Periodontist or Oral Surgeon for a Dental Implant?

In the Austin area? Dr. Verrett provides this care in North Austin. See Dental Implants in Austin, or request a consult.

Patients who need an implant are often given a choice between two specialists, a periodontist and an oral and maxillofacial surgeon, and the answers they find online tend to declare a winner. The accreditation standards for both residencies and the studies that have compared them do not support a blanket ranking in either direction. Both specialties are trained to place implants and to rebuild bone for them. They differ in where their training goes deepest, and that difference is useful for some patients and irrelevant for many others.

What Both Specialties Are Trained to Do

Both are recognized dental specialties. The National Commission on Recognition of Dental Specialties and Certifying Boards, an agency of the American Dental Association, defines periodontics as the prevention, diagnosis and treatment of diseases of the tissues supporting and surrounding the teeth or their substitutes, along with maintaining the health, function and esthetics of those tissues, and defines oral and maxillofacial surgery as the diagnosis and surgical treatment of diseases, injuries and defects of the hard and soft tissues of the mouth and jaws.

Every residency in either specialty must meet standards set by the Commission on Dental Accreditation (CODA), and both sets of standards are public. The CODA standards for periodontics require a program of three consecutive academic years, with at least 30 months of instruction, and clinical training to competency in implant site development, including hard and soft tissue preservation and reconstruction, ridge augmentation, and sinus floor elevation, as well as placing implants. The CODA standards for oral and maxillofacial surgery require at least four years of full-time training, with outpatient experience that must include placing implants, augmentations and other hard and soft tissue surgery, and implant training that covers placement with hard and soft tissue grafts and the management of complications.

So the procedures that the online comparisons most often argue over, bone grafts and sinus lifts, appear in the required training of both specialties. Neither standard reserves them for the other.

Where Periodontists Go Deepest

The center of a periodontics residency is the disease that loses teeth and the tissue around teeth and implants. The CODA periodontics standards require each resident to complete documented cases of moderate to severe periodontitis, and to reach competency in non-surgical treatment, resective and regenerative surgery around teeth, and periodontal plastic surgery such as gum grafting and root coverage. On the implant side, the same standards require instruction in managing peri-implant disease and in maintaining implants, and clinical competency in managing the tissue around implants in health and in disease. The American Academy of Periodontology describes the training as at least three years of advanced education beyond dental school in periodontal dentistry and dental implants.

That depth matters because the main risks to an implant over the long run are periodontal ones. The review of peri-implantitis prepared for the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases found strong evidence that a history of periodontitis, poor plaque control, and the absence of regular maintenance after treatment each raise the risk of peri-implantitis, the inflammatory bone loss that can cost an implant. It is not rare: a systematic review by Derks and Tomasi estimated it in roughly 22 percent of patients with implants, with the earlier, reversible stage in roughly 43 percent.

Where this tends to matter for a patient: remaining teeth with active gum disease, which needs treating before or alongside the implant; a front tooth, where the gum contour around the implant decides how natural it looks; a plan that removes teeth which might be kept; and an implant that develops problems years after it was placed.

Where Oral Surgeons Go Deepest

Oral surgery training is longer, hospital-based, and broader. The American Association of Oral and Maxillofacial Surgeons describes four to six years in a hospital surgical residency, training alongside residents in medicine, general surgery and anesthesiology, and lists impacted wisdom teeth, corrective jaw surgery, facial trauma, and the diagnosis and surgical treatment of growths of the mouth, head and neck among the specialty’s work.

Anesthesia is the clearest difference. The CODA oral and maxillofacial surgery standards require at least 20 weeks on a hospital anesthesia service and at least 300 cases of general anesthesia or deep sedation per graduating resident, at least half of them outside the operating room, along with training in trauma, jaw pathology, corrective jaw surgery, and reconstruction that includes harvesting bone from sites outside the mouth such as the hip, rib, skull and shin. The CODA periodontics standards, by comparison, require clinical competency in moderate intravenous sedation and knowledge, not clinical competency, of deep sedation.

Where this tends to matter for a patient: someone who needs or strongly wants to be fully asleep, whose medical situation calls for general anesthesia, whose reconstruction needs bone from outside the mouth, or who also needs jaw surgery, impacted wisdom teeth removed, or a lesion of the jaw treated.

What the Outcome Studies Show

Very little research compares implant outcomes by specialty, there are no randomized trials, and what exists has real weaknesses.

The largest study looked at 26,865 implants placed by 27 oral surgeons and 30 periodontists across 54 clinics of a national dental chain in Israel between 2017 and 2019. Early failure was 1.3 percent for the periodontists and 1.7 percent for the oral surgeons, a difference that was not statistically significant. The one factor that did predict early failure was the number of implants each surgeon had placed during specialty training. It measured only early failure, not long-term health or appearance, and training in Israel is not identical to training in the United States.

A study of 1,449 implants placed by residents at Louisiana State University reported survival of 94.1 percent for periodontics residents, 91.5 percent for prosthodontics residents and 89.6 percent for oral surgery residents, and found that both the department and the residents’ year of training were associated with the outcome. These were trainees, not practicing specialists; the study was retrospective, follow-up ranged from one to five years, and the authors themselves concluded that further studies are needed to explain the differences. It does not show that practicing periodontists outperform practicing oral surgeons.

The clearest signal points at the individual surgeon rather than the specialty. A 2017 systematic review and meta-analysis by Sendyk and colleagues found that being a specialist did not significantly change implant failure, while having placed more than 50 implants did, with an odds ratio of 2.18 for failure among the less experienced. That second finding rests on only two retrospective studies, one of them the Dental Implant Clinical Research Group study in which Lambert and colleagues found that surgeons with fewer than 50 implants had about twice the failures of more experienced surgeons. The evidence is limited, but it consistently says the same thing: experience with the procedure matters more than the specialty label.

How to Actually Choose

Experience with the specific procedure. A sinus lift, a ridge graft and an implant placed the same day a tooth comes out are different operations. Ask how often the surgeon does the one being proposed, given the Sendyk meta-analysis finding that volume, not specialty, tracked with failure.

Imaging and planning. The American Academy of Oral and Maxillofacial Radiology recommends cross-sectional imaging for the assessment of every implant site, with cone-beam CT as the method of choice. A plan should be made on a 3D scan and shown to the patient.

The rest of the mouth. If remaining teeth have periodontitis, it raises the risk to a new implant, according to the 2017 World Workshop review, so the plan should say how it will be treated.

Who handles problems later. An implant needs care for as long as it is in the mouth. In a five-year study by Costa and colleagues of patients who already had early inflammation around their implants, peri-implantitis developed in 18 percent of those who kept preventive maintenance and 43.9 percent of those who did not, and a meta-analysis by Monje and colleagues recommended recall at least every five to six months. Ask who sees the implant at five and ten years, who treats it if the tissue around it becomes inflamed, and what happens if it fails early.

Working with the dentist who makes the crown. Both sets of standards expect this: the periodontics standards call for implant treatment planned in consultation with whoever will complete the restoration, and the oral surgery standards list interaction with restorative dentists as evidence of implant training. A good plan names who does what and when.

Anesthesia. If being fully asleep matters, ask directly what level of sedation is offered and under what permit. The Texas State Board of Dental Examiners issues separate permits for each level, from nitrous oxide through general anesthesia.

Where This Office Fits

Dr. Andrew Verrett is a periodontist and a Diplomate of the American Board of Periodontology. He places implants, rebuilds ridges with particulate bone grafting, and performs sinus lifts, and treats the tissue around implants for years afterward, including peri-implantitis. Treatment is done with local anesthetic, with nitrous oxide, oral sedation, or IV moderate sedation available after medical screening under his Texas permit for moderate sedation; general anesthesia is not offered, and a patient who needs it, or whose reconstruction calls for bone from outside the mouth, is better served by an oral surgeon. An implant placed here that fails within the first year is replaced at no surgical cost once the site is ready. The patient’s own dentist makes the crown.

A patient already holding a plan from either specialty is welcome to bring it for a second opinion, with a written comparison and, if the first plan is sound, a straightforward confirmation. Request a consult in North Austin, or call (512) 346-6097.