowledge of anatomy, and a good helping of common sense will get you through any case. These have worked for me for over 20 years.

I agree that most implants can be placed with good panoramic and perioapical radiographs. The value of cat scans lies in collaborative treatment planning. The GP can see for themselves that a wide diameter fixture can't be placed and the surgeon is not arbitrarily placing a small diameter implant. The GP and specialist can decide if bone grafting should be suggested or if a compromise in implant diameter or position is acceptable. Everyone's on the same page.

The simple fact is that the most critical aspect of implant treatment planning is having the dental laboratory involved in pre-surgical planning. Also, if any of you even consider using any form of standard fixed (stock) abutment for your fixed cases, then you're practicing compromised dentistry. I recommend the Atlantis Components, patient-specific custom abutment.

If the implant is placed properly in all three dimensions all you will ever need is a stock abutment.

Rubbish. Given the technology we have now and the fees that our patients pay for treatment, a stock abutment should NEVER (I shout for emphasis) be used and is paramount to compromised dentistry. There is nothing standard or fixed about any patient.

I agree that there is nothing standard or fixed about any patient. But if you are familiar with Tarnow's work, the principles of emergengce profile, and place implants where the tooth roots once were, custom abutments are not needed, especially with the ITI system. I have hundreds of cases that verify this statement the earliest of which dates back to 1988, still functioning, still beautiful.

For those of you out there who think GP's should not place implants,let us not forget that implant dentistry is not a specialty recognized by the ADA. Secondly, and possibly most importantly most of the major innovations that have occured in implant denistry in the past and currently have been made by general dentists or non dentists(Brannemark) Orthopedic surgeons. It is unfortnate that the specialist feel so threatened by GP,s placing and restoring implants. Should GP's feel threatened by specialists placing final abutments? I am a GP who has been placing and restoring implant since 1988. I do sinus lifts and bone grafts routinely. My results are and have been since 1988 equal to or better than most specialists in my area. Go figure. Implant dentistry is not rocket science but it does require some extensive training. By the way there are some great programs out ther that will give the GP all of the tools necessary to sucessfully place and restore implants. Just for the sake argument how many of you out there would disagree with the fact that if you have enough bone, placing a single implant is about as easy as taking out a tooth. By the way most specialty programs(perio,OS) didn't offer very much training in implant dentistry until recently. So how many specialists started placing implants with the equivalent of a weekend implant course? We need to support each other not attempt to destroy each other. There are plenty of missing teeth out there for everyone to replace with an implant if you so choose. P.S. In Italy 55% of the implants placed are placed by. You guessed it GP,s. The numbers in other countries in the civilizes world are pretty close to this Italian figure. Why is it that less than 5% of the implants in the US are placed by GP's. Fear? Intimidation? ???????

The US is one of the very few countries that maintains a rigid and formal infrastructure of dental specialists. This is more of an anomaly than mainstream.When endo first became organized as a dental specialty in the US few GPs did endo.Now 80% or more of the endo is done by GPs. I think we are going to see the same trend in implants. Placing implants has revitalized perio and oral surgery. Protecting this turf is understandable but not justifiable.

As our knowledge increases, so do our patient's demands. I have spent years training in Prosthodontics and Implant surgery at the post graduate level, to graduate and find out that there are plenty of general dentist out there who call themselves specialists in cosmetic dentistry and implants after taking a bunch of courses. Would you rather go to a cardiac surgeon for a bypass or to a general surgeon who took "courses"? There are, of course, excellent GP's who place and restore implants very successfully, sometimes due to proper training, and sometimes just plain luck, however, mostly, I get many referrals of patients who's dentist, unknowingly, got in "over his/her head". I find this true expecially in Prosthodontic planning and execution of full mouth reconstructions. At the same time, I have seen several patients with executed sinus grafts by well meaning periodontists and OMS's to later never use the grafts since "there are no teeth that far back"--obviousely a failure of the surgeon to get a proper prosthodontic treatmet prior to surgery. Mistakes are made on both ends. Ultimately, it is up to us as a profession to educate ourselves in proper execution, as well as how not to overstep our training. I never did understand how medical doctors are trained to consult and work with each other, and we dentists are trained to antagonize and compete.

To all supporters of European dentistry... please take a plane to Italy or any other European country and check out their teeth! Is it a wonder that their specialists come to the USA to train? May I remind you that they also do not have the same accountability as we do here. I'll take our dentistry anyday.

ENOUGH DEGRADTION OF GENERAL DENTISTS BY SO CALLED "IMPLANT" SPECIALISTS. IF GENERAL DENTIST IS SINECERE AND HARD WORKING AND GET PROPER TRAINING FROM MANY nonweekend courses,HE/SHE CAN PERFORM AS GOOD AS ANY SPECIALISTS IN SURGICAL PLACEMENTS OF IMPLANTS. I KNOW MANY FROM MY AAID ASSOCIATION WHO ARE FELLOWS AND DIPLOMATES OF AAID. MAY BE IT IS ECONOMICAL THREAT OR NOT. I DO NOT KNOW. BUT IN MANY INSTANCES SOME MISGUIDED PERIODONTISTS BELIEVE THAT GENERAL DENTISTS SHOULD NOT PLAY ANY ROLE IN SURGICAL IMPLANTS PLACEMENTS. MANY PERIODONTISTS ARE AWARE OF GENERAL DENTISTS INVOLVEMENT AND RESPECT IT. LET ME GIVE YOU ONE RECENT INCIDENT HAPPENED TO ME. ONE PATIENT APPROACHED ME FOR RECENTLY( 8WEEKS) EXTRACTED TOOTH NO.31. I PLACED ONE STAGE IMPLANT AND PATIENT DID NOT RETURN AFTER. NOT EVEN FOR REMOVAL OF SUTURES INSPITE OF REPEATED NOTICES. PATIENT DISAPPEARED FOR ONE YEAR. ONE DAY SHE VISITED PERIODONTIST FOR THE COMPLAIN OF MINOR IRRITATION NEXT TO IMPLANT. PATIENT WAS ASKED WHO PLACED THE IMPLANT WHETHER AN ORAL SURGEON OR A PERIODONTIST? SO PATIENT CALLED MY OFFICE TO FIND OUT AND WAS TOLD THAT I AM A GENERAL DENTIST. AND THEN YOU WOULD NOT BELIEVE BUT THAT OONOXIOUS PERIODONTIST CALLED MY OFFICE AND TOLD MY STAFF THAT BEING A GENERAL DENTIST I SHOULD NOT BE PLACING AN IMPLANT. i HAVE MADE A BIG MISTAKE IMPLANT IS TOO SUPERFICIAL AND HE HAS TO EXPLANT IT TO PLACE ANOTHER IMPLANT AT DEEPER LEVEL. SO I CALLED PATIENT TO MY OFFICE AND TO MY SUPRISE I FOUND OUT THAT THERE WAS NO PROBLEM WITH IMPLANT. IT WAS TOOTH NO.2 WHICH WAS OVEREXTRUDED DURING LAST YEAR AND HITTING RETROMOLAR AREA. I EXPLAINED TO PATEINT AND ADVISED FOR FULL COVERAGE RESTORATION FOR OR INTRUSION OF NO.2,TO MAKE A ROOM FOR RESTORATION OF IMPLANT. I CALLED THAT PERIODONTIST AND EXPLAINED THE SITUATION AND HE FELT VERY OFFENDED THAT NOT ONLY HE MISSED PROPER DIAGNOSIS BUT ALSO ADVISED FOR UNNECESSARY EXPLANT OF FULLY INTEGRATED IMPLANT. IT IS SUFFICE TO SAY THAT THER ARE MANY SPECIALISTS WHO RESPECT PROPER ROLL OF GENERAL DENTISTS IN IMPLANT DENTISTRY BUT THERE ARE FEW SPECIALISTS WHO DO NOT LIKE GENERAL DENTISTS DOING SURGICAL IMPLANTS PLACEMENT. REASON? I DO NOT KNOW??????????????????

Why Should General Dentists Place Dental Implants? By Dr. Jack Hahn This author is a general dentist that has successfully placed over 25,000 dental implants over the past thirty-one years. After graduating Ohio State University College of Dentistry, I realized that I needed further training in periodontics and restorative dentistry. I enrolled in as many continuing education courses on those modalities as I could. In 1969, a patient presented herself to my office with fifteen sets of dentures in a shoebox. I call this the "Shoe Box Syndrome". She had every configuration or type of denture that one could imagine: dentures with magnets, dentures with small rubber suction cups and metal base dentures are just some examples. Her husband was an orthopedic surgeon and asked me about dental implants that he read about in his orthopedic literature. I gave him the standard answer that we were told in school, which was that implants don't last, there is rejection and infection. They left my office disappointed as she was basically a "dental cripple" not being able to chew or be seen in public. I saw them six months later at a social function and they told me that they went to New York and had implants placed by a general dentist. She can eat comfortably and has renewed self-confidence and their social life has been changed dramatically for the better. The orthopedic surgeon said that implant dentistry at that time was in its infancy, but I should begin to study now as it is the future of dentistry. His statement was a wake-up call. He was correct in that implant dentistry was my future and still is. Every year there are new techniques and materials. Implant dentistry has had more advances and innovations than any other field of medicine. Before 1984, over seventy percent of the implants placed were placed by general dentists. After 1984, implant training was given in the dental schools but only in the specialty programs and the team approach started to become popular. By team approach, I mean surgical placement was performed by one doctor and the restorative by another. The general dentist who can place implants has an advantage in that they know where the implants should be placed according to the desired prosthesis, thus having complete control of the final result. In my opinion, what is happening in implant dentistry has happened in other dental specialties. For instance, many general dentists extract teeth in their offices. If it were a complicated extraction such as a mesio-angular bony impacted mandibular third molar where the roots are infringing on the mandibular nerve canal, they would probably refer the patient to an oral surgeon. Another example is that many general dentists perform endodontic treatment in their offices on teeth with relatively straight roots with obvious pulp chambers and canals. The twisted, convoluted roots they most likely would refer the patient to an endodonist. The examples given are also happening in implant dentistry. The single tooth replacements with adequate height and width of bone are performed by general dentists. The cases involving totally edentulous mandibular ridges with adequate height and width of bone can be treated using various over dentures or fixed denture techniques by general dentists. Partially edentulous patients with, again, adequate height and width of bone may be treated by general dentists giving the patient a fixed prosthesis eliminating the free end partial denture. Patients with a fractured or unrestorable tooth should be able to have the tooth extracted and an implant placed immediately by a general dentist. Patients requiring bone grafts, sinus cavity manipulation and nerve repositioning would generally be referred to specialists such as oral surgeons, periodontists or general dentists who have been trained and have extensive experience in those modalities. These practitioners may be called oral implantologists. For the past twenty-five years I have trained general dentists all over the world how to place and restore dental implants safely and predictably. Dr. Gordon Christensen states that if you are not placing and restoring dental implants in your practice, you will be behind the times. Dr. Christensen goes on to say that he will no longer make a patient a new lower denture without placing at least two implants. Two implants for a lower denture in his office is a standard of care. There are thirty-five million edentulous patients in the United States. In fact, every minute some person in this country is losing a tooth. As you can see, there is a great need and demand for implant dentistry. In July 1989, the National Institute of Health issued a statement regarding patients who are missing teeth. The statement is as follows: Patients missing one or more teeth should be offered the option of a dental implant or implants. The general dentist can perform or refer the service. Dr. Roger Blackwell, Professor of Marketing and Dean of the Business College at Ohio State University, had his graduate students research the future of the business of dentistry. The conclusion of that study was that for dentists to grow their practices in the millennium, they must be involved in cosmetic dentistry and the placement and restoration of dental implants. How many of your patients get excited over a three-unit fixed bridge? But patients do get excited over a single implant and not having to have adjacent teeth prepared. Satisfied patients refer new patients. In my office, single implant tooth replacements require only three visits and we have a satisfied patient. We have found over the years our practice has experienced growth. In conclusion, dentists can be trained to perform implant dentistry. Patient selection, surgical and restorative techniques are skills that can be attained by general dentists. Dentists should be able to treat patient's edentulous areas that have sufficient height and width of bone in low risk areas. Please send comments concerning this page to info@perio.com © Copyright 1996 by Perio Institute, Inc. P.O. Box 449 Union, WA 98592-0449 1-800-327-3746 1-360-898-7787

Why are some of you specialists acting like placing an implant is like doing open heart sugery. It is not that difficult. Granted, there are risks involved however very few that are life threatening. Prior to 1984 few periodontists or oral surgeons were placing implants. It was the general dentists who took all the heat and now some of you are trying to act like GOD. Get real: pinch yourselves. The exclusive reign you had over implant placement for the last two decades is rapidly coming to and end. Suck it up and get over it.

I still do not understand why are these specialists hate general dentists so much? Is it really a true concern for the welfare of patients? or Just "M" word. All those specialists should be thankful to thier referring GPs not only for their RICHES but SURVIVAL. A person with sound mind will never compare implant placement with a heart surgery. In otherwords all endo patients should be treated by endodontists. Apart from varios grafting procedures implants placement is not so difficult. GP knows how to reflect flap,make a hole in bone and insert a screw.Most of the cases handle by GPS are simple cases or over dentures. sometimes I find ATRAUMATIC extraction of endodontically treated tooth is more difficult than placing an implant. With the help of to day's advanced technology and gadgets implant dentistry is becoming far easier. Ofcourse when need arise for complicated cases GP should seek help of proper experts. In short, placing an implant should not be made big deal. Bigest deal should be proper diagnosis and treatment planing. Howmany oral surgeon can claim to place more dentures (removable or fixed) than GP ? How many periodontists know difference between polyether and poly vinyl siloxane? Only specialist who may claim to be better than GP in that matter should be prosthodontist. But can he/she claim to be more experienced in surgical procedures than GP? I do not think so. Most prostodontists refer out their patients for surgery. I am glad Dr. Jack Hahn responded propery.

Many periodontists and oral surgeons are running Mentor Programs where they teach general practitioners to place implants. The feedback that I get is that the GP's place implants in the simple cases and refer the more complex ones. The sum total is more implants being placed and more GP's diagnosing implants and referring more and more cases to the Mentors. Clearly a win-win situation for all parties.

All these verbal attacks are missing the point. The truth is usually somewhere in the middle. I am an oral surgeon who trains oral surgery residents in implant surgical treatment planning and placement. I also have the opportunity to train some prosthodontists who are in our implant fellowship in implant surgery. I also assist our periodontal residents in their difficult surgical cases. Many of our cases are also restored by dental students. I believe this background allows me a unique perspective in this debate. The last prosthodontist whom I trained used to say that she finally understood that there was no simple implant surgery. While this is not true in all cases, but it illustrates the point that implant surgery does require advanced training. Therefore, the debate should be how one obtains this training. The current dental educational system in the US places the major focus in implant surgical training in oral surgery and periodontal training programs and prosthetic restorative training in prosthetic training programs. I tell my residents the advantages of our general dentists, prosthodontists, and periodontists have over the oral surgeons in some areas of treatment planning. Similiarly, there are many unique abilities that the oral surgeon brings to this field. Not many dentists, specialists or not, have all the training in all aspects of dentistry to treat all implant patients. So please do not discount the advantages of a specialist, due to his/her concentrated training and experience in certain aspects that are important in implant dentistry. The discussion should be how all dentists, GP’s and specialist, obtain adequate training not normally included in their respective education and training to offer our patients the best implant treatment possible. We may start our implant career from different beginnings, and we should find pathways of training that complement our traditional training. We should only provide treatments that are appropriate to our level of training.

you all make me laugh. I guess it's true that dentists are a strange bunch of misfits. The subspecialty of medicine called dentistry is for the care & well-being of the patient. "Realizing the privileges and opportunities that have been given to me in my study of the art and science of dentistry and appreciating the significance of the dental degree which has been conferred upon me, I do hereby pledge: "That I will diligently uphold the dignity, honor, and objectives of the dental profession and, to the best of my ability, will contribute to its prestige, proficiency, and progress.: "That I solemnly accept my responsibility to my patient, to make available to him or her the best of my knowledge and skill, and to maintain a relationship with my patient that will warrant his or her trust and confidence: That I will faithfully observe the ethical standards established by the profession: That I will lend my influence and support to all segments of the profession which contribute to the fulfillment of its purpose." WE all should be placeing implants & doing bone grafts if we feel comfortable. But most of all we should offer our patients what is the best for them. We are not in this field to get ourselves into trouble, specialist or not. We are all held to the same standard!

Thank you for Drs. like Jack Han, Satish Joshi and the many dentists that has gone on to specialize whether in prostodontics implantolgy or the other subspecialities that continue to think that we all can continue to practice all aspect of dentistry as long we continue to improve our knowledge and skills whether by attending fulltime courses or week-ends. I have attended week-end courses conducted by world renowned experts and it is my opinion that these teachers gave thier best too. As a GP practising in Malaysia I have conducted several classes in Implantology and Lasers in dentistry and those that attended are both Gps and specialists. It does not matter what we are as long as we know to ask questions when we do not know about the subjects. That to me makes a good dentist.

This is the first time in osseo news that I see such a high incidence of doctors writting as "Anonimous", I wonder why? I WONDER WHY? Some people speaking their minds without showing their faces? WHY? Afraid of loosing referrals? Lets face it! it is an advantage to have a specialty or an advanced degree if you place implants, it makes you a more complete practicioner; basic science is very important at the time of making decisions (or somebody else will have to make them for you, as when selecting a bone substitute for an specific site or any specific material)anatomy and disections are a must, surgical techniques are a must. Nobody will argue that! A specialty program makes you very strong in basic science and so many other things that are paramount for success. But all that is available now out there in courses, articles and books! The top courses in the country are taken by specialists and GPs sitting together and sometimes you would be very surprise of the quality of the hands on work, about the questions asked (some silly, some very important)and about who has the true knowledge!! I have sat in so many of those, I have given so many of those. I know a great number of excellent specialists and a great number of sloppy ones that live their lives up to their degree and even walk around with arrogance (that they do or dont deserve) I also know a great deal of sloppy GPs and excellent ones that perform better or to the same level that the best specialist would. Being a GP or a specialists doest mean that you read or you dont, reading and studying is a habit that some people have and some other dont. Implant dentistry is a field that belongs to everybody! it is a trend that will not stop! no email, no blog and no resentment will stop that momentum! The time of implant dentistry is now as Dr Linkow said to me last year! The courage and bravery of many GPs in the 60s and 70s that risked their reputation and their finances make most of the actual advances of implant dentistry possible! It would be unfair to deny that! It would be unfair to take that away of the practicing GPs now that things work well and are predictable. Implant dentistry went from being a cucu (cuack) field that most people even would make fun of, to the high predictability field of dentistry that it is today. The actual university programs for specialists, have implant dentistry but the intensity when you put all the hours together is not necesarily more than the intensity of many courses put together. The position of Dr Kaplowitz makes a lot of sense! if you feel your field of action threaten by GPs, then there is something wrong with the way you are practicing! you need to reevaluate your practice! There are some specialists getting patients referred by GPs but wouldnt listen to the actual requests of the referring dentists, if you deny that as something that happens in real everyday dentistry, then you might be doing that to your reffering dentists. If you dont listen to their imput (even if they are wrong) then you wont get a patient next time and it will be referred somewhere else. The reality of the actual point of Dr Kaplowitz might be painful, he is talking about the lack of comunication, lack of LISTENING to the referring dentists expectations and it is no different than handling the expectations of a patient, sometimes they want things that cant be delivered, but we must have the right words to explain the reasons and as a specialists you should be aware of that! Dr Kaplowitz is right, the frustration that a GP feels when getting back implants that are poorly placed or not placed as requested (angulation, diameter, etc)is tremendous and it is a common topic of conversation that you as specialists dont get to hear because of being a specialists! This situation very often drives the dentists to get the training to eventually place the implants himself. As an oral surgeon, implant dentistry is a small part of your field of practice, what about orthognatic? reconstructions? third molars? biopsies? etc. Because the programs are more designed to train you in those aspects and at the end of the specialty program you need additional WEEKEND COURSES in implant dentistry and ancillary techniques, most of the time as a complement. For the periodontists, it is a different story, because the field has shifted from being the savers of teeth to "Timely removal" to place the implants. I would like to see the periodontology field trying to develop strategies to keep the teeth healthy and in place or to repair the defects but it is now easier to place implants. The more difficult situations will usually end up in your hands specialists since the bulk of GPs wont want to handle it. And as somebody said, there is just so much need for care and so much work for GOOD practicioners that this shoudnt even be an issue. The reality is that there are good and bad in everything and the problem is the selection of the right professional by the patient to do the job well! Again, the funny thing is the world record of anonimous here!!

Very well stated and a breath of fresh air

Dear Dr. Ordonez, Bravo to you as I am one of those General dentists you speak of. I place some implants but very few. I stick to the easy ones and refer the rest and I feel implants can be shared. I have to disagree with you on a number of points. You seem to have a GP vs Specialist mentality, and you seem to put the blame on specialist for the problems of the profession. In my experience the blame is equal. You talk about communication. I feel alot of the communication error is on the part of the general dentist. We often dont take the time to speak to the specialist. We often send the patient over and ask for an implant placed, without ourselves having the knowledge of what size implant is best placed or where we even want it. You talk about angulation errors. How many general dentists out there are taking the time to make a PROPER SURGICAL GUIDE FOR THERE SURGEON. Not many, often we as general dentists dont send or take the time to make a guide. Then even the ones that do rely on there lab to make the guide. Some of use out there just drill a hole in the guide without the common sense of what we want the hole there. I have heard from some, if its in the center its good. I myself make my own guide and place a metal tube for the two twist which then can be removed leaving a hole in the guide for the 3 mm twist. Sure it takes time and may hurt the number of patients I can see in a day, but my practice is about quality and not quantity. I have never had a problem with poorly placed implants since I send a guide and work with the specialist on the case. I take the time to talk to them on what I want as oppose to send the patient over with a give me an implant on #9 attitude. You can't fling mud at the specialist, and then not look at how we as the generalist have failed. I have many friends that are specialist who we work togethor and share the patient load. It works out fine. We all benefit and the patients stand the most to gain. I have some friends that are periodontists that arent doing well because of lack of referrals. "For the periodontists, it is a different story, because the field has shifted from being the savers of teeth to “Timely removal” to place the implants. I would like to see the periodontology field trying to develop strategies to keep the teeth healthy and in place or to repair the defects but it is now easier to place implants." This sums of some of periodontists issues with general dentist nicely. In my conversations with some of my buddys the the shift isn't because they want to do just implants the shift is they arent getting "TIMELY REFERRALS". By the time they get the patients its to late. Yet we want to blame them for not trying to save the teeth. What can they do, they are beholden to the referral, they certainly arent going to bite the hand that feeds them and criticize the General dentist for refering to late. Many general dentists are to blame for this. We often dont refer because of fear of losing the patient or trying to keep as much in our office to increase the bottom line. Perio disease is often the last thing that gets looked at. I have seen Doctors in my area that do all the crown and bidge, and at the very end after they eaten up the insurance or patient has spent x thousands of dollars, O by the way you have perio disease. How many General dentist in your area place arestin all over like its candy or now we have a general dentist in California who rather laser all over rather then refer. Why? Because many of us are driven by the bottom line rather then do whats right for our patients. I myself am more then busy enough to refer. I send cases to oral surgeons, endo and perio alike. And they refer to me. Somehow we forgot what it means to refer and we gotten into a GP vs Specialist mentality. Maybe its because im of an older generation, who can say. Before we as Generalist throw stones we need to look at are own sins. Dr Ordonez you seem to be well versed and have alot of knowledge. How many patients do your refer to specialist in a timely matter? I would be Anonimous to if I was a specialist practicing in your neck of the woods: Dr Ordonez Comments: "This is the first time in osseo news that I see such a high incidence of doctors writting as “Anonimous”, I wonder why?" "Afraid of loosing referrals?" That to me sounds more of a threat. If you lived and died by referrals would you criticize the hand that feeds you? Once again, trying not to bash as I am a big fan of your posts here and feel you are a great dentist. But there are two sides to ever story.