Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2010; 55: 441–445
CASE REPORT
doi: 10.1111/j.1834-7819.2010.01267.x

Dental implant tourism

RA Barrowman,* D Grubor,*  A Chandu* à
*Department of Oral and Maxillofacial Surgery, The Royal Dental Hospital of Melbourne, Victoria.
 Melbourne Dental School, The University of Melbourne, Victoria.
à
Department of Oral and Maxillofacial Surgery, The Royal Melbourne Hospital, Victoria.

ABSTRACT
Access and affordability of dental care can be problematic for some in the Australian community. Therefore, dental tourism
is increasingly becoming more attractive to some patients due to decreased expense, increased convenience and immediacy
of treatment. However, there are significant issues for both clinician and patient in regards to dental tourism. Lack of
accountability and regulation are the main issues and this is particularly evident when complications occur. This paper
presents five cases where complications have arisen in the setting of dental tourism.
Keywords: Dental tourism, medical, dental implants, complications.
(Accepted for publication 28 June 2010.)

the professional, moral, legal and ethical duty of the

INTRODUCTION
Access to affordable dental care can be a significant
problem for some in the Australian community.
Increasingly, some patients have been turning to
treatment overseas as an option rather than accessing
routine dental care in Australia. There are some benefits
for accessing dental care outside Australia. These
include increased affordability, speedy completion of
treatment plans, convenience of treatment, combina-
tion of treatment with some leisure activity or visiting
family and avoidance of public waiting lists. The
affordability factor is a significant issue as a procedure
may be performed at a far lower financial cost
compared to the amount that a patient would otherwise
spend in Australia.1,2 This affordability has been made
even more attractive by a recent strong Australian
dollar as compared to other currencies and the ease and
affordability of overseas travel. Improvements in the
standard of care overseas may also play a role.2,3
Medical or dental tourism is a term that describes
seeking medical or dental treatment in another coun-
try.1,3 The necessity for travel may be the sole or
primary motivation for medical or dental treatment
sought. The internet and internet advertising may also
be an important source for accessing and researching
treatment possibilities overseas.
However, there are significant disadvantages to
dental tourism. The main issue for patients undertaking
dental tourism is accountability. Accountability implies
ª 2010 Australian Dental Association
practitioner regarding the outcome of treatment. Once
a patient leaves the country that they have undergone
treatment in, it may be difficult to address accountabil-
ity, even if the patient returns to that country. If
complications occur, review and management by the
practitioner who provided treatment is almost impos-
sible. Patients are often not covered by insurance
companies and are unable to seek compensation.
Therefore, clinicians in their home country may be
warranted with managing complications and giving
second opinions. There has been a reluctance by local
practitioners to provide remedial treatment, however
they are obliged to make a diagnosis and provide
treatment.4,5 Other disadvantages may include differ-
ences in training and risk of nosocomial infections,
particularly those that are blood-borne.
Implant dentistry is now part of routine dental care
which is practised by both generalist and specialist
alike. It could be considered as the gold standard of
care for the management of the partially or fully
edentate patient. However, the cost of implant treat-
ment as a treatment option can be prohibitive and this
can be the justification for seeking dental tourism.
Complications related to dental implants may be
related to the patient, implant or prosthetic components
and these complications are seen by oral and maxillo-
facial surgeons in both hospital and outpatient settings.
Little has been documented in the literature regarding
dental tourism, particularly in reference to dental
441
RA Barrowman et al.
implant treatment. The aim of this paper was to
document a series of cases with suboptimal outcomes
related to dental implant placement in the setting of
dental tourism that have presented to the Department
of Oral and Maxillofacial Surgery at both the Royal
Melbourne Hospital and Royal Dental Hospital of
Melbourne.
CASE DESCRIPTIONS
Case 1
A 60-year-old Australian man with poorly controlled
type 2 diabetes had three dental implants placed in the
posterior right mandible in sites 45, 46 and 47 (Fig 1a)
whilst on holiday. Ten days later in Australia, he
presented to the emergency department of the Royal
Melbourne Hospital with a large, tender and hard facial
swelling in the right submandibular region and progres-
sive odynophagia. He was administered IV antibiotics
(amoxicillin and metronidazole), fasted and taken to
theatre for surgical drainage. The patient required an
awake fibre-optic intubation as computerized tomogra-
phy (CT) scanning of his head and neck taken preop-
eratively demonstrated a narrowing of the trachea as a
result of his infection. Once the patient was prepared
and draped, extraoral incision and drainage of the right
submandibular, buccal and lingual spaces with insertion
of a penrose drain into the right neck was performed.
(a)
(b)
Fig 1. (a) Orthopantomogram showing dental implants placed in posterior right mandible. The placement of the implant fixtures appears satisfactory
on the OPG. (b) Coronal scout computerized tomography showing the extent of soft tissue swelling bilaterally in the submandibular region. Note the
deviated and compressed trachea to the left. (c) Axial computerized tomography of the patient’s larynx and neck. Note the oedema in the parapharyngeal
and retropharyngeal spaces resulting in severely diminished patency of the airway.
442
The amount of oedema and swelling required that the
patient remain intubated in the intensive care unit (ICU)
(Fig 1b). The patient was closely monitored under the
shared care of oral and maxillofacial surgery, ICU and
endocrinology departments. The following day, the
patient developed a marked increase in the amount of
submandibular swelling. A repeat CT scan exhibited
almost complete occlusion of the patient’s airway with
marked oedema of the parapharyngeal and retropha-
ryngeal spaces (Fig 1c). The patient was taken to theatre
for urgent redrainage and redebridement of his fascial
spaces, and IV antibiotics were continued as advised by
the infectious diseases unit. The patient made a slow but
steady recovery with the aid of IV antibiotics and strict
control of his diabetes. The patient remained in hospital
for a total of eight weeks.
Case 2
A 58-year-old female was referred to the Department of
Oral and Maxillofacial Surgery at the Royal Dental
Hospital of Melbourne complaining of pain and
swelling associated with both maxillary and mandibu-
lar implant supported prostheses. The patient had been
unhappy with her conventional full upper and lower
dentures due to retention problems. The implant
supported prostheses were delivered six months earlier,
whilst visiting family in the patient’s country of origin
(Fig 2a). The patient reported that the implants were
(c)
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 Dental implant tourism

(a) placed in one day, and the final porcelain–metal fixed

prostheses were fitted one week later.
On examination, both maxillary and mandibular
implant supported prostheses were mobile and painful.
Radiographic examination revealed non-conventional
screw implants had been placed, with six screw-type
implants in the maxilla and a further eight screw-type
implants in the mandible. All of the implants had
significant peri-implant radiolucencies.
Treatment required urgent removal of all maxillary
and mandibular implant supported prostheses under
general anaesthesia (Fig 2b). The implant surfaces,
when removed, appeared to have a green crust which
was not removable and resembled copper corrosion.
(b) Her postoperative course was unremarkable and she
reverted to her old complete set of dentures whilst
awaiting consultation at the multidisciplinary implant
treatment planning clinic at the Royal Dental Hospital
of Melbourne.

Fig 2. (a) Orthopantomogram showing the full mouth implant sup-
ported rehabilitation and peri-implant radiolucencies. (b) The maxillary
and mandibular dental prostheses and screw implants after removal
under a general anaesthesia.
Case 3
A healthy 64-year-old male was visiting family whilst
overseas. He visited a dentist who performed an
examination and recommended the placement of seven
mandibular dental implants. The patient agreed to have
the implants placed with the intention to have the
prosthetic restoration in Australia. The deciding factor
was that the overseas dentist was able to provide
treatment the following day. Seven implants were
placed in the mandible in sites 32, 35, 36, 42, 45, 46
and 47 (Fig 3a). Once back in Australia, two months
after placement of the implants, the patient presented to

(a)

(b) (c)

Fig 3. (a) Orthopantomogram showing seven implants placed in the mandible. Note the orientation of the 35 fixture into the apex of tooth 34.
(b) Axial computerized tomography of mandible in the region of 35 ⁄ 36. Shows proximity of the osteotomy to the inferior alveolar nerve.
(c) Tooth 34 after removal. Note the grooves from the implant thread in the apical region.
ª 2010 Australian Dental Association 443
RA Barrowman et al.

a local dentist, reporting pain and paraesthesia of the placement of dental implants overseas. A 24-year-old
distribution of the left mental nerve. The patient was Australian woman, with congenitally missing maxillary
referred to a prosthodontist who decided five of the lateral incisors and canines (Fig 5a), elected to have
seven implants were not restorable. Cone beam CT dental implants placed whilst overseas as she was
revealed impingement of the left inferior alveolar nerve dissatisfied with her maxillary partial denture. The
by a fixture (Fig 3b). The 35 fixture had also been patient had four dental implants placed (sites 12, 13,
inserted into the apical root of the 34 tooth which had 22, 23) (Fig 5b). Her aim was to reduce the overall cost
become non-vital. The patient was then referred to an of her dental implant rehabilitation, which was to be
oral and maxillofacial surgeon. Upon examination, the completed in Australia. Upon return to Australia, the
gingiva associated with the implants was inflamed and
pus drained from the area with significant mobility of
the fixtures. Five mandibular implants were removed, (a)
as well as the iatrogenically devitalized 34 tooth
(Fig 3c) under local anaesthesia. The implant sites were
then debrided of remaining granulation tissue and pus.
The implant sites healed uneventfully but some residual
paraesthesia of the left lip still exists. The patient is
under long-term follow-up.

Case 4
A 71-year-old edentulous male had ongoing problems
retaining his lower denture due to a flat mandibular
ridge and shallow sulci. The patient could not afford an
implant retained prosthesis at the time and therefore
sought full mouth rehabilitation with dental implants in
his country of origin. (b)
Four months after placement of the implant sup-
ported prostheses, the patient presented to the Royal
Dental Hospital of Melbourne with debonded fixtures
33–43 and loose 33 and 31 implant abutments (Fig 4a).
These were recemented provisionally by a prosthodon-
tist. Two months later, the maxillary unit prosthesis
also failed. It was noted that the reason for failure of
the unit was deficient anterior support (in regions 13–
22) (Fig 4b). Several of the maxillary implants had been
placed in a buccal orientation relative to the maxillary
arch (Fig 4c). The patient is now awaiting multidisci-
plinary implant treatment planning.

Case 5 Fig 5. (a) Patient presenting with congenitally missing lateral incisors
and canines with implants in situ. (b) Orthopantomogram showing
This case demonstrates communication and logistic dental implants placed in the maxilla. The treating dentist refused to
difficulties that can occur for patients electing to have disclose the type of implants placed.

(a) (b) (c)

Fig 4. (a) Orthopantomogram showing maxillary and mandibular implant supported dental prostheses. The bridge in the anterior mandible had
debonded. Two months later, the maxillary dental prosthesis also failed. (b) Failed maxillary prosthesis. Note lack of implant support in the anterior
region which contributed to failure of the prosthesis. (c) Buccal orientation of maxillary implants.
444 ª 2010 Australian Dental Association

patient presented to her local dentist for restoration of
the maxillary implants. From the OPG examination it
was unclear what system of implants were used. The
dentist she had seen overseas refused to disclose the
implant system used to the local Australian dentist on
the grounds that the implants had not been paid for,
although the patient disputed this and had evidence of a
receipt.
DISCUSSION
The modern success rates for non-complicated dental
implants is approximately 93% to 98% at five years,6,7
generally depending on the number of stages of surgery,
surgical training and the timing of loading. A number of
factors can influence implant failure, including patient
factors, such as poorly controlled diabetes as in case 1;
implant related factors, such as the implants placed in
case 2; and restorative factors as in case 4. Case 5 was
also interesting as it demonstrated a failure in commu-
nication.
Failure in implant dentistry does occur, in Australia
and overseas. Clinician training can also be quite
variable where in Australia it may range from company
sponsored courses over a period of days to periodontal
or full oral and maxillofacial surgical training, includ-
ing undergraduate training in dentistry and medicine.
However, the benefit for the patient who does not
travel overseas for treatment comes from multiple levels
of accountability. It is the regulation of dentistry which
allows this accountability to be available to protect the
patient. These levels include various state and now
federal legislation, state and federal dental boards, the
Australian Dental Association (ADA), both state and
federal, and compulsory clinician indemnity. In this
way, if a complication does occur, there are a number
of mechanisms for the patient to be followed up and
managed in an appropriate fashion. If the management
of such complications are suboptimal, then opportunity
exists through the dental boards, the ADA and the legal
system to claim recompense. This may be quite difficult
to undertake for treatment carried out overseas and it is
this lack of accountability which is the main issue
facing Australians and dental tourism.
Regulation can also be an issue affecting different
countries in their practice of dentistry. This can also
affect the materials used in the treatment of patients.
This issue is particularly important in regards to
ª 2010 Australian Dental Association
Dental implant tourism
sterilization and hygiene processes, and the risk of
cross-contamination and nosocomial infections as some
overseas countries may have a higher prevalence of
specific infectious agents and poor cross-infection
control.1,4 Regulation is also important in defining the
minimum training requirements for dentists and their
scope of practice.
These cases of complications related to implant
dentistry treatment illustrate some of the issues that
dental tourists may experience when seeking dental
implant treatment overseas. Although the patients
ranged in socio-economic status, a common motive
for treatment overseas was to save on cost. Some of the
patients were visiting their country of origin. However,
two of the patients (cases 1 and 5) were not. It is
important for clinicians to educate and advocate to
their patients regarding the costs of treatment, partic-
ularly in relation to dental tourism. The costs of
dentistry are not only related to the costs of service
and running a practice, but for the provision of safe and
effective dentistry where the clinician is accountable for
the planning, quality and outcomes of treatment.
REFERENCES
1. MacReady N. Developing countries court medical tourists. Lancet
2007;369:1849–1850.
2. Turner L. Cross-border dental care: ‘dental tourism’ and patient
mobility. Br Dent J 2008;204:553–554.
3. Horowitz MD, Rosensweig JA, Jones CA. Medical tourism:
globalization of the healthcare marketplace. MedGenMed
2007;9:33.
4. Asai RG, Jones KD. Am I obligated to treat a patient whose need
for emergency care stems from dental tourism? J Am Dent Assoc
2007;138:1018–1019.
5. Leggat P, Kedjarune U. Dental health, ‘dental tourism’ and trav-
ellers. Travel Med Infect Dis 2009;7:123–124.
6. Krennmair G, Seemann R, Schmidinger S, Ewers R, Piehslinger E.
Clinical outcome of root-shaped dental implants of various
diameters: 5-year results. Int J Oral Maxillofac Implants
2010;25:357–366.
7. Smith LP, Ng M, Grubor D, Chandu A. Outcomes of dental im-
plants placed in a surgical training programme. Aust Dent J
2009;54:361–367.
Address for correspondence:
Dr A Chandu
Level 1, 665 Mt Alexander Road
Moonee Ponds VIC 3039
Email: chandua@unimelb.edu.au
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