Oral Health Group

Endo VS Implant: What is YOUR Hierarchy in the Decision Making Process?

May 1, 2018
by Gary Glassman, DDS, FRCD(C)

One of the most controversially debated topics of modern dentistry has been whether to retain a tooth with endodontic treatment or to extract it and replace it with an implant.

In the 1980s, implant dentistry became the mainstream treatment modality, with the purported promise of a maintenance free, definitive and long term solution for a compromised tooth. It seems that the promise of the 80s did not materialize as expected and times have certainly changed!


Endodontic treatment is regaining favour as the primary strategy for saving a tooth for a number of reasons. Despite the fact that endodontic treatment can be difficult to perform, because of the complex anatomy of root canal systems, research has shown that the survival rate of endodontically treated teeth is at least as effective as dental implants, and includes the added benefit of maintaining the natural dentition. It has also been well documented that implants are more predisposed to both biological and technical complications, which may require more remedial treatment overall. That said, implants offer an important next line option for patients where endodontic options have been exhausted.

The risk factors that could affect implant prognosis are plentiful. General risk factors may include, but not limited to, patients who have diabetes, immunosuppressive conditions, poor oral hygiene, history of periodontal disease and of course those who smoke. Local factors may include, but not limited to, faulty implant placement technique, faulty ridge augmentation procedures, restorative failures, inaccessibility to professional oral hygiene services, and deep peri-implant pocketing.

Plaque related diseases are more commonplace with implants than with the natural dentition. It is important to make patients aware of this issue in order to maximize long term success rates of implants. One must also consider the reason why the patient lost their natural dentition in the first place, that necessitated the need for extraction and subsequent replacement. Behavioural change, especially in high risk patients is of paramount importance.1

The objective of endodontic treatment has been consistent since root canal treatment was first performed – to successfully restore and preserving the tooth and retain what nature has created. Specifically, the focus is the prevention and/or treatment of apical periodontitis such that there is complete healing and absence of infection.

Dental imaging has made leaps and bounds with the advent and use of cone beam computed tomography (CBCT). Limited field of view images taken preoperatively will allow a three-dimensional rendering of the tooth to be treated. In essence, the practitioner is provided with a more precise ‘road map’ with respect to the anatomic makeup of the tooth to be treated. CBCT has enlightened us to the complexities of the root canal system and thereby necessitates 3D disinfection and obturation.

High magnification in the form of the dental operating microscope and the development of ultrasonics for conventional endodontics have enabled many practitioners to treat complex root canal anatomic variations more thoroughly and to tip the balance in favour of healing.

Although the hierarchy of treatment planning in the early days first looked at implants as the pinnacle of treatment compared to retaining the natural dentition with endodontic/restorative treatment, this has dramatically changed as increasing reports have come to light regarding the complications now associated with implants. The priority in recent years has seemed to revert back to maintaining the natural compromised teeth through remedial endodontic and restorative procedures.

The future of endodontics is bright as we continue to develop new techniques and technologies that will allow us to perform endodontic treatment painlessly and predictably, and continue to satisfy the underlying objective – tooth retention.

Thanks to the following article in which inspiration and thoughts were culled from:

  1. Nemcovsky CE, Rosen E. Biological complications in implant-supported oral rehabilitation: as the pendulum swings back towards endodontics and tooth preservation. Evidence-Based Endodontics 92017) 2;4

About the Editor
The author of numerous publications, Dr. Glassman lectures globally on endodontics, is on staff at the University of Toronto, Faculty of Dentistry in the graduate department of endodontics, and is Adjunct Professor of Dentistry and Director of Endodontic Programming for the University of Technology, Kingston, Jamaica. Gary is a fellow of the Royal College of Dentists of Canada, Fellow of the American College of Dentists, the endodontic editor for Oral Health dental journal and Faculty Chair for DC Institute. He maintains a private practice, Endodontic Specialists in Toronto, Ontario, Canada. His personal/professional website is www.drgaryglassman.com and his office website is www.rootcanals.ca. He can be reached at gary@rootcanals.ca.

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