Dr. Darshan Parikh: So, the best way to explain this is that whenever you start doing something new, especially implant dentistry, there is a natural tendency to see everything through that lens. To someone who has just started placing implants, every missing tooth begins to look like an implant case. In simple terms, to a person holding a hammer, everything starts looking like a nail. This happens because you have invested time, money, and effort into learning implants, and naturally, you want to apply that skill.

This is exactly where maturity and experience come in.

One very important point, and this is something I strongly believe should be highlighted, is that one should not call oneself an “implantologist” unless there is a minimum of 5 years of experience after placing the first implant, and after having those patients come back for long-term follow-ups and recalls. Ideally, this should be in the range of 5 to 10 years. Until you have seen your own implants function over time, dealt with complications, managed failures, and followed patients longitudinally, you should not even put “implantologist” on your clinic board.

Just because you have done a course or received a certificate does not make you an implantologist. It is exactly like dentistry itself. You did not become a dentist the moment you entered dental school. You went through five years of structured education, clinical exposure, examinations, and supervised training before receiving your degree from the university. As professionals, we should apply the same standard to implant dentistry as well.

Now, coming back to patient management, over a period of time, as experience increases, you automatically become more cautious and more balanced in your approach. Awareness among patients is also increasing. Sometimes, patients now come with the expectation that they want “fixed teeth.” They may not use the word implant specifically, but they want a permanent solution. Even today, I honestly do not recall a single patient who has walked in saying, “Doctor, I don’t have a tooth, please place an implant.” They come saying they want their teeth fixed. More educated patients might mention implants, or say something like “I know there is a screw-based option,” but fundamentally, they are coming for teeth, and not specifically implants.

So what we now do, consistently, for every patient who walks in, is start with a thorough examination. We point out which teeth are missing, which teeth are compromised, or which teeth may not survive long term. Then we explain that before deciding anything, we need to do certain diagnostic tests. Based on those diagnostics, we will advise whether an implant is even a possibility, whether fixed teeth are feasible, and what the realistic options are for that particular patient.

And most importantly, the patient is always given all available options. These include: 

• A removable prosthesis (denture)

• A fixed partial denture (bridge)

• A single, freestanding tooth supported by an implant

These options should always be presented clearly and neutrally. The goal is not to push implants, but to educate the patient and let them understand what choices exist, along with the advantages, limitations, and long-term implications of each. Once that information is shared honestly, the decision becomes a shared one, rather than something imposed by the clinician.

Dr. Darshan Parikh: In many places today, especially in cities, it is no longer a question of whether you should get a CBCT or not. I would say it is non-negotiable. CBCT centers are easily available in urban areas. Now, of course, if you are practicing in a very remote location where the nearest CBCT center is 40–50 kilometers away, that becomes a different practical challenge. But in routine urban practice, CBCT is mandatory for implant dentistry in this day and age. One very important reason for this is medical–legal safety. You want it clearly documented that before you took up the patient for implant treatment, you had done the appropriate radiographic evaluation. If something ever goes wrong, you should be able to say that your diagnosis and treatment planning were based on a CBCT scan. So from that standpoint alone, CBCT has become essential in implant practice today.

From the patient’s perspective, however, your basics should never change. Your foundation has to be extremely strong. That means you still start with a thorough clinical examination. You take a proper and detailed medical history. You try to understand the reason for tooth loss. Did the patient lose the tooth 5 years ago, 10 years ago, or 15 years ago? If the tooth has been missing for so long, why are they suddenly looking for a replacement now? What is their overall oral health like? What is the periodontal condition? How are the remaining teeth? Are there mobility issues, inflammation, plaque control problems? All of these factors have to be carefully evaluated before you even talk about placing an implant. Based on this, you then present a comprehensive treatment plan to the patient. You explain that, yes, you are missing XYZ number of teeth, but at the same time, you may also have ABCD problems, like periodontal issues, caries, occlusal discrepancies, hygiene concerns, etc., which should be addressed before replacing the teeth. The basic idea is that if you place implants in a healthy and stable oral environment, the treatment you deliver will last much longer. This entire phase also gives you time to assess the patient’s motivation and their ability to maintain oral hygiene. The goal is not just to place an implant and collect a fee. The goal is to have a happy and satisfied patient and to ensure that the work you do lasts for as long as possible. If you see that a patient is motivated, understands instructions, and maintains hygiene reasonably well, then that patient becomes a good candidate for implant therapy.

From a systemic health point of view, there are several parameters you look into. Basic investigations such as blood sugar levels are important, especially whether diabetes is controlled or uncontrolled. Blood pressure, by itself, is usually not a contraindication, but it still needs to be recorded and monitored. You need to be aware of the medications the patient is taking and have a fair understanding of their medical implications. Then there are relative contraindications—patients undergoing chemotherapy, those with major systemic illnesses, or conditions that compromise healing. These patients are not necessarily ruled out, but they need to be handled with extra caution and careful planning.

Then come the local factors, especially bone assessment. CBCT gives you one important set of data. Along with that, you still correlate it with intraoral periapical radiographs. An orthopantomogram also plays a role, particularly in larger or more complex cases, such as full-mouth rehabilitations, rather than a single implant. An OPG serves as an excellent baseline record, allowing you to compare bone levels at 3 years, 5 years, or even 10 years down the line. So radiographically, you are usually working with three tools: 

• intraoral periapical radiographs, 

• OPGs, and 

• CBCT. 

Together, they give you a comprehensive picture.

When it comes to bone quality assessment, there is also the concept of Hounsfield Units, which some CBCT centers can provide as additional feedback. However, beyond numbers and scans, bone quality assessment is ultimately a clinical judgment. There are situations where the maxilla, for example, appears to have adequate bone volume on CBCT, and even the density looks reasonable. But once you raise a flap and actually start working with the bone, you get a real tactile feel of the bone quality.

That tactile feedback, how the bone behaves during drilling and how it responds to instrumentation, is something that only comes with experience. The more implants you place, the better you become at understanding bone quality and at modifying your surgical and prosthetic protocols to suit each individual case. This refinement, more than anything else, develops over time with consistent clinical exposure.

Dr. Darshan Parikh: Okay, so there is definitely a minimum age for implant placement. You would not place implants in children. What we look at is skeletal maturity. In general, girls tend to reach skeletal and sexual maturity earlier than boys. So, as a rough ballpark figure, we usually consider an age range of about 18 to 21 years. Anyone above 21 years can be considered a reasonably safe candidate for implants, because by that age, skeletal growth is essentially complete and all growth phases have settled.

There is no upper age limit as such. I have placed implants in patients in their 70s, 80s, and even in their 90s. Age by itself is not a contraindication. What really matters on the upper end is the patient’s overall medical health, mental faculties, and level of engagement. For example, a 90-year-old patient who comes alone, walks upright, understands everything that is explained to him, and is mentally alert and involved in the decision-making process. Patients like that can absolutely be considered for implants. On the other hand, if you have an 80-year-old frail lady whose dentures are not fitting well, and the children are insisting that she undergo implant surgery, those are cases where you need to be very cautious. Such patients may not be fully engaged in understanding the procedure, the post-operative care, or the long-term maintenance involved. If a patient is highly dependent, both physically and cognitively, a removable prosthesis is often a better option, even from the caregiver’s perspective. It is easier to manage, easier to clean, and places less overall burden on the patient. So, at the upper end, especially for patients in their 70s and 80s, you have to carefully assess their physical well-being and mental alertness. You need to see how well you can communicate with them, how present they are during consultations, and how capable they are of understanding and following instructions.

At the same time, given today’s lifestyle-related health issues, particularly in India, where we are often referred to as the diabetes capital of the world, and where hypertension is extremely common, you cannot assume fitness based on age alone. Even a 30- or 40-year-old patient who says, “I work out regularly, I go to the gym every day,” still needs proper medical evaluation. Necessary investigations should always be done to ensure that the patient is medically fit for implant surgery, regardless of whether they appear young, active, or outwardly healthy.

Dr. Darshan Parikh: So, one thing that we routinely explain to patients now is that, in dentistry, almost everything is a form of surgery. The moment I drill a tooth, I am essentially cutting tooth structure. And surgery, at its core, simply means cutting tissue. So whether we are using a bur for a filling, performing a root canal, or extracting a tooth, we are already doing surgical procedures. An implant is also a surgery, but conceptually, it is not very different. We explain it by saying that just like we remove a tooth, we will numb the area and place a foundation for a new tooth. Framing it this way helps to downplay the fear associated with the word “surgery” and makes it more relatable for the patient. Many times, you do not fully realize how anxious a patient is until they are actually seated in the dental chair. That anxiety can manifest in different ways, like gag reflexes, restlessness, or sudden fear, and that can be challenging to manage. This is one of the reasons why I strongly believe it is better to do foundational dentistry with a patient first, rather than having their first or second visit to your clinic be for implant surgery. It is far better to begin with procedures like scaling or fillings. This helps build rapport and trust. At the same time, you also get a sense of the patient’s temperament, like how anxious they are, how calm they are, how they respond to procedures, so you are better prepared to manage them during a surgical appointment.

Of course, if you have the infrastructure and the ability, especially for larger surgical procedures, sedation is an option. In many places abroad, and even increasingly in India, IV sedation is used for longer or more complex surgeries. In such cases, you can have an anesthetist on call and use sedatives to help patients manage their anxiety. For single-tooth implant cases, I have almost never needed this. There may have been one or two particularly difficult cases where I felt that IV sedation could have made the experience easier for the patient. Typically, these situations arise in full-mouth cases rather than single implants. When we talk about surgical duration, a rough ballpark for a routine implant surgery is about one to one and a half hours. This includes the time from when the patient walks in, administering local anesthesia, raising the flap, placing the implant, suturing, and finally giving post-operative instructions. This is very manageable because local anesthesia works well for this duration. Even for well-adjusted patients undergoing full-mouth procedures, such as full-arch extractions with implant placement, the surgery can last two to three hours, and most patients tolerate it quite well. That said, this is one of the challenges of dentistry compared to other surgical specialties. In many other surgeries, patients are under general anesthesia and completely unconscious. In dentistry, the patient is awake, conscious, and aware throughout the procedure. Managing not just the surgical steps but also the patient’s comfort, anxiety, and cooperation simultaneously is an added challenge. It is definitely not an easy job.