Dentists balk at referring implant patients to endodonists
Article Thumbnail ImageAugust 19, 2011 -- When it comes to referring patients for dental implants, the majority of general dentists say they would not choose an endodontist, according to a new survey in the Journal of Endodontics (August 1, 2011).
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Among 366 general dentists who responded to a survey sent to 1,500 randomly selected practicing general dentists in the U.S., 66% said they were opposed to endodontists placing dental implants, and as many as 73% indicated that they would not refer patients to an endodontist for implant placement.

The survey was part of an ongoing effort to better understand thoughts in the profession on the role of endodontists in implant placement, said co-author Michelle McQuistan, DDS, of the University of Iowa College of Dentistry.

"There has been a lot of talk at meetings and within the specialty of endodontists going into implant placement, and we wanted to find out what people think about the idea," Dr. McQuistan said.

In a previous survey by the same team, similar questions were posed to endodontists, themselves, and the results showed a higher number, 57%, in favor of endodontists placing implants.

“Referral patterns will continue to be driven by what is most convenient for the patient and the relationships between the general dentists and specialists.”
— Kimberly Harms, DDS

Interestingly, in the more recent study, general dentists who were most likely to support endodontists' implant placement were those who said they never or only sometimes referred patients for molar root canal treatment, Dr. McQuistan and her team noted. This group was 3.5 times more likely to support endodontists' implant placement, compared with those who always refer molar root canal treatment.

Supporters also included general dentists who planned to retire in the next five years, who were 2.8 times more likely to be in favor of the practice, compared with those who did not plan to retire in the near future.

"Historically, general dentists were expected to provide a vast range of treatment for their patients; thus, they may be more be tolerant of specialists providing a variety of services than more recent graduates who are encouraged to rely upon specialists for specific procedures," the authors wrote. "Another possibility may be that dentists who plan to practice for an extended period may envision learning to place implants themselves; thus, their perception may be that there will be a decreased need for implant referral services."

In fact, nearly a quarter, 23%, of the dentists expressed an interest in learning how to place implants themselves. And according to an ADA survey, the percentage of general dentists who reported ever having placed a dental implant increased from 8.8% in 1996 to 12.3% in 2006.

Demand for implants on the rise

The figures reflect rising levels of interest across multiple dental specialties in being prepared to meet an anticipated increase in demand for implants in coming years.

Implant companies are helping to fuel the interest, offering training to nearly any dental professionals qualified to offer the service. As many as 83.7% of survey respondents indicated that they had learned to place implants through an implant company or representative, and about 90% indicated they had learned through continuing education courses.

Only 47.2% said they had learned through formalized, accredited educational programs.

Oral surgeons have traditionally been the specialists charged with placing dental implants due to their extensive training and advanced surgical skills. Periodontists began to join the surgeons in the 1990s, and the field of dental practitioners currently placing implants has expanded even further, to include everyone from general dentists to prosthodontists and endodontists.

The numbers of endodontists currently placing implants remains relatively small -- only 7%, according to an American Association of Endodontists (AAE) survey. That may be a key reason why so few general dentists said they would refer implant patients to these specialists, according to Dr. McQuistan.

"Right now the figures make sense because most endodontists aren't placing implants," she said.

Kimberly Harms, DDS, a consumer advisor spokesperson for the ADA, agreed, noting that referrals are largely based more on faith in the dentist or specialist's knowledge than their specialty.

"There are some general dentists that other general dentist can refer implant patients to, so it's completely a matter of the dentist's expertise knowledge and training levels, and I think the referral patterns will continue to be driven by what is most convenient for the patient and the relationships between the general dentists and specialists," Dr. Harms said.

Endodontist advantages

Still, the case can be made in favor of endodontists offering implant placements in that it allows patients to have nonrestorable teeth addressed without having to be passed on to yet another specialist, according to Dr. McQuistan.

"One of the advantages of referring to an endodontist is if you have a tooth that is questionable and the endodontist determines that the tooth in fact cannot be restored, they could extract it and do perhaps a same-day implant or the patient could come back," she said.

There are a host of arguments that favor endodontists placing implants, according to James Kulild, DDS, president-elect of the AAE.

"Endodontists are particularly skilled in surgical treatment, pain management, and local anesthetic techniques, which are extremely important considerations for many patients," he told DrBicuspid.com.

Endodontists are one of the three critical dental specialists who can appropriately determine restorability of the tooth and are experts in interpreting radiographs Dr. Kulild added. They are also accustomed to measuring finite distances during surgical and nonsurgical treatment down to a half a millimeter, and skilled at proper alignment of drills and endodontic rotary files, he said.

According to Dr. Kulild, arguments against endodontists placing implants include the following:

  • There may be a conflict of interest in treatment planning (this is a concern for all dentists placing implants).
  • Maintenance of the health of the implant has to go back to the referring dentist.
  • Maintenance of the necessary armamentarium may be challenging.

While only a small number of endodontists actively place implants at this time, the AAE survey indicated that as many as 16% of respondents planned to begin the practice in the next five years.