Clinicians often have to make a decision whether a tooth with pulpal and periradicular disease should be saved through RCT or extracted and replaced with an implant. Several factors need to be considered upon treatment planning. The aim should be high levels of comfort, function, longevity and aesthetics.
Advantages of preserving natural teeth in healthy condition
1- Preservation of function (chewing and speech)
2- Preservation of aesthetics
3- Preservation of proprioception
4- Preservation of arch integrity and occlusion
5- Psychological aspect
Disadvantages of preserving natural teeth in diseased condition:
1- Risk of acute apical abscess/ cellulitis
2- Loss of alveolar bone
3- Risk of systemic infection/ focal infection theory??
Osseo-integration is successful in >98% of the cases. What about root canals???
Outcome of endodontic treatment:
Success: complete resolution of clinical and radiographic signs of peri-apical disease.
Range from loosening of screws to fracture of implant components
Success and survival in implant dentistry:
Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review.
Moraschini et al. Int J Oral Maxillofac Surg. 2015 Mar;44(3):377-88
A total of 23 articles were included in this review.
10 prospective studies, 9 retrospective studies, and 4 randomized clinical trials. 7711implants were evaluated (mean follow-up time 13.4 years).
Overall survival rate: 94.6%
Mean marginal bone resorption: 1.3mm
So which treatment option is superior?
Meta-analysis of the relative survival rates of single-tooth implants versus endodontically treated and restored natural teeth. 57 studies on single-tooth implants (totaling ~12,000 implants) and 13 studies about restored, root canal-treated teeth (totaling ~23,000 teeth) were included. Survival rates for the two treatments were equivalent (After 6 years: survival rate 97% for both treatments)
Iqbal M, Kim S. International J Oral Maxillofac Implants 2007, 22(Suppl):96-119
Doyle and colleagues compared the outcomes of 196 endodontically treated teeth with 196 matched, single-tooth implants, with both treatments provided in the same setting . Survival rate: 94% for both groups. Even though the survival rates were similar, the implant group experienced a much greater incidence of post-operative complications (e.g., prosthetic repairs, etc.)
Doyle S, Hoidges J, Pesun I, Law A, Bowles W. J Endod 2006; 32, 822-7.
The authors concluded that “…the decision to treat a compromised tooth endodontically or replace it with an implant must be based on factors other than treatment outcome” Both nonsurgical root canal therapy followed by an appropriate restoration and single-tooth implants are excellent treatment modalities for the treatment of compromised teeth
• Any tooth that has a strategic value, functional, restorable and periodontally sound.
• In trauma cases where esthetics and arch stabilization are a concern.
• In patients with high-risk medical conditions (eg, high-risk heart problems, bisphosphonate-associated osteonecrosis, severe osteoporosis, hemophilia, uncontrollable diabetes) that contraindicate surgery (extraction).
Contra-indications for endodontic treatment:
• In teeth that are unnecessary (eg, non-occluding third molar, severely angled or positioned tooth out of buccal or lingual arch alignment).
• In teeth that are non-restorable (eg, severely decayed or vertically fractured teeth with the cervical border below the crest of bone).
• In teeth displaying severe periodontitis with extensive pocket depths, spontaneous bleeding, and/or level 3 or higher mobility.
• In teeth with severe injury to the roots and the alveolar ridge (eg, shattered or vertically fractured).
There is no competition between dental implants and endodontic treatment. Both options can and should be used to better serve the patient. The choice between dental implants and endodontic treatment should be decided on a case-by-case basis Though the final decision rests with the patient, the case presentation must include all treatment options, be presented in language the patient understands, show valid reasons (based on the conditions) as to which option is best, explain how the procedure will be done, predict how long the procedure will take, identify the expected prognosis, and estimate how much the treatment will cost. The manner in which a case is presented should always be designed toward what is best for the patient and only the patient