CHAPTER 3
Patient Management
3.1 INTRODUCTION
The members of the dental team who are engaged in the provision of dental implant treatment have specific professional responsibilities in addition to those that are normally expected of a competent dental professional. The Faculty of General Dental Practice UK (FGDP(UK))’s Standards in Dentistry, as well as other similar documents, specify the core and supporting competencies expected of skilled dental professionals [1–4].
Before undertaking a dental implant procedure, the dental team must receive comprehensive theoretical and clinical training under the supervision of a mentor. That way, they acquire the necessary knowledge and competence to deliver safe and reliable implant treatment across a wide spectrum of clinical and non‐clinical areas, both restoratively and surgically [1–5] (B). This also applies to acquiring evidence‐based critical appraisal skills to evaluate and clinically apply newly emerging materials and techniques safely and predictably. Dental professionals should also be able to objectively appraise the complexity of each treatment they wish to undertake, and critically appraise their own skills and knowledge base before deciding whether or not it falls within their level of competence or if an onward referral is in the best interest of the patient (B). In this context, clinicians have a duty of care to limit their practice to the use of clinically proven and evidence‐based techniques, medical devices or biomaterials, with the exception of ethically approved clinical studies or research [6]. When the use of new techniques or materials is proposed, full patient disclosure, documented discussion and education are needed as part of a more rigorous consent process. Patient education is a crucial aspect of dental implant treatment, particularly when it comes to obtaining informed consent. Informed consent involves providing patients with all the information they need to make an informed decision about their treatment options, including the risks, benefits and alternatives. Various tools can aid in patient education, such as informative brochures, videos and interactive multimedia resources. These tools can help patients understand the implant procedure, the care required before and after surgery, and the potential complications that may arise. By providing comprehensive patient education, dental professionals can ensure that patients are empowered to make informed decisions about their dental health and feel confident in their choice to undergo dental implant treatment. The future of IT tools in healthcare is promising, with the potential for further advances in artificial intelligence (AI), deep learning (DL), machine learning (ML) and augmented reality (AR). With the integration of IT tools and healthcare systems, patients can play a greater role in managing their health, and healthcare providers can improve their services by utilising the wealth of information collected through these tools (Figure 3.1).
FIGURE 3.1 Empowering patients through education: tools for informed consent in dental implant treatment.
Empowering patients through education and informed consent is essential in dental implant treatment. Patients should be provided with clear and concise information regarding their treatment options, potential risks and benefits, and expected outcomes. This can help patients make informed decisions about their treatment and feel more confident and comfortable throughout the process. Informed consent is a critical component of patient education, and dental professionals should obtain the patient’s consent before any treatment is initiated. This not only ensures that patients are aware of the potential risks and benefits but also helps to establish trust and rapport between the patient and the dental team. By providing patients with the tools and resources to make informed decisions about their dental implant treatment, dental professionals can improve patient outcomes and satisfaction.
Very few individual dentists can master the full spectrum of experience and skills needed for the rehabilitation of complex cases using dental implants, therefore, in general, clinicians need to work in a multidisciplinary team, in which each member can contribute to a satisfactory outcome within their individual areas of experience and competence (B). In this respect, a structured process of individual patient assessment, diagnosis and systematic case planning is paramount prior to commencing any treatment with dental implants. This is a fundamental requirement to ensure patients’ wishes and expectations are met satisfactorily, predictably and efficiently (B).
An objective analysis of the complexity of the proposed treatment must be carried out as an integral part of such planning to ascertain that each member of the team has the necessary skills and experience to deliver the treatment satisfactorily. Normally, the restoring dentist should assume a leading role in planning and delivery of the treatment from start to finish, although the most experienced member of the team has the overriding professional responsibility to ensure the well‐being and satisfactory treatment of each patient under his/her care.
The ultimate objective of any dental implant treatment is to provide a satisfactory final prosthesis for the replacement of failing or missing teeth to restore function, comfort and dental aesthetics. This should be done in respect to each individual patient’s oral and systemic conditions, financial constraints, wishes and requirements. In the complex field of dental implant treatment, case assessment, planning, delivery and maintenance of a desired and satisfactory outcome requires meticulous attention to detail during each stage of treatment. It also requires systematic history taking, thorough clinical examination, special investigations and appropriate diagnostic imaging [7–9].
For the thorough delivery of the surgical and restorative phases of treatment, detailed treatment planning, identification of risks factors and strategies for managing these are also necessary.
Furthermore, the prognosis needs to be determined in relation to patient‐specific factors, such as bruxism, oral health, diabetes or smoking. Specific patient education and good communication skills between all the members of the dental implant team and the patient are additional essential parts of the satisfactory provision of implant treatment.
3.2 MEDICALLY COMPROMISED PATIENT
Medical conditions can impact the delivery and outcomes of dental care. It is important for dental professionals to obtain a detailed medical history, consult with the patient’s primary care physician or specialist, and develop a comprehensive treatment plan that accounts for the patient’s medical needs and potential risks. Proper management of medically compromised patients can help improve patient outcomes and minimise the risk of complications during dental treatment (Figure 3.2).
FIGURE 3.2 Patients with medical conditions often need special attention when undergoing dental implant treatment due to their underlying health issues.
Medically compromised patients often require special considerations in dental implant treatment due to their underlying health conditions. These patients may have compromised immune systems, delayed wound healing or be at an increased risk for postoperative infections. As a result, it is important to carefully evaluate and manage these patients before, during and after implant treatment to minimise potential risks and ensure successful outcomes.
Prior to implant treatment, a thorough medical history and physical examination should be performed to identify any potential systemic issues or contraindications for implant placement. This evaluation should include a review of the patient’s medications, allergies and previous surgeries or hospitalizations.
If a patient is deemed medically compromised, additional precautions and modifications may be necessary during the implant procedure. For example, antibiotics or anti‐inflammatory medications may be prescribed to prevent infection or minimise inflammation. The implant site may also need to be carefully prepared and sterilised to reduce the risk of infection.
After implant placement, medically compromised patients should be closely monitored for signs of infection or other complications. Postoperative care instructions should be provided to the patient, along with any necessary medications or follow‐up appointments (Figure 3.3).
| Aspirational | Basic | Conditional |
|---|---|---|
| Review all systems by asking specific questions on cardiovascular, haematological, respiratory, urinary, renal, dermal, neurosensory and mucocutaneous systems. (ii) | Obtain accurate medical history in writing and clarify verbally, seeking additional information if necessary. (i) | Analyse how the patient’s pre‐existing medical condition can have an impact on the planned dental treatment. (ii) |
| Check history of chemotherapy, radiotherapy, use of immunosuppressive drugs, oral/intravenous bisphosphonates or similar medication. (i) | Analyse and fully understand the patient’s existing medical condition and list of medications. (i) | Evaluate any potential drug interactions that might occur between the patient’s prescribed medication and those that will be used during treatment. (i) |
| Ask the patient if they have had adverse reactions during dental treatment in the past. (i) | Check medication history, alcohol, drug misuse and smoking. (i) | Carry out routine investigations such as full blood count and haemoglobin A1c (also known as glycated haemoglobin), or refer to the patient’s general medical practitioner or a hospital service to do so. (ii) |
| Prepare to deal with possible complications arising from the patient’s compromised medical condition. (i) | Carry out an extensive examination looking for oral manifestations of systemic diseases as well as general appearance (weight, skin and nails), blood pressure, temperature, pulse and respiratory rate. Examine lymph nodes and salivary glands. (i) | Consider referring patients with haematological disorders who require laboratory investigations for platelet count, partial thromboplastin time, bleeding time or factor replacement for treatment at a hospital setting. (i) |
| Instigate a protocol of adequate preparation for surgery with the help of the patient’s physician. (i) | Contact the patient’s GP and hospital specialists to inform them of the proposed treatment and request a summary of the patient’s current condition. Ask if there is anything else that might alter your management of the patient during dental implant treatment. (i) | Consider the complexity of the treatment (number of implants placed/staged bone grafting), including the duration and number of procedures required, when deciding whether treatment in a primary dental care setting is appropriate. (ii) |
| Take pre‐ and postoperative precautions to reduce the risk of infection and bleeding. (i) | Provide patients with transparent and itemised costs of treatment and indicate when payment will be due if collected in instalments at specific stages of treatment. (i) | |
| Evaluate the patient’s current disease status and assign American Society of Anesthesiologists (ASA) Physical Status Classification System in consultation with the patient’s GP and hospital specialists. Refer patients who require complex or extensive dental implant treatment if ASA II, and consider referring patients to a hospital setting if ASA II but their condition is not stable. Refer ASA III patients for treatment at a hospital setting under medical supervision. (ii) |
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