Introduction

General dental practitioners (GDPs) are fortunate to have a host of roles in their patients' oral health journeys, from delivering primary care to facilitating and managing patients through a specialist referral for treatment. This is extremely prominent in the facet of implant dentistry, where the long-term upkeep of the treatment is vital to success, and patients tend to see the implantologist for the initial treatment and perhaps annual reviews, whereas the generalist is likely to see the patient more regularly, giving the opportunity to catch complications sooner. Implantology can also be an area of dentistry that is most obscure for generalists as it falls outside of any great detail of teaching at the undergraduate level. For the general dentist, surgical placement and knowledge tend to come as the result of highly targeted continuing professional development for those outside of the periodontic or prosthodontic training pathways and so can remain a daunting topic for many GDPs.

There are a number of stops along the implant journey where our communication, both with the patient and with those receiving our referral, is vital. These can essentially be broken down into:

  • Discussion of options with the patient before agreeing to referral

  • Referral contact with the implantologist

  • Management of any post-surgical concerns

  • Long-term maintenance, including encouraging reviews and reassessment as required.

Given these considerations, it is vital to communicate well and build good relationships with the implantologists to whom you refer.

Before referral

When identifying a patient for a potential implant referral, it is good practice to discuss all relevant, suitable options for the replacement of one or multiple missing teeth. This can range from no treatment to orthodontics, dentures, bridges and implants. When discussing implant care, however, it is invaluable to already have an awareness of your desired implantologist's workflows and preferences when dealing with various situations to be able to quote the patient correctly with regard to treatment timeframes and costings. This will allow the patient to make a more informed decision as to whether the implant will be a plausible option for them in relation to the alternatives. This can be invaluable in maintaining a good relationship with the implantologist by ensuring patients do not attend consultations when the final terms are not suitable.

Medical considerations

There are a number of factors to consider when assessing implant placement:

  • The medical status of the patient and whether they are suitable for the possible surgical requirements of implant placement

  • Medications that may have an effect at the time of surgery, such as anti-coagulation medication, should be noted1

  • Medications that may affect healing, such as bisphosphonates and steroid use, should also be taken into consideration2

  • Other conditions affecting the systemic health of the patient, as well as being risk factors for peri-implantitis, such as uncontrolled diabetes and smoking, must also be noted and discussed with the patient

  • Another area which is becoming increasingly prevalent in research is the importance of Vitamin D in dental implantology, with deficiency shown to result in a reduction of bone formation, as well as bone-to-implant contact, both crucial in osseointegration. This is particularly the case when other co-morbidities such as diabetes are involved.3 Given the prevalence of vitamin D deficiency in the UK, this may form an important part of the pre-surgical screening in implant care.

Oral health considerations

The patient's overall oral health and risk factors must also be noted to ensure they are a suitable candidate. Periodontal risk factors have already been mentioned, with a history of periodontal disease leading to a 10x increased risk of peri-implantitis when compared to those without a history of periodontal disease.4

It is important to consider warning the patient that they may need to be referred to a periodontist first or will be by the implantologist; again, it is valuable to know the implantologist's preference here to avoid unnecessary referrals or delays.

Current status of the space

The next factor to consider is whether the site is healed or whether the tooth or root is still present. This is described with the classification of implant placement:5

  1. 1.

    Immediate placement - placing the implant within the extraction site

  2. 2.

    Early placement with soft tissue healing - typically 4-8 weeks post-extraction

  3. 3.

    Early placement with partial bone healing - typically 12-16 weeks post-extraction

  4. 4.

    Late placement − six months or more healing - this includes fully healed sites.

If the tooth is still present, it is imperative to know the implantologist's preference for extracting the tooth themselves or having this done by the referring clinician. Is an immediate placement suitable?6 Is there chronic periapical pathology that would require healing? Would the patient benefit from ridge preservation protocols and delayed placement?7 Many implantologists prefer to make this decision and therefore consider referring to the implantologist with the tooth in situ. Figure 1 shows immediate placement and grafting in a site with chronic periapical infection.

Fig. 1
figure 1

a) Planning highlighting pathology. b) Sectioning of the roots for atraumatic extraction. c) Implant placement using guided surgery. d, e) Placement and grafting. f, g) Composite healing abutment. h, i, j, k) Definitive restoration placed

Full size image

Regarding healed sites, a suitable history is important, as well as radiographs. How long ago was the tooth extracted and how much bone has been lost?8 Will an additional grafting procedure be required? Figure 2 shows a case illustrating replacement of hypodontic maxillary laterals, a situation where lack of labial bone is a common occurrence.

Fig. 2
figure 2

a) CBCT with overlaid planning illustrating lack of labial bone. b) Placement before grafting showing extent of grafting required. c) Illustration of angulation of placement. d) Definitive restoration

Full size image

Another consideration is if there has been any movement of the teeth, and is the space still suitable, either restoratively or surgically? Would orthodontics or alteration of the crown be beneficial? Similarly, has there been any dento-alveolar compensation leading to insufficient restorative space? Figure 3 illustrates a case where localised orthodontic intrusion was used to restore restorative space in the opposing arch.

Fig. 3
figure 3

a, b, c, d) Using orthodontics to create restorative space

Full size image

Posteriorly, has there been encroachment of the maxillary sinus floor during the healing process? Will a sinus procedure be required to produce sufficient bone for placement? (Fig. 4). All of these factors can greatly alter the duration and complexity of the treatment recommended, which may make the option unsuitable for patients, either financially, logistically, or surgically.

Fig. 4
figure 4

a) Planning illustrating proximity to maxillary sinus. b) Lateral window sinus graft

Full size image

Aesthetic considerations

Another factor to consider is the aesthetic challenges that may be present. This will include an assessment of the patient's smile line; the higher the lip line, the more aesthetically challenging the case can become. This is particularly challenging when the gingival phenotype in the area is also thin, which may require soft tissue grafting to allow suitable amounts of keratinised tissue.9 Figure 5 illustrates an anterior implant placement that required soft tissue grafting. This is vital for not only the aesthetic but the long-term prognosis of the restoration, with a thick cuff of keratinised tissue required for cleansability.10

Fig. 5
figure 5

a, b) Presentation of failing upper right central incisor. c) Planning for guided surgery. d) Harvested de- epithelialised. e) Connective tissue graft at time of immediate placement. f) Immediate provisional and graft in situ. g) Scanning for definitive restorations. h) Definitive restorations

Full size image

It is important to note in the aesthetic region that gingival surgery may not be considered just for the site in question, but gingival and restorative treatment may also be considered and discussed as a part of a wider treatment plan rather than a single-tooth approach.

Aesthetic concerns may also require staged provisionals with multiple visits to achieve the desired emergence profile. This can then also add a significant time and cost factor to the treatment.11 For anterior restorations, if the implants are unlikely to be immediately loaded or restored with a temporary crown on the day of surgery, then knowing the implantologist's preferred method of replacing the tooth and whether they would like the referrer to provide it is important.

The consultation process

The final stage before referring is to have an idea of the consultation process and, of course, the cost of treatment. Will there be photographs taken, an intra-oral scan, additional radiographs such as cone beam computed tomography (CBCT) and is this included in the consultation or subject to additional charges? It is also worth considering the implantologist's desired review and recall periods, both with themselves, the GDP and the hygiene team, to ensure the patient can commit to this. Once the patient has agreed to explore this avenue, then it is time to consider the content of the referral.

Point of referral

Once this information has been gathered suitably, then the referral process should be an easy one; many referral centres will have their own form or layout, which can be easily followed. If not, creating a template, both in the notes and in the referral to act as a checklist, can be invaluable.

An ideal referral letter from a dentist to an implantologist should contain essential information about the patient's dental health and the reasons for the referral. Appendix 1 below is an example implant referral to use as a starting point.

The referrer could also make a note if they would like to be present at the consultation or if they wish to be contacted before the consultation. Sometimes there might be an element of the referral that the referrer may prefer to discuss with the implantologist before the patient sees them, especially in scenarios where there may be some friction from the referred patient.

Lastly, be specific if you want to restore the case as the referrer - importantly, let the implantologist know what level of involvement you wish to have and, where appropriate, collaborate. However, respect that sometimes the best treatment for a referred patient may not be what you initially think.

Management of post-surgical concerns

Depending on the location of the implantologist in comparison to yourself and the patient, or depending on their own availability, the referrer may see the patient post-surgery with any number of concerns. Having an idea of the implantologist's post-operative instructions and guidance can be useful to remind and reassure patients and relieve any concerns they may have. Appendix 2 shows an example of typical post-operative instructions.

Long-term maintenance

At the final review appointment, before discharging the patient back to the referring dentist, there should be a candid and thorough discussion regarding the level of hygiene required to keep their dental implant(s) healthy. Demonstrate the use of interproximal devices and X-floss and advise the patients that they must clean their implant(s) for at least 30 seconds and use interproximals and floss at least once a day. Patients may be advised to contact us directly if there is a problem with the implant, especially screw loosening, and reinforce the need for close monitoring.

It may be considered good practice for the patient to attend a yearly review with the implantologist, including periapical radiographs, as well as at least two hygiene appointments specific to their dental implants each year. These appointments are in addition to the hygiene they would be having with the referring GDP clinic. The first is recommended 4-6 weeks after the delivery of the implant restoration(s) so that their home cleaning protocol can be reviewed and further advice given if required.

The patient should also be made acutely aware that they must continue to see their own GDP regularly. Regardless of this recall routine, there are a number of checks required from GDPs that should be considered with every implant seen in practice. This way, if concerns are noted, the patient can be encouraged to return sooner to the implantologist for review.

The best thing to do when reviewing dental implants and implant restorations is to consider the two parts as separate but connected items.

The restoration should be checked for movement. This could be caused by a number of issues, including loose crown, loose abutment, screw loosening and loss of integration. A gentle percussion test is helpful with this. The implant crown should have a nice crystalline ring on gentle percussion with a metal instrument. If not, then it is possible that the diagnosis is a loose restoration or even a failed implant.12

The occlusion should be checked and, if necessary, refined and polished.13 The contacts should be checked over time; it is possible that these can open with continued skeletal growth. The integrity, shade and shape of the restoration should all be reviewed too, as fractures to the restorative material can occur. The composite restoration for the screw access hole may need to be replaced, ensuring to check the occlusion again after replacing.

The gingival health and emergence profile of the dental restoration and implant can be initially evaluated via digital palpation of the region buccal to the implant. If the implant is healthy, there will be no bleeding or suppuration. This should be repeated on all sides of the implant. Sometimes, a small amount of white exudate can be produced that is not pus or blood. The GDP can also check with interproximal cleaners - these should be able to be used without creating any bleeding. If there is concern about the health of the dental implant, then this is the time to take a radiograph.14 This can form a part of the overall recall examination assessment of oral hygiene and periodontal screening.

If there is bleeding from the implant but no discernible bone loss, then gently clean the implant restoration with hand instruments, being careful to just remove the plaque and biofilm, irrigate with chlorhexidine or iodine, reinforce oral hygiene instruction and get the patient to reinstate rigorous home cleaning, for 7-10 days. If there is no improvement and the GDP is not confident in their ability to treat peri-implantitis, it would be recommended to refer back to the placing clinician, or if they are not available, to a colleague with this experience.

Even if the implant looks to have an issue, one should still be wary of probing. If the radiograph shows early (minimal) bone loss, then it is sometimes possible for demineralised bone to reappear when decontamination therapy is used.15

What can the GDP manage and when should they refer?

It is often considered that the last person to touch a problem with a patient gets to own it. So, while simple things like replacing a missing composite from a screw access hole should be easy to do, do not forget to place some polytetrafluoroethylene tape before you do it.

Often, if there is a problem, it is valuable to be able to diagnose the cause of the problem. If this is easily done, or the GDP feels confident, then it is a potential win for all involved not to refer back to the implantologists. Patients are usually more than happy enough to get referred back. It shows that the GDP is concerned about their patients' best interests and also allows for the implantologist to assess and manage the situation if it is delicate.

figure 6

Appendix 1 Sample implant referral letter

figure 7

Appendix 2 Sample post-operative instructions