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      Similar observations might be made about the short, companyled programs. Often the aim of this training is to make practitioners aware of the processes needed to handle that company’s componentry, and thus these programs often focus on the “how” rather than the “why” or “why not.” Also, due to the brevity of these courses, the biologic and biomechanical principles involved in implant treatments must be greatly abbreviated or are simply not covered at all. Unfortunately, this method can be fraught with danger to patients and cannot allow for a focus on best-practice protocols, as these concepts may be unknown to those learning.

2.3.1.6 STRUCTURED EDUCATION AND TRAINING

      The most effective training comes from structured programs that provide a sound basis for patient selection and treatment. These courses address the basic sciences that underpin successful treatment, introduce protocols for patient assessment and selection and treatment planning, and then provide candidates with the opportunity to perform actual treatment and patient maintenance with assistance and guidance from more experienced mentors. Given the breadth of the topics to be covered, these programs must extend over longer periods compared with other approaches. Thus, these programs can be expensive in terms of time and money and difficult to fit in alongside daily practice, leading to under-utilization of this type of education and training.

      Intuitively, one might expect that better-quality training would result in fewer complications or failure. While this is generally accepted in health care, little evidence is available to support these conclusions. Certainly, patients and regulators see this connection as true, and this forms that basic assumption that underpins mandated continuing professional development requirements.

2.3.2 Reducing clinician-related risk

      2.3.2.1 RECOGNIZING “HUMAN FACTOR” RISKS

      What have been described as “human factors” are becoming recognized as sources of error in health care provision. Much of the research in this area comes from the commercial aviation industry, but these findings are beginning to permeate into health care safety considerations.

      A second edition of Renouard and Rangert’s book about risk factors was published in 2008 (Renouard & Rangert, 2008) and brought the topic of experience and human factors to the discussion.

      In a recent review of these factors and their influence in dental implantology, Renouard and coworkers (Renouard et al, 2017) described five hazardous attitudes or behaviors that are potentially detrimental to safe practice. Originally identified in aviation, these types are:

      1. Impulsiveness The urge to get things done quickly, without necessarily considering potential dangers.

      2. Anti-authority The attitude held by some practitioners that rules, regulations, and protocols are for others, and do not pertain to them.

      3. Invulnerability Practitioners who believe that adverse outcomes only happen to others, and not to them.

      4. Macho The belief that a practitioner must be constantly demonstrating their superiority over others. While this is mostly a male trait, it can affect women as well.

      5. Resignation The belief that no matter what a practitioner does, it will not have any effect on the outcome.

2.3.2.2 STRESS AS A RISK FACTOR

      Renouard and coworkers also discuss stress as a potential problem. While the stress response is adaptive (ie, it is protective against external threats), it can have negative effects in a health care setting where the stress is mostly self-induced. Stress factors such as time pressures, staff problems, and interpersonal frictions between the dentist and the patient can all have a negative effect on performance. Stress tends to reduce the practitioner’s ability to rationally think through a problem and rather promotes the use of automatic responses, which may be incorrect or unhelpful. These factors are well studied in the medical literature as well, as it relates to many daily issues, like less sleep, financial problems, and health or family issues (West et al, 2006).

2.3.2.3 MITIGATING THE HUMAN FACTOR ISSUES

      To counter these “human factor” issues, Renouard recommends using techniques that have been developed for the airline industry to address safety problems: so-called “crew resource management.” The concept of the “sterile cockpit” where all extraneous activity is banned during high-risk periods, such as take-off and landing, can be transferred to the dental implantology setting for use during critical periods of treatment provision. Strict division of responsibilities between team members also reduces stress and “information overload.” Additionally, checklists can be very useful in concentrating attention on critical steps, especially in highly procedural tasks such as those seen in medicine and dentistry. This approach has also been promoted by other authors (Gawande, 2009; Pinsky et al, 2010). Here the SAC classification can be used as a checklist to ensure that all factors relevant to the patient’s presentation are assessed and incorporated into treatment plans.

2.3.2.4 CLINICIAN RISK FACTOR IN RELATION TO OTHER SOURCES OF risks

      The clinician is central to most decisions and their practical application in implant treatment. Risks in implant dentistry can be attributed to four main sources: the patient, the treatment approach, the biomaterials, and the clinician. This relationship between the clinician, the materials, and the patient factors was first described by Chen and Schärer in 1993 (Chen & Schärer, 1993). Further, Buser and Chen (Buser & Chen, 2008), published on a model that also illustrates the potential interactions between these factors, as shown in Figure 2.

      Fig 2. Potential sources of risk (Source: ITI Treatment Guide Vol. 3 “Implant Placement in Post-Extraction Sites”)

      In this model, the clinician has a potentially disproportionate influence: they select the patient, the treatment approach, and the biomaterials, and they subsequently carry out the treatment on the patient. Thus, a flaw or shortcoming in their knowledge or skills will put their patient at greater risk of adverse outcomes. Therefore, in answer to the question posed earlier, we must conclude that the clinician has the potential to be a significant risk factor.

      Can the SAC classification assist in reducing risk? By focusing the attention of the clinician on potential risk factors, it should ensure that the clinician-related risk is mitigated. However, the review group did not believe that the clinician could be considered as a factor in determining the SAC classification for a case, as they were not confident that all clinicians could accurately self-assess their ability. Nonetheless, discussions such as this may assist individuals in progressing along their own learning journey and improve their ability to control this potential risk.

2.4 Classification Rationale

      In the 2009 version of the SAC classification (Dawson & Chen, 2009) the main determinants of the classification were:

      • The esthetic risk

      • The complexity of the process

      • The risks of complications

      These factors were considered for each of the treatments considered in this publication, and a normative SAC classification was derived for each of these case types. Further modifiers were considered that might increase or decrease the level of complexity or risk, but these did not change the normative classification for the case type.

      In this update, the normative classifications have been reviewed, but they have not altered greatly. These are still based on the factors above, with an increased emphasis on the SAC classification as a risk management instrument.

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