DOH implant privileging oral assessment prep

Knowledge: The thromboembolic risk of stopping an anticoagulant usually outweighs the bleeding risk of a single implant, so I would not stop apixaban for a week, and bridging is not used for DOACs in dentistry. Under the SDCEP guidance (2nd edition, 2022), dental implant surgery, as a flap-raising procedure, is listed among the higher-bleeding-risk procedures, and for twice-daily apixaban or dabigatran the advice is to miss the morning dose on the day of treatment and take the evening dose as normal, provided haemostasis has been achieved, whereas for once-daily rivaroxaban or edoxaban taken in the morning the morning dose is delayed until after treatment, once haemostasis is achieved. If he were on warfarin instead, I would check the INR ideally within 24 hours, and no more than 72 hours, before surgery and proceed if it is stable and below 4, liaising with the anticoagulation clinic otherwise. Renal function matters because apixaban and especially dabigatran accumulate in renal impairment, so I would ask about recent eGFR in this diabetic patient. Anatomically, the lingual concavity at 36 is the main hazard: perforating the lingual cortex can injure branches of the facial or lingual arteries and cause a sublingual or submandibular haematoma, which is far more dangerous in an anticoagulated patient than oozing from the socket. CBCT lets me measure the angulation needed to stay within bone, often meaning a slightly buccal or more upright trajectory and a shorter implant.

Management: I would confirm the indication, dose and timing of apixaban, kidney function and any antiplatelet co-therapy, and inform his prescriber of the plan rather than asking permission to stop. I would book an early morning appointment early in the week so that any problem arises during working hours, and plan the osteotomy from the CBCT with a surgical guide that respects the lingual concavity, using a drill stop and checking angulation clinically. On the day he would omit the morning apixaban dose. I would use a minimal flap, careful lingual retraction and palpation of the lingual plate during drilling, achieve primary closure with sutures, and apply pressure with gauze and an oxidised cellulose or collagen haemostat where needed, then keep him in the practice until haemostasis is confirmed, advising him to take his usual evening dose only if the site is not bleeding. Analgesia would be paracetamol, avoiding NSAIDs because they add to bleeding risk with anticoagulants. He would leave with written instructions, a contact number, and clear advice to call emergency services if he notices floor-of-mouth swelling, tongue elevation or difficulty breathing or swallowing, with a review the next day by phone.

Ethics and communication: Consent should include the bleeding risk, the rare but serious possibility of a floor-of-mouth haematoma, nerve injury and implant failure, and alternatives such as a bridge, a removable denture or leaving the space. I would correct his friend's advice gently and explain that stopping his anticoagulant could cause a stroke, documenting this conversation and the agreed medication plan. Changes to anticoagulation outside the guidance are a decision for his prescribing physician, and I would record the communication with them. If his medical picture is complicated, for example poor renal function or combined antiplatelet therapy, I would consider referral to a hospital-based oral surgery service.

Reference: Scottish Dental Clinical Effectiveness Programme. Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs, 2nd edition (2022); Misch's Contemporary Implant Dentistry, 4th edition.

Knowledge: The widely taught safety margin is at least 2 mm between the apex of the osteotomy and the roof of the inferior alveolar canal, so with 8.5 mm of bone I have about 6.5 mm of usable height. I must also allow for the drill tip, because many twist drills cut beyond the nominal length of the implant, by up to about 1 mm depending on the system, so a 6 mm implant is the realistic maximum, which falls in the short implant category (6 mm or less) as defined in ITI consensus work. Short implants in the posterior mandible have shown survival comparable to longer implants placed in vertically augmented bone over short- to medium-term follow-up, although the ITI consensus notes greater variability in survival than with standard-length implants in native bone, with less morbidity, fewer complications and lower cost than vertical augmentation, although longer-term data are more limited. A wide-diameter implant, for example 4.8 to 5 mm in 7.5 mm of crestal width, would leave about 1.25 to 1.5 mm of bone buccally and lingually, which is at the lower limit; I would check the lingual concavity because the submandibular fossa can reduce the effective width further down. Mesiodistally, 10 mm allows a 5 mm implant with at least 1.5 mm to each adjacent root. The crown-to-implant ratio will be unfavourable, but this is less important than once thought if the occlusion is controlled, and the over-erupted upper molar needs addressing to create an acceptable occlusal plane and interocclusal space. CBCT measurements carry some error and the canal can be hard to see in low-density bone, so I would trace the canal in cross-sectional slices rather than relying on a panoramic reconstruction.

Management: I would complete a restoratively driven plan: diagnostic wax-up, assessment of the over-erupted 16 (with options such as enameloplasty, orthodontic intrusion or a crown, discussed with the patient), and a CBCT-based digital plan with the canal traced in cross-sections. I would use a fully guided or pilot-guided surgical guide with drill stops calibrated to the system's drill overshoot, and plan a short, wide implant, for example 5 x 6 mm, keeping at least 2 mm from the canal. During surgery I would use a periapical radiograph with a depth gauge before final drilling if not fully guided, and avoid infiltration-only reasoning: I would use an inferior alveolar nerve block as normal, because the safety margin, not patient feedback, protects the nerve. Healing would usually be conventional loading after about two to three months depending on primary stability, with a single screw-retained crown and narrow occlusal table, light centric contact and no lateral interferences. If the patient wants a longer implant or the restorative space requires it, I would refer her to a specialist for vertical ridge augmentation rather than attempt it myself, and I would also discuss a conventional bridge from 45 to 47.

Ethics and communication: Consent must explain the risk of inferior alveolar nerve injury causing numbness or pain of the lip and chin, which is uncommon with proper planning but can be permanent, as well as the alternatives of a bridge, a removable denture, no treatment, and referral for augmentation with a longer implant. Because this is elective treatment in a healthy patient, I would document the CBCT measurements, the chosen margin and the reasoning for implant length in the notes, as this is central to defending the decision if a complication occurs. Treating the over-erupted opposing tooth adds cost and time, which I would present honestly rather than ignore. If the guide or system is unfamiliar to me, practising within my competence means planning a case I am confident in or referring.

Reference: ITI Treatment Guide series; ITI Consensus Conference statements on short implants; Misch's Contemporary Implant Dentistry, 4th edition.

Knowledge: Under the 2017 World Workshop classification, peri-implant mucositis is bleeding on gentle probing, with or without suppuration, erythema or swelling, and no bone loss beyond the initial remodelling, so the first molar implant is mucositis, which is reversible with plaque control. Peri-implantitis requires bleeding or suppuration on probing, increased probing depth compared with previous examinations and bone loss beyond initial remodelling; where no previous data exist, the case definition is bleeding or suppuration with probing depths of 6 mm or more and bone levels 3 mm or more apical to the most coronal part of the intraosseous implant. The second molar implant meets the definition with baseline data, and it also meets the no-baseline thresholds. Probing depth around implants is influenced by mucosal thickness and restoration design, so the change over time matters more than the absolute value, and gentle probing at around 0.25 N with a standard probe does not damage the peri-implant seal. His history of periodontitis, smoking, poor plaque control and lack of supportive care are the established risk indicators, and peri-implantitis tends to progress faster and in a non-linear pattern compared with periodontitis. Defect morphology guides surgery: circumferential contained intrabony components are amenable to regenerative approaches, whereas horizontal or dehiscence-type defects are treated with resective or access surgery.

Management: For both implants step one is the same: risk factor control including smoking cessation advice with referral to a cessation service, oral hygiene instruction with interdental brushes or a power brush adapted to the implant crowns, checking that the crowns allow cleaning access, and professional mechanical debridement of the implant surfaces. For the mucositis I would re-evaluate at around two to three months, expecting resolution of bleeding, and place him on supportive care. For the peri-implantitis I would add non-surgical submucosal instrumentation and, if possible, remove the screw-retained crown to improve access, and re-evaluate after a healing interval. Persistent bleeding or suppuration with probing depths of 6 mm or more means step three: surgical access with implant surface decontamination and either regenerative treatment of the contained defect or resective treatment with implantoplasty for supracrestal threads, which I would refer to a periodontist if outside my competence. Systemic antibiotics are not recommended as a routine adjunct to non-surgical therapy, and an implant that becomes mobile or has lost most of its support is removed. Supportive care at three to four monthly intervals with charting at each visit and radiographs when probing changes is essential, as his two-year gap in maintenance contributed to the problem.

Ethics and communication: He needs a clear explanation that one implant has a reversible gum problem and the other has lost bone and may need surgery, with no guarantee of success, and that smoking and missed maintenance substantially affect the outcome; this should be explained without blame but honestly. Consent for surgery should cover the alternatives of continued non-surgical care with monitoring, removal of the implant and replacement options including no replacement, as well as costs and the risk of recession and exposed threads. I would document the diagnosis using the case definitions, the comparison with baseline, the smoking advice given and his decision, because a record of advice and attendance matters if the implant is later lost. I would also review why he dropped out of recall and make sure he leaves with a booked appointment and a reminder system in place.

Reference: 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions (Berglundh et al., J Clin Periodontol 2018); EFP S3 level clinical practice guideline on the prevention and treatment of peri-implant diseases (Herrera et al., J Clin Periodontol 2023); Lindhe's Clinical Periodontology and Implant Dentistry, 7th edition.

Knowledge: This is a malpositioned implant: too buccal, too shallow and too close to the canine root, where a minimum of about 1.5 mm between implant and tooth is generally recommended to preserve the interproximal bone and papilla. The cause is a planning or execution error, freehand placement in an aesthetic site, rather than an unpredictable complication, and that distinction matters for the honesty of the explanation. Restorative options are a cement-retained crown on an angled or custom abutment, which can correct angulation of this degree but will not fix the vertical position or the grey margin; an angulated screw channel abutment if the system supports it; or accepting a compromised result with a pink ceramic or composite. Surgical options are removal of the implant with a reverse-torque kit or trephine, grafting, and replacement in the correct position guided by a wax-up, with a longer timeline and cost, or burying the implant as a sleeper if removal would damage too much bone. I would also check the canine for vitality and any root damage on a periapical or CBCT, as proximity to 1 mm raises that concern.

Management: I would see her before the crown appointment, explain in plain language what I found, show the radiograph and models, and apologise sincerely that the implant is not in the position it should be. I would set out each option with its likely appearance, time, risks and cost, and offer referral to a prosthodontist or periodontist for an independent second opinion, at no cost to her if the clinic's policy allows. Whatever she chooses, I would not proceed until she has had time to decide, and if removal and replacement are chosen I would use a fully guided protocol or refer to a colleague with more aesthetic experience. I would record the findings, the radiograph, the discussion, the options offered, her questions and her decision contemporaneously, without altering or adding to earlier entries. I would report the incident through the facility's incident reporting system, inform the medical director, and notify my professional indemnity insurer as my policy requires. I would also reflect on and change my own practice, using guides for aesthetic sites in future.

Ethics and communication: Honest and prompt disclosure of an error is a core professional duty, and fitting the crown and hoping she does not notice would be dishonest and would compound the harm. An apology is an expression of regret and taking responsibility, and it should not be avoided out of fear of liability; under Federal Decree-Law No. 4 of 2016 on Medical Liability, whether the outcome amounts to a medical error is determined through the formal review process the law provides, not by what I say to the patient. Consent for any corrective option must be fresh and fully informed, including the possibility that the final result will still not be ideal, and she has the right to her complete records and to make a complaint. Waiving fees or offering to cover corrective treatment is reasonable and ethical, but I would not make it conditional on her not complaining.

Reference: ITI Treatment Guide Volume 1: Implant Therapy in the Esthetic Zone - Single-Tooth Replacements; ITI Consensus Conference statements on computer-guided implant surgery; Misch's Contemporary Implant Dentistry, 4th edition; Federal Decree-Law No. 4 of 2016 on Medical Liability.