Implant Manual


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Implant Manual

  1. 1. The University of Texas Dental Branch at Houston POLICY ManuaL FORDentaL IMPLant theRaPY Revised September 2008 UTDB Implant Steering Committee Robert L. Engelmeier, DMD, MS Chairman
  2. 2. IMPLant PROgRaM FaCuLtY 1. Dr. R. Engelmeier Program Director, Graduate Prosthodontic Program Implant Steering Committee Chairman Implant Board Chairman 2. Dr. A. Ridall Director, Undergraduate Implant Program Implant Steering Committee Implant Board 3. Dr. R. Hanna Periodontics Coordinator, Undergraduate Implant Program Implant Steering Committee Implant Board 4. Dr. G. Suchko OMFS Coordinator, Undergraduate Implant Program Director, OMFS Graduate Program Implant Steering Committee Implant Board 5. Dr. R. Mayhew Implant Steering Committee Director, AEGD and GPR Programs 6. Dr. K. Sudarat AEGD Faculty Implant Board 7. Dr. S. Jessee Director, Undergraduate Clinical Education Implant Steering Committee (Advisor) 8. Dr. C. Flaitz Dean Implant Steering Committee (Advisor) 9. Dr. J. English Chairman, Orthodontic Department Implant Steering Committee10. Dr. Paula O’Neill Associate Dean for Educational Research and Professional Development Implant Steering Committee (Advisor)Implant Manual – Revised 9/2008 1
  3. 3. IMPLant PROgRaM FaCuLtY11. Dr. N. Olvera Prosthodontic Faculty Implant Steering Committee Co-director, Graduate Implantology Course12. Dr. P. Pierpont Associate Dean for Student and Alumni Affairs Implant Steering Committee (Advisor)13. Dr. R. Weltman Director, Graduate Periodontics Program Implant Steering Committee Implant Board14. Dr. Peggy O’Neill Associate Dean for Patient Care Implant Steering Committee15. Dr. L. Roeder Associate Dean for Academic Affairs Implant Steering Committee16. Dr. D. Belles Interim Chairman, Department of Prosthodontics Implant Steering Committee17. Dr. M. Wong Chairman, OMFS Implant Steering Committee18. Dr. K. Busaidy OMFS Faculty Implant Board19. Dr. A. Jeske Chairman, Department of Restorative Dentistry Implant Steering Committee20. J. Katancik Chairman, Department of Periodontics Implant Steering Committee21. J. Kennedy Implant Board OMFS Faculty2 Implant Manual – Revised9/2007
  4. 4. Implant Manual – Revised 9/2008 3
  5. 5. The University of Texas Dental Branch at Houston Policy Manual for Dental Implant TherapyI. Patient Selection No student/resident can independently accept an implant patient and begin treatment without first referring the patient for screening by the appropriate faculty member. There is no charge for undergraduate implant screening. Undergraduate implant cases are limited to one implant supported crown or a two implant-supported mandibular overdenture. Undergraduate screening appointments are made (only assigned days) by calling Ms. Ann Yue at 713-500-4048. Graduate screening appointments are made with the Director of one of the Graduate Restorative Programs (AEGD, GPR, or Graduate Prosthodontics). An evaluation fee is charged by the Graduate programs. AEGD and GPR cases are limited to implant supported overdentures or implant supported fixed prosthodontic cases restricted to a single quadrant (provided that the contralateral occlusion is intact, stable, and in a good state of repair.) The intention of this limitation is to only allow assignment of cases that can realistically be completed by the student’s expected graduation date. More involved cases usually need to be transferred to another student or referred to another program (mid-treatment), greatly reducing training value. Patients referred to the Dental Branch for implant fixture placement only do not need to be screened by a restorative department. However, the case must still be entered into the school’s EPR database, along with all pertinent implant information.II. Initial Diagnosis and Treatment Plan Once a patient has been selected and assigned to an undergraduate student, the patient is scheduled for an appointment in his/her primary bay, with supervision from the Department of Prosthodontics. At the first appointment, the student is expected to obtain appropriate diagnostic records and develop a treatment plan. Once the prosthodontic treatment plan has been completed, it is the student’s responsibility to contact a periodontic/OMFS resident, who has been assigned to review the case and develop the final combined treatment plan. If needed, tomographic, or CT radiographic requests are referred to an external source and all fee transactions for these services are processed through the external entity. A laminated copy of the school codes and fees for undergraduate implant restorations can be found in each clinic. Once the final treatment plan has been approved by the supervising faculty, the student is required to complete all necessary documentation and schedule an appointment to present the case to the Implant Board for final approval. The Implant Board must approve the combined surgical/restorative treatment plan before an implant is placed. No commitment is made to treat a patient with implants until the final treatment plan has been approved by the Implant Board and until the patient has accepted that same plan along with the final estimate of fees.4 Implant Manual – Revised 9/2007
  6. 6. In addition, a standard of care at this school is that No implants are placed until all oral disease is eradicated. This includes: All periodontal and oral hygiene treatment, all restorations needed for carious teeth, all necessary endodontic treatment, and all needed extractions. Residents in the surgical and restorative programs are paired up to develop a Treatment Plan for each implant patient. The Implant Board must approve all graduate Surgical/Restorative Treatment Plans before any treatment is begun. If the patient does not approve the implant treatment plan, students under faculty supervision have the following options: a. refer the patient to the in-house faculty practice or to an outside dental practice b. discontinue the patient c. keep the patient and plan alternative treatment that does not involve implants If the patient approves the implant treatment plan, the residents should: a. have the patient sign the Sequential Treatment Plan in the EPR along with the mentor to whom the resident/student is assigned b. prepare the case for the Implant BoardIII. Implant Board The Implant Board meets bimonthly at appointed times to review prospective implant patient’s records before commencement of treatment. No implant treatment is begun prior to the Board’s approval of the Plan! The resident/student assigned to the case must make a board presentation appointment with Ms. Mary Baines (room DB 422, extension 4136) within two days of the board meeting. The minimum composition of the Board is: ♦ Chairman – The Implant Program Director (representing Prosthodontics) ♦ The UG Implant Program Director ♦ OMFS Representative ♦ Periodontics Representative ♦ The surgical and restorative students/residents involved with the implant case The purpose of the Implant Board is: a. To assure the best case selection and treatment experience for undergraduate students and residents b. To assure the best method of treatment, and the most expeditious course for that method of treatment c. To update the Implant Database; to assure and enhance quality of care and follow-up of implant patients; and to afford research opportunities to the UTDB faculty and residentsImplant Manual – Revised 9/2008 5
  7. 7. d. To complete the “Request for Implant Parts” form prior to any treatment (Attachment 1) e. To assure that the patient has read, understood, and signed the “UTDB Informed Consent Form for Implant Surgery” (Attachment 2), The “Memorandum of Understanding for Dental Patients in the Graduate Prosthodontic Program,” (Attachment 3) and the treatment plan. A typical work-up for the Board minimally requires: ♦ Clinical examination by the designated Restorative and Surgical residents/students ♦ Diagnostic mounting of the patient’s casts (with a facebow and CR record) ♦ Clear dentures in the case of edentulous patients ♦ Diagnostic wax-up in the case of partially edentulous patients ♦ Pertinent radiographs (the surgical residents call . . .) Panorex Cephalometic radiographs Periapical radiographs Tomograms CT Scans MRI Occlusal radiographs ♦ All pertinent medical referral reports ♦ All pertinent dental referral reports ♦ Written sequential treatment plan including estimated cost, treatment time, and patient signature. ♦ Signed “UTDB Informed Consent Form for Implant Surgery” (Attachment 2) ♦ Signed UTDB Department of Prosthodontics “Memorandum of Understanding for Dental Patients in the Graduate Prosthodontic Program Care” (Attachment 3) ♦ Updated EPR ♦ The Board may request to examine the patient ♦ Bone sounding results Note: The restorative student/resident is expected to provide all mountings, wax-ups, radiographic and surgical stents, and transitional appliances. Note: The restorative student/resident and the surgical resident must be present during the presentation of the case to the Implant Board.IV. Finalization of the Treatment Plan at the Board Meeting includes: ♦ The number and location of dental implants to be used ♦ Implant manufacturer and type of implants to be used ♦ Size of implant (length and diameter) ♦ Type of abutments to be used6 Implant Manual – Revised 9/2007
  8. 8. ♦ Type and timing of provisional restorations ♦ Type of prosthetic restorations (including materials) ♦ The timing of each phase of treatment ♦ The type of occlusion (if pertinent) ♦ Any alternative plans Note: All undergraduate implant cases are restored with Zimmer implants. Note: A restorative fee (code 06000) is charged for this diagnostic service. The fee covers everything except radiographs. Failure to adhere to the policy of presenting all implant cases to the Board prior to any treatment is not tolerated! Any and all implant surgery or pre-prosthetic surgery performed on a patient prior to the presentation of that patient’s joint (surgical/restorative) treatment plan to the Implant Board results in the following disciplinary action: 1. The provider, mentor, and Program Director involved are referred to the Associate Dean for Patient Care and the Credentials Committee with the recommendation of indefinite suspension of all clinical privileges. This action might make it impossible of them to fulfill both their clinical and teaching responsibilities at UTDB and could adversely affect their employment and/or association at the Dental Branch. 2. The program involved in this breech of policy is indefinitely denied the right and privilege of rendering implant therapy (both surgical and restorative) to their patients. This action could adversely affect that program’s accreditation status.V. Policy for Accepting outside Patients for Implant Surgery 1. Patients from the private sector who are to be restored and followed by their private dentists may be accepted by the Oral and Maxillofacial Surgery and Periodontics Departments for the placement of implants. 2. Patients are not accepted by UTDB for the restoration of implants placed outside the school! 3. The referring restorative dentist must refer patients for implant placement to the school in writing. In addition, the referring dentist must state in the letter that he/she assumes full responsibility for restoration of the requested implants and a statement of responsibility for all future maintenance and repairs needed by the patient. The patient must co-sign this letter as matter of evidence of understanding the responsibilities of the surgeon and restorative dentist. The restorative dentist must also provide the surgeon with all of the records normally provided by the AEGD, GPR and Graduate Prosthodontic Programs (i.e.) mounted casts, drill guides, tomograms, x-ray stent, etc. (Attachment 4) 4. After Phase II surgery the UTDB surgeon must include an entry in the progress notes of the patient’s dental record that clearly states that the patient is being referred back toImplant Manual – Revised 9/2008 7
  9. 9. his/her referring dentist for timely restoration of the implants. This entry should be co- signed by the patient.VI. Revenue Collection All patients of the Implantology Program are given an accurate estimate prior to the commencement of treatment. They are expected to pay for services at the beginning of each phase of treatment. All involved programs use the UTDB Fee Schedule. The patient must pay 50% of the surgical fee prior to the placement of the fixture hardware order. They must pay the other 50% by the time of Phase I surgery. See Attachment 5 for several typical implant scenarios that illustrate the codes and fees for the procedures involved. Charges for restorative procedures should be made at the time of those services (i.e.) at least by the time that the final impression is made for that restoration. The patient must pay for any attachments and/or implant related hardware in full before those restorative parts are ordered. They must pay one-half the fee for all castings before precious metal can be issued to fabricate those restorations. Finally, the fee for all restorations must be paid in full by the time of delivery of those restorations. There are no exceptions.VII. Treatment A. Prior to Phase I Implant Surgery: 1. All partially dentulous implant patients must have all periodontic, endodontic, and restorative dental work completed prior to any implant placement. 2. The Surgical resident completes all preparatory surgery such as Grafts, Sinus Lift or Nerve Repositioning procedures. 3. The undergraduate student/graduate restorative resident must fabricate all surgical guide stents. The stent(s) must be sterilized prior to surgery. The design of the stent must be approved by the supervising faculty and the Implant Board. 4. The Surgical residents must collect all surgery fees. 5. The Surgical residents must order the implant fixtures for the case through the Division of Clinical Services (DB348) for graduate cases or the Periodontal Coordinator of the UG Implant Program. Implants must be ordered at least two weeks prior to the appointment for Phase I surgery. 6. Management of Implant Products Implant hardware devices from various manufacturers are supplied on request to the dentist placing the implant and to the dentist providing the restorative care. The Dental School does not maintain a stock of implant products.8 Implant Manual – Revised 9/2007
  10. 10. All surgical implant kits for Zimmer Tapered Screw Vent implants are maintained by the Departments of Periodontics and OMFS. Restorative implant tools are maintained and loaned through the second floor dispensary. All Zimmer Tapered TSV implants are obtained through the Periodontics Coordinator for the Undergraduate Implant Program. It is the surgical resident’s responsibility to make sure that the proper implant and healing cap are ordered. It is the restorative student’s responsibility to make sure that the restorative components are ordered and available at the time of treatment. Prosthodontic parts (abutments, temporary abutments, transfer copings, and healing collars) must be obtained through the Director of UG Implant Program. Restorative parts for Graduate cases are ordered through the Clinical Services office. The following procedures are recommended for management of implant products. A. Ordering Stage I Implant Products The surgical resident can order Phase I implant products by: 1) Completing an Implant Product(s) Request Form (Attachment 1). 2) Having an implant board member and attending faculty member sign the form. 3) Turning in the completed form to the Clinical Services Office or the Periodontic coordinator for the Undergraduate Implant Program. Ordering Stage II Implant Products 1) Completing an Implant Product(s) Request Form (Attachment 1). 2) Having an Implant Board member and attending faculty member sign the form. 3) Turning the completed form to the Clinical Services Office or the Coordinator for the Undergraduate Implant Program. Ordering Restorative Implant Products These products may be ordered by the restorative resident by: 1. Completing the information requested on the restorative section of the Implant Products Request Form (Attachment 1). 2. Having attending faculty member and Implant Board member sign the form. 3. Turning in the completed form to the Clinical Services Office or the Coordinator for the Undergraduate Implant Program. Return Policy Unused product(s) must be returned within 48 hours after it is determined that the product(s) cannot be used in treatment. Failure to do so may result in the graduate student/resident or the program having to pay for the product. Manufacturers of implantImplant Manual – Revised 9/2008 9
  11. 11. products have a limited time period within which products may be returned for exchange or credit. B. Phase I Implant Surgery Appointment: 1. Surgical procedures are only performed by: • OMFS residents in their respective OR’s and Surgical Suites • Periodontic residents only in their respective surgical treatment areas • Graduate Prosthodontic residents in the UTDB, OMFS Surgical suite • AEGD and GPR residents in their respective clinics 2. The restorative resident/student is responsible if the patient needs a transitional prosthesis or a reline of an existing prosthesis. They are also responsible for timing such treatment with the implant team. Patients with implants placed in completely edentulous arches are not to have a relined transitional or existing prosthesis delivered until 10 – 14 days after the surgery. In such a case any existing prosthesis should be kept from the patient and only returned to them after needed modifications. A suitable temporary tissue conditioner is used for initial reline procedures followed by another reline after one week. Patients should not wear the denture if discomfort is experienced and must contact the restorative resident/student for an evaluation appointment as soon as possible. The tissue conditioning materials are temporary and over several weeks can get quite hard because the plasticizers leech out of the material. They must be changed at regular intervals throughout the restorative phase of treatment. 3. The Surgical resident should obtain a post-Phase I surgery radiograph of the implant(s) at the surgery appointment or no later than the first post-op appointment. 4. After Phase I surgery, the Surgical resident is responsible for reporting the following data in the Electronic Record (EPR). a. name of implant system and type of implant b. size (length and diameter) and location of the implant c. site(s) of grafting and/or GTR procedures and the materials used d. any other procedures, e.g. extraction and immediate implant placement The surgical resident includes any intraoperative problems encountered whereby the planned procedure was either not completed or was altered and briefly describes the reason(s). 5. The Surgical resident must record all “sticker” label information for all implanted material and/or hardware in the progress notes of the patient’s electronic dental record. 6. If at the time of Phase I Implant Surgery, the surgeon deems that the planned site or planned angle of implant placement is not feasible (as in a case of unforeseen10 Implant Manual – Revised 9/2007
  12. 12. bone defects, unfavorable contours or trabeculation, or a hole that was inadvertently drilled too large), the implant must not be placed. The difference of a mm or so or a few degrees in angulation can have a huge impact on occlusion, biomechanics, esthetics, and the patient’s ability to keep the area clean. In effect, such minor changes in implant position can greatly alter the treatment plan. In these cases, the surgeon should either close or, at most graft any defects then close. Getting permission to alter the implant site or orientation from an observing Restorative Resident/undergraduate student is not acceptable approval for the surgeon to place implants in such cases. In most cases, the observing Restorative Resident has not accumulated enough experience to make such on-the-spot decisions during surgery. C. Healing Period: During the healing period: 1. The Surgical resident must: a. Verify patient is scheduled for Phase II surgery on the indicated date (3½ or more months for implants placed in the anterior mandible; four plus months for all other areas; and six plus months for implants placed into a site, which has undergone a sinus lift). 2. The Restorative resident must: a. Follow the patient post-operatively. If the patient has a removable transitional prosthesis, the soft lining material must be monitored by the undergraduate student/graduate restorative resident. D. Phase II Surgery 1. Phase II surgery must be performed in a timely manner (i.e., three to six months post-Phase I surgery, as the case dictates). 2. The patient must be referred to the Restorative resident/undergraduate student for timely restoration of the implants as soon as possible after Phase II surgery. 3. Independently, the Surgical resident must recall the patient for maintenance and reassessment (approximately every three to six months). E. Restorative Phase 1. Restoration procedures are only performed by: • UTDB Third and fourth year students • Graduate Prosthodontics Residents • AEGD and GPR residents All in their respective clinicsImplant Manual – Revised 9/2008 11
  13. 13. 2. The restorative phase must be performed in a timely manner (i.e.) as soon as possible after Phase II surgery. 3. During the restorative phase of treatment, the Restorative resident/undergraduate student is responsible for all maintenance of any provisional restorations (fixed or removable). 4. All restorative hardware (i.e.) abutments, attachments, etc., must be recorded in the patient’s electronic dental record. 5. Transfer casts must be verified by means of a transfer jig, if the case involves an implant supported FPD, hybrid denture, or a fixed bar (i.e. multiple implants supporting a fixed prosthesis). 6. Provisional restorations must be placed by the time the transfer impression is taken. 7. Post delivery radiographs must be taken of all castings attached to implant fixtures. 8. Patients are to be recalled according to the policy listed below in item XI.VIII. Records All dental implant patients at UTDB must have an updated electronic dental health record. All implant patient visits require a chart entry whether or not a charge or payment is made that day.IX. Clinical Facilities Implantology activities carried on by Oral and Maxillofacial Surgery, Periodontic, Prosthodontic, AEGD, GPR and Undergraduate Programs are carried out in their respective clinics, and supervised by their own assigned faculty.X. Implant Systems The Surgical residents only place implant fixtures for which the Restorative programs are equipped with the proper tools (i.e., screwdrivers, torque wrenches, wrenches, etc.). At present the school is limited to the following seven implant systems: Straumman, Nobel Biocare, 3I, Zimmer, MDL (mini Implants), Biohorizons and Astra. The Undergraduate Implant Curriculum uses Centerpulse Implants exclusively. It is the responsibility of each program to store their respective hardware in their own department. Each department has the latitude to decide whether or not to establish a centralized depository for these parts or to leave it to each resident/student to keep track of his/her patients implant parts. It is also the responsibility of each department to acquire and maintain their necessary tool kits (surgical and/or restorative).12 Implant Manual – Revised 9/2007
  14. 14. XI. Failed Implants 1. Early Failure – failure of the implant fixture between the time of Phase I surgery and Phase II surgery. a. If the reason for failure is due to the surgical technique or accuracy where the implant is not restorable, the non-restorable fixture should be removed and correctly replaced at no charge to the patient. If the patient does not wish to undergo any more surgery, he or she should be given a full refund of the fees paid for the fixture in question. Further, with the patient’s permission the offending fixture should be removed at no charge to the patient. The non-restorability of such implants must be confirmed by a consensus of the restorative and surgical mentors. Disputes will be resolved by the Implant Board.. b. If the reason for failure has to do with patient factors (e.g.) failure to integrate, the following policy is to be followed. If the patient is willing to undergo an additional attempt at implant placement, the fixture(s) should be replaced at half the normal fee. If the patient does not wish to undergo any additional surgery, no refunds should be given. Note: No refunds or discounts are ever given for I.V. sedation because the patient does receive the benefits of the I.V. sedation at the time of surgery and further because the I.V. sedation has no bearing on the success or failure of a fixture. c. No attempt should be made to replace failed implants in ‘high risk’ patients. The risks for a patient should always be identified in the pre-surgical evaluation notes. High risk patients may be smokers, HIV positive individuals, patients suffering from underlying systemic or metabolic conditions affecting healing and/ or bone metabolism, individuals with diet or nutritional problems, etc. 2. Late Failure – failure of the implant fixture following Phase II surgery and loading. a. There should be no reimbursement or discount given to the patient at this point if a failure is identified as a surgical failure or failure due to patient factors as: systemic problems, smoking habits, or poor hygiene practices. An attempt can be made to replace lost fixture(s) and/or restorations but all remakes in this instance must be done at full fee, (i.e.) full surgical as well as restorative fees. b. If the reason for failure can be identified as a result of the restorative technique, the entire case can and should be redone at no fee to the patient. Such restorative errors could be such things as: poor biomechanical design, inappropriate occlusion, a design that does not allow for adequate hygiene, etc. If the patient does not wish to undergo the entire process of implant replacement and remake of the restorations, he or she deserves a full refund for the failed treatments.Implant Manual – Revised 9/2008 13
  15. 15. XII. Recall and Follow-up of Implant Patients 1. The Restorative resident must place the patient on recall in the electronic record system once an implant patient’s treatment plan has been completed. 2. The standard time limit for implant patient follow-up at UTDB is one year after the definitive restorations are delivered. The patient should be recalled for a cleaning and examination at the six-month point. The patient is expected to pay for this service along with any necessary maintenance procedures as screw or attachment replacement. Patients are again recalled at the twelve-month point, post delivery, for a final cleaning and evaluation prior to discharge from the program. If any discrepancies are found (whether surgical or restorative), they are corrected before the patient is discharged. If necessary, the patient’s recall period can be extended. At the discharge visit patients should be given hygiene instructions again and informed of the importance of follow-up in the private sector in the future to assure the longevity of their restoration. 3. The Graduate Periodontics Program has agreed to accept the responsibility of follow- up and tissue management of patients who have failing implants, which were placed at UTDB (even if placed by another Department). In addition, they offer routine dental hygiene support for any implant patients being followed by the Dental Branch. 4. A simple discharge letter is sent at the end of a patient’s follow-up period (Attachment 6).XIII. Credentialing of Implant Faculty 1. All faculty members mentoring Graduate and/or undergraduate students in the surgical or restorative phase of dental Implantology must be credentialed in that phase of Implantology. Likewise, faculty members directly treating dental implant patients at the Dental Branch must be appropriately credentialed as a provider of that treatment. 2. Training standards must be met before a faculty member is given surgical and/or restorative implant clinical privileges. Clinical privileges are granted to faculty members at UTDB by the Credentials Committee based on the recommendation of the faculty member’s Department Chairman. This document is intended to be a minimum, common standard that the Implant Steering Committee recommends for the Chairman and the Credentials Committee to use when evaluating faculty being considered for implant related privileges. The Steering Committee recognizes that it is clearly the responsibility of the Department Chairman to assure the level of training and competency of their individual faculty members before recommending any permanent, implant related,14 Implant Manual – Revised 9/2007
  16. 16. clinical privileges. The Chairman also has the discretion to delegate the evaluation of a faculty member to another credentialed faculty member already recognized for his/her implantology expertise (both in a surgical discipline and in a restorative discipline). The Steering Committee further recommends that only provisional implant privileges be initially awarded to new faculty members to enable the Chairman to have adequate time to thoroughly evaluate that faculty member’s knowledge and performance. The length of this evaluation period again is left to the discretion of the individual Chairman. Note must be made that the ADA Commission on dental accreditation has not set implant training standards for AEGD and GPR Programs. The Commission has set forth training standards for the specialty training programs of prosthodontics, periodontics, and oral and maxillofacial surgery. These standards are generalized and are not at all quantitative. They do, however, insist that residents must accomplish “sufficient experiences to become proficient” at certain implant procedures, which the standards list. The UTDB Steering Committee recommends that surgical implant privileges be granted to graduates of ADA accredited periodontic and oral and maxillofacial surgery programs after 1998. Likewise, the Committee recommends that restorative implant privileges be granted to graduates of ADA accredited prosthodontic programs after 1998. The Committee further recommends that surgical implant privileges be granted to pre-1998 graduates of ADA accredited periodontic and oral and maxillofacial surgery programs, provided that they can produce evidence that they have met the UTDB minimum training requirements listed below for surgical procedures, at which the faculty member must be proficient. Likewise, restorative implant privileges should be granted to pre-1998 graduates of ADA accredited prosthodontic programs, AEGD and GPR programs, provided that they can produce evidence that they have met the training requirements listed below for restorative procedures, at which the faculty member must be proficient. Appropriate implant clinical privileges (surgical and/or restorative) should be awarded to faculty members who have gained diplomatic status from the American Board of Oral Implantology and Implant Dentistry. UTDB faculty members who are not qualified to be credentialed in dental implantology, but who aspire to earn those credentials can do so by: a. Working with their respective Chairman to achieve competency at the surgical and/or restorative procedures listed below. b. Attending the Graduate Implant Lecture Series given by Drs. Olvera and Weltman on Wednesday morning at 7:00 a.m. from September through December. c. Attending the Periodontal Department’s Implant course during the Spring Semester is required (for individuals seeking surgical credentials in oral implantology).Implant Manual – Revised 9/2008 15
  17. 17. d. Demonstrating competence at case selection, diagnosis, and treatment planning of oral implant cases. They must have a thorough understanding of both the fixed and removable approaches to restoration of the patient along with the advantages, disadvantages, and limitations of each approach. They must understand the procedure for preparing a case to meet the UTDB Implant Board and be able to show that they have received the Board’s approval of all the treatment plans of the patients whom they have treated/mentored at UTDB The minimum surgical experience at which a faculty member must be competent in order to receive complete surgical implant privileges are the placement of endosseous implants in the anterior as well as the posterior of both jaws. The minimum restorative experiences at which a faculty member must be competent in order to receive complete restorative implant privileges are: a. A single implant retained crown. b An implant supported overdenture. (Note: there must also be an understanding of attachment systems in general use to retain implant-supported overdentures.) Partial implant privileges (both surgical and/or restorative) can be granted as a line item only after the faculty member demonstrates satisfactory training and/or competence at that time. All faculty members who currently have credentials at UTDB for surgical and/or restorative implant privileges are “grandfathered” and allowed to continue to exercise those privileges. Those faculty members are expected to be the ones to both teach Dental Implantology as well as assess the competency of students and faculty seeking training and credentialing in implantology. All newly granted implant privileges are provisional. During this provisional period the faculty member should be mentored by their respective Chairman or his/her designee to assure that the individual is satisfactorily advancing in skill and knowledge before permanent credentialing in oral implantology is granted. All faculty members credentialed in oral implantology are subject to a review of their implant credentials pending renewal of those clinical privileges. They must provide their Chairman with a report of all of their implant related CE courses, patients treated, courses taught, research projects, and papers written, which have furthered their knowledge and skill in dental implant therapy. The UTDB Credentials Committee makes an annual report to the Implant Steering Committee listing all faculty members who are credentialed both in the restorative as well as the surgical phase of dental implantology. The report should also contain the year in which the privilege was granted. This report should be made by the beginning of each academic year (i.e. September 1).16 Implant Manual – Revised 9/2007
  18. 18. UNDERGRADUATE REQUEST FOR IMPLANT PARTS Patients name CIS Record # Date Approved by Board Board Member (Signature/CIS #) Surgical Program or Department (circle one) OMFS Perio Restorative Program or Department (circle one) UG Implant Program Date of Stage I Surgery Arch (circle one) Max Mand Both Surgical Resident (name/#) Attending Faculty (name/#)Stage I FIXTURES - MANUFACTURER Clinical Services Use Only Quantity Type/Size Product # Total Fee $ Quantity Type/Size Product # Payment verified by Quantity OrderedProduct # Type/Size Received Quantity Type/Size Product # Date of Stage II Surgery Number of Abutments to be Uncovered Surgical Resident (name/#) Attending Faculty (name/#)Stage II HEALING PARTS - MANUFACTURER Clinical Services Use Only Quantity Type/Size Product # Total Fee $ Quantity Type/Size Product # Payment verified by Quantity Type/Size Product # Ordered Quantity Type/Size Product # Received Restorative Resident (name/#) Attending Faculty (name/#) ABUTMENT - MANUFACTURER Quantity Type/Size Product # Clinical Services Use Only Quantity Type/Size Product # Quantity Type/Size Product # # Implants to be restored Quantity Type/Size Product # Fee $ ANALOGS - MANUFACTURERS Quantity Type/Size Product # Payment verified byRestorative Phase Quantity Type/Size Product # Ordered Quantity Type/Size Product # Quantity Type/Size Product # Received IMPRESSION COPINGS - MANUFACTURE Notes Quantity Type/Size Product # Quantity Type/Size Product # Quantity Type/Size Product # Quantity Type/Size Product # ATTACHMENTS - MANUFACTURER Quantity Type/Size Product # Quantity Type/Size Product # Quantity Type/Size Product # Quantity Type/Size Product # OTHER SUPPLIES OR COMMENTS Attachment 1 Implant Manual – Revised 9/2008 17
  19. 19. Agreement and Consent for Placement of Dental ImplantsPATIENT NAME CHART NO. _____DATE ___________1. This is my consent for Dr. and/or any doctor who is working with him/her to perform surgery upon me, to insert metal root form dental implants in my upper and/or lower jaw as follows: ______________________________________________________________________________________ ___________________________________________________________________________________ Bone or soft tissue grafting (as applicable) at ADDITIONAL FEES ( Fee range: $ _____ to $_______) ______________________________________________________________________________________ ______________________________________________________________________________________2. I understand that incision(s) will be made inside my mouth for the purpose of placing one or more metal root form structures in my jaw(s) to serve as anchor(s) for a missing tooth or teeth or to stabilize a crown (cap), denture or bridge. I acknowledge that Dr. (surgeon)has explained the procedure, including the number and location of the incisions to be made, and the risks/ complications noted in items 3- a or b below. I understand that the crown (cap), denture or bridge will later be attached to this implant by Dr. (restorative dentist) and that the cost for all restorations is not included in the charge for this procedure.3. a. Failure to Osseointegrate (the bone does not attach to the implant). I understand that implant success is based on: (1) quality and quantity of available bone (this has been explained to you) (2) posterior location in the mouth has a lower percentage of overall success (explained to you) (3) infections causing the loss of the implant(s) or graft(s) Should an implant fail to osseointegrate for any of the above reasons and a new implant can be placed, the implant will be replaced at a reduced fee of 50% per implant. Any additional grafting procedures required to remedy the situation will be at 50% of usual fees. Intravenous sedation, if desired, will be charged at the usual fee. No refunds or discounts will be given for intravenous sedation or bone grafting materials associated with initial surgery. b. High Risk Conditions. I acknowledge that one or more of the following conditions exist(s) in my case, and understand that because of this/these condition(s), a higher risk of failure of implants exists. i. ____ Connective tissue disorders ii._____Diabetes mellitus iii. ____Head and neck cancer radiation iv. ____Immunocompromised health states Initial all that apply v. _____Osteopenia/osteoporosis vi. ____Smokers vii. ____Clenching, bruxingI understand that because I have one or more of these high risk medical conditions and that if the implant(s) or any graftsassociated with the implants fail, that no refund or reimbursement for treatment will be applicable.4- No guarantee or assurance has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction. I believe that the doctor adequately has explained the potential risks to me.5- If an implant fails after the restoration ( crown, bridge or overdenture) has been placed , the case will be reviewed bythe Faculty Implant Board at the Dental Branch regarding further management.6- I have been informed of the alternatives to the use of dental implants and / or bone grafting.7- I understand that any treatment of the implant and/or the surrounding bone or gum tissue AFTER the prosthesis hasbeen placed will be considered maintenance therapy and will be at an additional charge.8- Because successful treatment often depends upon compliance with a doctor’s instructions, I agree to cooperate completely with the recommendations of the doctor and/or his/her assistant while I am under his/her care, realizing that any lack of same could result in a less than optimum result. Attachment 218 Implant Manual – Revised 9/2007
  20. 20. 9- Dr. has explained to me that there are certain inherent and potential risks in any treatment or procedure, and that in this specific instance such operative risks could include, but are not limited to: 1. Postoperative discomfort and swelling that may necessitate several days of home recuperation. 2. Damage to adjacent teeth, if applicable. 3. Significant bleeding that may be heavy or prolonged. 4. Postoperative infection or abscess requiring additional treatment. This may result in the loss of bone grafts and/or the implant(s). 5. Opening of the sinus (a normal cavity situated above the upper teeth) during the placement of implants or bone grafts possibly resulting in infection or requiring additional surgery, e.g. sinus lift procedure 6. Poor or delayed healing which may result in additional surgical procedures. 7. Fracture of the lower jaw if the jaw is atrophic (severely resorbed) or a serious infection occurs. 8. Injury to nerves near the treatment site which may cause pain, numbness or tingling of the lips, chin, face, mouth, teeth and/or tongue. This may persist for several weeks, months or, in unusual instances, permanently. 9. Loss of or reduction in the ability to taste. 10. Stretching of the corners of the mouth with resultant cracking and bruising. 11. Loss of the dental implant due to failure to osseointegrate. 12. Other ____________________________________________________________________________________I also understand that any of these treatment complications may necessitate additional medical, dental, or surgicalrecuperation at home or even in the hospital.10. ANESTHESIA: (If you have opted to have your surgical procedure performed using intravenous drugs the following applies) I agree and understand that I am not to have and/or have not had anything to eat or drink for hours before my surgery. I consent to administration of such local anesthesia (numbing injections), and/or sedation and/or general anesthesia as deemed necessary by the doctor and/or his/her designated assistants to accomplish the proposed procedure as discussed with me. a. Medications, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and coordination, which can be increased by the use of alcohol or other drugs; thus, I have been advised not to operate any vehicle, automobile or hazardous devices, or work, while taking such medications and/or drugs, or until fully recovered from the effects of the anesthetic medication and drugs that may have been given to me in the office or hospital for my care. I agree not to drive myself home after surgery and will have a responsible adult drive me or accompany me to my home after my discharge from surgery. b. I understand that certain anesthetic risks, which could involve serious bodily injury, are inherent in any procedure that requires a general anesthetic. c. If any unforeseen condition should arise in the course of the operation, calling for the doctor’s judgment or for procedures in addition to or different from those now contemplated, I request and authorize the doctor to do whatever he/she may deem advisable. d. I have had an opportunity to discuss and have made a full disclosure of my past medical and health history including any serious problems and/or injuries. This includes any past or present substance abuse. 11. I authorize the making and use of photos, slides, x-rays and TV videotape at the Dental Branch faculty’s discretion to be potentially used for educational or professional purposes. If any of these are to be used for other than educational or professional purposes, then a separate release will be obtained.I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDSWITHIN THE ABOVE CONSENT TO THE OPERATION AND THE EXPLANATION REFERRED TO OR MADE, AND THATALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND INAPPLICABLEPARAGRAPHS, IF ANY, WERE STRICKEN BEFORE I SIGNED. Witness Patient or Guardian Date Witness Doctor DateImplant Manual – Revised 9/2008 19
  21. 21. Memorandum of Understanding forDental Patients in The GraduateProsthodontics Program The University of Texas Houston Dental Branch Memorandum of Understanding for Space Available Dental Care in the Graduate Prosthodontics ProgramI, , understand that dental patients are accepted at The University of Texas - Houston Dental Branch in thePostgraduate Prosthodontics Program on a space available basis to meet the needs of the graduate and undergraduateteaching programs. I further understand that:Acceptance for treatment does not entitle a patient or family members to follow-up or on-going care. Acceptance for careis for a specific treatment at this specific point in time. That specific treatment is to be itemized, along with an estimate,on the Treatment Plan in the dental health record. Further, the Treatment Plan must be cosigned by the patient and thestudent’s mentor before any treatment is commenced. I f a patient is only accepted for partial treatment, that fact must beclearly pointed out on the Treatment Plan and the patient understands that they must seek completion of the treatmentfrom a source outside the school.Though the Dental Branch may follow some patients for an indefinite period of time due to the uniqueness of their case,the Program does not have the capability to follow most of its patients once they have been restored. It is understoodthat dental patients need regular follow-up and maintenance after undergoing complex dental rehabilitation. Follow-up isthe patient’s responsibility. Ultimately patients must seek follow-up and maintenance care outside the school. The DentalBranch only follows patients for maintenance and/or repairs for one year following the completion of their TreatmentPlan. A fee is charged for such maintenance or repairs.The treatment must strictly conform to the needs of the training program and must be consistent with the standardsrecognized by the dental profession. Individual appointments may be unusually long and the total course of treatmentmay be prolonged over many months. When appointments are made in a series to meet a residents’ class schedule,they cannot be changed.Certain procedures may be accomplished by faculty members at their discretion when they deem it necessary fordemonstration, illustration, evaluation, proficiency or as preparation for a subsequent phase of treatment. Depending onthe needs of the program, the patient’s treatment may be accomplished by several residents rather than by just oneprovider.It is the patient’s responsibility to provide timely notification of address or telephone number changes. Patients can bedismissed from further treatment at the Dental Branch for chronic tardiness and/or failed appointments.This agreement does not constitute a commitment on the part of the Dental Branch or Graduate Prosthodontics Programto provide treatment. If, after thorough diagnosis and treatment planning, a patient is found to be an acceptable teachingcase, the patient is presented with a written Treatment Plan and estimate for services. It is at that time that the schooland patient commit to the Treatment Plan. Patients are encouraged to seek care elsewhere (as in a private practice) ifexpediency is a concern or if their goals in treatment are not the same as those presented in the Treatment Plan.Once treatment is begun, there is no assurance that all the treatment that a patient needs will be completed. Facultymentors are obligated to determine, and tell patients at what point the continuation of treatment or follow-up is no longerbeneficial to the training programs. If and when treatment is terminated, patients are counseled on their other dentalhealth needs and are advised to seek treatment and follow-up care from an outside source, at their own expense. Attachment 3 p 1 20 Implant Manual – Revised 9/2007DBGPMU Page 1 of 2 DB-C010 (2/2008)
  22. 22. Memorandum of Understanding forDental Patients in The GraduateProsthodontics Program Implant Manual – Revised 9/2008 21
  23. 23. Memorandum of Understanding forIt is understood that payment is required for services (according to the estimate) before each procedure begins.Delinquency in payment for services can lead to dismissal of a patient from the program.I authorize The University of Texas - Houston Dental Branch and all individuals acting pursuant to its authority to record,videotape, audiotape, film and/or photograph my participation and appearance during the execution of the agreed uponTreatment Plan. I further authorize them to exhibit or distribute such recordings in whole or in part, without restriction orlimitation, for any official purpose including, but not limited to medical/dental education or publication in professionaljournals which The University of Texas - Houston Dental Branch or those acting pursuant to its authority deemappropriate and necessary. Dental Patients Treated Jointly by The University of Texas Dental Branch at Houston And Private Practice Dentists (Restorative Dentist) RE: Dental Implant and Restorative Treatment for (Patient Name) 1. The Restorative Dentist agrees to the following when referring the above named patient to the Dental Branch for surgical placement of implants: a) submit a written treatment plan and/or alternatives if applicable. Signature of Patient or Sponsor b) Date provide mounted study models (hinge articulation is acceptable) clear dentures if an edentulous patient or diagnostic wax-up of a partially Prosthodontic Graduate Resident/Preceptor: edentulous patient. c) fabricate the surgical stent(s) indicating implant position inclination. d) assume responsibility for completion of all restorative care of Prosthodontic Graduate Resident/Preceptor Signature Date patient. Note: The Dental Branch is not responsible for any restorative treatment or follow- up/maintenance of restorative treatment. Faculty: 2. The Dental Branch agrees to the following in accepting referral of the above named patient from the Restorative Dentist for surgical placement of implants. a) review the proposed treatment, including all records and surgical stent(s), prior to acceptance of the patient for surgical treatment. Note: This review is performed by the school’s Implant Board, which Faculty Signature has final authority for case acceptance. b) consult with the Restorative Dentist, as appropriate when necessary. c) provide surgical phase of dental implant care by: (circle one) [Oral and Maxillofacial Surgery], [Periodontics], or [other: ]. d) refer the patient back to the Restorative Dentist for restorative phase. The patient is aware of the agreed upon relationship, and he/she has indicted suchAttachment 3 p 2 understanding by affixing his/her signature below. 22 Implant Manual – Revised 9/2007
  24. 24. Restorative Dentist DatePatient DateSurgeon (Faculty) Date Attachment 4Implant Manual – Revised 9/2008 23
  25. 25. SAMPLE IMPLANT TREATMENT PLAN #1 SINGLE TOOTH REPLACEMENTCODE DESCRIPTION FEE UNDERGRAD GRADSURGICAL PHASE I - IMPLANT PLACEMENT06000 Implant Work-up -------- $190.0005988/06 Surgical Splint $50.00 140.0006010/06 Surgical Placement of Implant 350.00 670.0009241/05 IV Sedation - first one-half to two hours 75.00 75.0009242/05 IV Sedation - each addition 30 minutes 25.00 25.00SURGICAL PHASE II - IMPLANT UNCOVERING06015/06 Surgical Exposure of Implant N/C N/CRESTORATIVE PHASE06020/06 Abutment, Restorative N/C* Variable06081/06 Abutment Parts N/C* Variable06066/06 Implant Supported PFM Crown 359.00 575.00 Implant Supported Metal Crown 359.00 575.00OTHER SURGICAL PROCEDURES THAT MY BE REQUIRED (LISTED AT POSTDOCTORAL FEES)04914/05 Hard Tissue Grafting Material .375g to 1.5g, per vial $98.00 $150.0004915/05 Hard Tissue Grafting Material 2.0g to 3.0g vial 282.00 300.0004916/05 Fixation Screws, each (if necessary) 50.00 Variable04999/05 Guided Bone Regeneration Variable VariableMAINTENANCE PHASE00120/06 Periodic Oral Evaluation $14.00 $29.0001110/06 Prophylaxis, Adult1 25.00 60.0001330/06 Oral Hygiene Instructions N/C N/C06080/06 Implant Maintenance2 37.00 85.0006199/06 Screw Replacement (if broken) Variable VariableNOTES1 May select 04910 - Periodontal maintenance instead of 00120 and 01110 if patient is a Type II, III, or V periodontal patient in post-treatment phase.2 Includes removal of prosthesis(es), cleansing of prosthesis(es) and abutment(s), and reinsertion of prosthesis(es).*Provided by Implant Company Attachment 5 p124 Implant Manual – Revised 9/2007
  26. 26. SAMPLE IMPLANT TREATMENT PLAN #2 TWO-IMPLANT OVERDENTURECODE DESCRIPTION FEE UNDERGRADSURGICAL PHASE I - IMPLANT PLACEMENT06000 Implant Work-up ------------- $190.0005988/06 Surgical Splint $50.00 140.0006010/06 Surgical Placement of Implant 350.00 670.0009241/05 IV Sedation - first one-half to two hours 75.00 75.0009242/05 IV Sedation - each addition 30 minutes 25.00 25.00SURGICAL PHASE II - IMPLANT UNCOVERING06015/06 Surgical Exposure of Implant N/C N/CPROSTHETIC PHASE06020/06 Abutment, Restorative N/C* Variable06081/06 Abutment Parts N/C* Variable05730 or05740/06 Reline Denture (chairside) 57.00 $200.0006053/06 Implant/Abutment Supported Complete Denture 251.00 600.00OTHER SURGICAL PROCEDURES THAT MY BE REQUIRED (LISTED AT POSTDOCTORAL FEES)04914/05 Hard Tissue Grafting Material .375g to 1.5g, per vial $98.00 $150.0004915/05 Hard Tissue Grafting Material 2.0g to 3.0g vial 282.00 300.0004916/05 Fixation Screws, each (if necessary) Variable Variable04999/05 Guided Bone Regeneration 190.00 Variable VariableMAINTENANCE PHASE00120/06 Periodic Oral Evaluation $14.00 $29.0001110/06 Prophylaxis, Adult1 25.00 60.0001330/06 Oral Hygiene Instructions N/C N/C06080/06 Implant Maintenance2 37.00 85.0006199/06 Screw Replacement (if broken) Variable VariableNOTES1 May select 04910 - Periodontal maintenance instead of 00120 and 01110 if patient is a Type II, III, or IV periodontal patient in post-treatment phase.2 Includes removal of prosthesis(es), cleansing of prosthesis(es) and abutment(s), and reinsertion of prosthesis(es*Provided by Implant Company Attachment 5 p 2Implant Manual – Revised 9/2008 25
  27. 27. (DATE)(NAME)(ADDRESS)(CITY/STATE/ZIP)Dear Patient:Now that your dental treatment has been completed, we at the Dental Branch would like to take this opportunityto thank you for your contribution as a patient and review your follow-up care.Our primary concern is helping you maintain your oral health. To do so, our {name of restorative program} willfollow you for the next 12 months and would like to see you every 6 months. At these visits, we will perform anoral examination, cleaning, x-rays (if indicated), and any other procedures deemed necessary. Additional visitswith {name of surgical program} may be necessary, and we will coordinate all appointments for you. There is afee for this recall.It is also essential that you practice good home care, such as brushing and flossing, and follow any additionalinstructions already given to you. This may include nighttime removal of dentures, use of a bite guard, etc.Should you have any dental emergency during your follow up period, please contact us immediately at (713)500-{0000}. We will make every effort to resolve your problem as quickly as possible.Again, we appreciate the opportunity to serve you. Please note that at the end of your follow up period we willprovide you with a final evaluation. We will then release you from the program, at which time you must arrangeto continue your maintenance therapy with a private dentist of your choice to ensure continued good oral health.Should you have any questions or need further information, please contact Ms. Lorraine Alexander in PatientServices at (713) 500-4212.Sincerely,Peggy O’Neill, DDSInterim Associate Dean for Patient Carec: Patient Record [Treating Program(s)] Attachment 626 Implant Manual – Revised 9/2007