Endodontics vs dental implants a conflicting decision?



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Endodontics vs. dental implants

A conflicting decision?

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.

• 80-89% (Strindberg,L. - Acta Odontol. Scand.1957)

• 82% (Bender et al - Oral Surg.1964)

• 86.5% (Storms,J.L. - J. Can. Dent. Assoc 1969)

• 86-96% (Sjogren et al – JOE 1990)

• 86% (The Toronto Study - JOE 2008)

• 80-83% (Ng et al - IEJ 2011)

Survival: functional retention of a symptom-free root canal treated tooth.

• 91-97% (Friedman et al – J Calif Dent Assoc 2004)

• 86-93% (Ng et al – IEJ 2010)

• 95.4% (Ng et al – IEJ 2011)



Outcome of endodontic treatment:

Survey of outcomes of root canal treatment in patients insured by Delta Dental (more than 1,400,000)

97% of root canal-treated teeth were retained within an eight-year follow-up period

Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. JOE 2004; 30:846-50

Outcome of dental implants:

Albrektsson et al. 1986

1- That an individual unattached implant is immobile when tested clinically

2- That a radiograph does not demonstrate any evidence of peri-implant radiolucency

3- That vertical bone loss be less than 0.2mm annually following the implant first year of service

4- That individual implant performance be characterized by an absence of persistent and/or irreversible signs and symptoms such as pain, infections, neuropathies or violation of the mandibular canal

But implants fail too! And on more than one level!

1- Lack of integration:

a- Loss of integration: before loading the implant with the definitive restoration

b- Bone loss around an integrated implant

Failure to integrate

Removal and replacement with a wider implant and/or bone graft

After the definitive restoration has been placed

Progressive bone loss due to either peri-implantitis or occlusal over loading

Management:

Culture and antibiotics ??

Resection of the soft tissue to remove pockets

Removal of the implant

2- Positional failure:

Most common type Associated with poor planning and poor surgical execution.

Can result in:

Biomechanical problems

Aesthetic problems

Inability to restore in severe cases

Can be avoided by:

Proper treatment planning

Use of surgical guides

Good understanding of the restorative aspects by the surgeon



3- Soft tissue failure:

4- Biomechanical failures:

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

1- Outcome:



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



What are the other factors to consider?

a)Patient factors:

1- Systemic and local health factors

2- Age


3- Patient concerns

b) Tooth and periodontium-related factors:

1- Pulpal and periodontal condition, restorability and treatment plan

2- Biological and environmental considerations

3- Bone quantity and quality

4- Unique colour characteristics

5- Soft tissue anatomy

c) Treatment-related factors:

1- Procedural complications

2- Adjunctive procedures

3- Treatment outcomes

a- Patient factors:

1- Systemic and local health factors:

Diabetes

Smoking

Bisphosphonates

Radiotherapy

Osteoporosis

Paget’s disease of bone

Bleeding disorders??

2- Age:


Implant placement should be postponed until after the growth spurt has ceased. Implants placed in young patients are expected to serve for longer periods of time.

3- Patient concerns:

Time and cost

Potential for adverse outcomes

Satisfaction with treatment

Fear of surgery



b) Tooth and periodontium-related factors:

1- Pulpal and periodontal condition, restorability and treatment plan.

2- Aesthetic zone:

Unique colour characteristics

Soft tissue anatomy:

Lip line

Gingival biotype

3- Bone quantity and quality:

The success rate of dental implants depends to a great extent on the volume and quality of the surrounding bone.

Bone quantity of jawbone is broken down into five groups (from minimal to severe).

Bone quality is broken down into four groups according to the proportion and structure of compact and trabecular bone tissue

Type I: homogeneous cortical bone

Type II: thick cortical bone with marrow cavity

Type III: thin cortical bone with dense trabecular bone of good strength

Type IV: very thin cortical bone with low density trabecular bone of poor strength.

c) Treatment-related factors:

1- Procedural complications:

Hemorrhage and haematoma

Neurosensory disturbances

Injury to adjacent teeth

Loss of the implant or graft materials into the maxillary sinus

2- Adjunctive procedures

3- Maintenance

Management of biomechanical failure

Management of peri-implantitis and peri-mucositis

Who will do it??

So… Implants or endodontic treatment??



Indications for endodontic treatment:

• 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).

Indications for implants:

When endodontic therapy is not indicated:

Teeth with non-restorable crowns

Teeth with non-treatable periodontal conditions

Teeth with unfavorable crown: root ratio

Teeth with unsalvageable resorptive defects



Conclusion:

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


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