The ongoing pandemic has had a great impact on many fields in dentistry, including routine procedures and the way in which dental education is delivered. In order to find out more about the extent to which the field of implant dentistry has been affected, Dental Tribune International contacted Prof. Maher Almasri, dean of the College of Medicine and Dentistry at Ulster University in Birmingham in the UK, and Prof. Curd Bollen, head of implant dentistry at the same institution. In this interview, they discuss how implant dentistry can best be adapted to the current situation.
Profs. Almasri and Bollen, general dental care was greatly affected by the pandemic owing to the necessary close proximity of dentist and patient and the production of aerosols. Are there any treatment options in implant dentistry that cannot be performed at the moment?
Bollen: Implant dentistry faces, of course, the same infection risks as general dentistry, although the use of aerosols in our field is more limited. Using piezo-surgical instruments is, however, not recommended in the current situation. In the case of sinus elevation procedures, for example, a closed technique (Summers’ technique) is preferred, since the lateral window technique needs high-speed water-coolant or piezo-surgical equipment—both inducing extreme aerosols. All other surgical and prosthetic treatments can still be performed, as long as the strict infection prevention rules are respected by the patient, the practitioner and the staff.
Almasri: Intra-oral radiographs, although causing minimal radiation, should be reconsidered because of the higher contamination risk in comparison with an extra-oral radiograph. However, of course, we should not suddenly neglect the ALARA principle, but a partial dental panoramic tomogram or CBCT with a small field of view is recommended.
For general dentistry, study findings have established certain measures that can reduce the risk of infection. What are some measures that dental implantologists may apply during this challenging time?
Bollen: A thorough treatment room disinfection after every patient contact is of the utmost importance. Nowadays, there is excellent equipment available that uses ultraviolet C to guarantee strict disinfection of air, floor and surfaces of the operation room. Every respected clinic should be equipped with it!
Another possibility is that of applying non-submerged techniques where possible. When a one-stage non-submerged technique is used to install the dental implant, there is no need for a second surgical appointment to uncover the implant. The use of tissue-level implants offers this advantage and is well documented.
Almasri: Another option is to place dental implants that use low-speed drilling without cooling. Some specific brands, as Bicon or Nobel Biocare (N1 implant), show high long-term success rates with osteotomy drilling at 50 rpm without cooling.
Are there any other measures that can be taken to reduce the risk of infection for patients and staff during dental implant procedures?
Bollen: First of all, every patient should rinse before every intra-oral procedure with hydrogen peroxide (0.5%) or povidone-iodine (0.2%), which are highly effective against SARS-CoV-2 particles. We know that chlorhexidine has no effect on the virus at all!
It is also advisable to use magnification equipment such as a loupe or a microscope. These tools create more distance between the practitioner and the oral cavity of the patient, although not the recommended 2 m (6 ft), of course. This also helps to improve your posture. Furthermore, the introduction of a fully digital workflow can be helpful: no more—possibly infected—impressions have to be sent to the laboratory and fewer appointments are needed to finish the final reconstruction.
Almasri: Let’s try to avoid treating compromised patients, if the treatment can be postponed. Dental implant surgery is no first aid. Severely immunocompromised patients as well as patients taking anti-coagulants often present more complications and therefore require more attention and postoperative care. During a pandemic, this means extra and unnecessary appointments.
The limited access to routine dental care has had a negative impact on the oral health of many patients. How do you evaluate the situation for dental implant patients?
Almasri: As mentioned before, implant dentistry is no first aid. The only discomfort patients have to face is probably a delay of their treatment plan. Surgical or prosthetic appointments are often postponed, leading to a lengthened treatment process. So be it!
Of course, patients suffering from postoperative pain or infectious problems around their implants need to have access to a first aid service. Also, prosthetic repairs should remain available for the patient.
In addition to the psychological burden, the pandemic is financially challenging for patients and practice owners. Before SARS-CoV-2, the dental implant market was one of the fastest growing markets in the dental sector. How do you perceive the current situation?
Bollen: As with the psychological problems, the financial impact has two components: the impact on the patients and the impact on the clinicians. Both groups face financial insecurities nowadays owing to less income and rising expenses.
On the one hand, for patients this often leads to choosing personal care expenses over the more expensive treatments—like implant-supported rehabilitations—which are consequently postponed. Dental practitioners, on the other hand, are confronted with additional expenses that do not increase their income. Only rarely is the government willing to support those extra costs for all the new precautionary measures.
This leads to a lack in return on investment and can cause huge financial problems for new or recently started clinics or clinics with an unstable financial basis. Since there is no end date for a pandemic, the psychological and financial evolution during the next months or years is hardy to predict. However, times might stay tough for a while.
In your opinion, do you think the pandemic will have a long-term impact on the practice of dental implantology? If yes, in what way?
Bollen: Yes, it will. Since former pandemics often lasted several years or even decades, it is possible that we will have to face this pandemic for a longer period than we had hoped for. Although several vaccines are available now, there is no guarantee that they will be functional against the new or mutated SARS-CoV-2 variants.
Almasri: The only thing we have in our own hands is the ability to protect ourselves and our fellows as much as possible. Implant dentistry can contribute to this protection by taking into account those extra measures that Prof. Bollen and I have mentioned.
Would you like to add anything else?
Bollen: As with all previous pandemics, humanity will survive these dark times. Yet, if we want to win against this or any future virus, we will need a unified approach at all levels of society.