At least half a million adults in England, Wales and Northern Ireland have at least one implant according to a 2009 dental health survey, although the procedure is now such a feature of mainstream dentistry that this is likely to be a significant underestimate.

Most patients will have been delighted to lose their 'gap' but as implant treatment grows in popularity, it has also become a focus for concern. In July 2014, implant treatment was the subject of a debate in the House of Lords which focused on the information to be made available to patients, the need for clear and consistent guidance on treatment planning and defined standards for education and training. During the debate it was noted that the GDC has seen an increase in complaints about consent issues and unsatisfactory treatment.

The DDU has also noted a worrying rise in the number of claims involving implant treatment over the 10 years between 2004 and 2013: there were 182 claims notified in the second half of the decade compared to 129 claims in the first, an increase of 41%. Of the total 311 claims received, 115 have been settled for a total of nearly £4million in compensation and legal costs. A further 75 are still active and the remaining 121 have been closed. Some 37 cases also involved a patient complaint to the practice while 26 claimants had reported their concerns to the GDC.

Compensation for implant cases is at the upper end of the scale for dental claims because of the significant ongoing cost of addressing failed implant treatment, including bone grafts in some cases and the pain and suffering experienced by some patients who undergo multiple procedures. The average amount of compensation paid to claimants on behalf of these dental members to settle the claims against them was just under £30,000. The largest compensation pay-out, to a patient who was left with nerve damage after implants failed, was over £242,000.

The upward trend in claims prompted us to review those which were settled and draw risk management conclusions for members.

Managing the risk

Training

• You must have appropriate training and experience before carrying out the procedure. The GDC has endorsed the Training Standards in Implant Dentistry, published by the Faculty of General Dental Practice (UK).
• Ensure the course has formal, structured educational aims and objectives, assessment and certification.
• Keep a log of all your training to ensure you are up to date, and as evidence should your competence to carry out the procedure be called into question, for example in a claim or a complaint to the GDC.

Assessment and treatment planning

• Obtain and record a detailed patient history and be alert to the contraindications for implant treatment, such as untreated periodontal disease, immunosuppression and smoking.
• Base your treatment plan on a thorough evaluation of the patient. The Association of Dental Implantology guidance dedicates a section to case selection and treatment planning.

Consent and communication with patients

• Explain the benefits, risks and alternatives (including no treatment) to patients as part of the consent process and record the discussion. Be careful not to raise unrealistic expectations of what can be achieved.
• Give patients a cooling-off period to consider their decision.
• Provide a written fee estimate and be sure to warn patients of the cost implications if circumstances change.

Most common reasons for claims to be settled

Treatment failure	41	(36%)
'Unsatisfactory' treatment	20	(17%)
Assessment and treatment planning	16	(14%)
Fit of implant/prosthesis	15	(13%)
Nerve damage	11	(10%)
Adverse incident during treatment, e.g. ingestion of instrument	5	(4%)
Valid consent not obtained	4	(3%)
Persistent pain following treatment	3	(3%)

Failure of treatment was the most common reason cited in successful claims, accounting for over a third of cases. As well as problems with the implant fixture, 24 claimants in this category were unhappy with the restoration (the bridge, crown or denture) that was supported by the implant(s). For example, one patient was awarded over £25,000 when the abutment for an upper denture failed, as well as for unsatisfactory aesthetics of an implant retained bridge.

Implants can fail without negligence on the part of the dental professional - for example, osseointegration may not take place. Or the patient may consider the outcome is unsatisfactory (as in 17% of cases), either because it was unsatisfactory or perhaps because their expectations of what would be achieved were unrealistic. Nonetheless, it may still be difficult to successfully defend allegations of negligence when the dentist has not:

• properly risk-assessed the patient to ensure their suitability for implants
• formulated a comprehensive written treatment plan, and
• obtained valid consent, including warning the patient of potential complications such as nerve damage, post-operative pain, and failure to integrate.

Dentists may make technical errors during the procedure, such as placing implants incorrectly, which can cause overloading before integration is complete. In some cases, this is because they are carrying out a complex procedure that is beyond their professional competence, or perhaps they tried to undertake remedial treatment when a referral to a more experienced colleague would have been appropriate. There is no specialist list or recognised formal postgraduate curriculum for implantology, but the GDC expects registrants to be fully trained and competent, and it supports the Faculty of General Dental Practice's Training Standards in Implant Dentistry.

A significant proportion of implant procedures fail over time because of deficiencies in patients' aftercare. Careful post-procedure monitoring, patient education and regular assessments are essential elements of implant treatment. In several claims, it appears that the patient's restoration/implant failed because of bone loss, which is a symptom of peri-implantitis, a serious complication of implant treatment. We have seen an increasing number of cases concerning the prevention, diagnosis, and treatment of peri-implantitis in the last few years and we expect this number to continue to rise as awareness of the condition grows.

Disputes over treatment fees were an aggravating feature in nine settled claims (8%) - usually when the patient objected to the cost of a revised treatment plan or demanded a refund and/or payment for remedial treatment when problems arose.

Evidence-based treatment

• Follow available national guidance to ensure your treatment is evidence-based, e.g. guidance provided by the Faculty of Dental Surgery or the ADI.
• Always use materials and systems which are supported by authoritative research and clinical studies. Don't be swayed by marketing claims for new implant systems.

Referrals

• Recognise the limits of your clinical skills. Offer referral to a periodontist, oral surgeon or restorative dentist in complex cases if you lack the necessary experience or technical competence. If a referral is made, it is essential that all relevant clinical information, including copies of radiographs, is provided with the referral, in line with GDC guidance.
• Effective communication with all colleagues involved in the patient's dental care is essential because implant treatment is often multidisciplinary e.g. GDP, oral surgeon, restorative dentist and a dental technician might all have a role in a patient's implant treatment and aftercare. All dental professionals should liaise with each other to ensure they have the information they need, understand what is expected of them, and can easily raise any queries.
• Responsibility for the patient's long-term care and the maintenance of implants should be agreed in advance between the various dental professionals involved.

Long-term management of implant patients

• Explain to patients how to care for their new implant and stress the importance of rigorous oral hygiene and regular dental check-ups.
• Ensure patients are carefully monitored for symptoms and signs, such as bone loss or inflammation at the implant site (peri-implant mucositis) which, if left untreated, will develop into peri-implantitis.
• Consider a log of implant patients at your practice to ensure appropriate recall intervals are maintained and that enough time is allocated for appointments.