Oral Health Group

Re: An Evidence Based Endodontic Implant Algorithm: Back to the Egg; Part 2,Oral Health, February, 2010

May 1, 2010
by Oral Health

After reading Dr.Serota’s articles on the endodontic vs. implant controversy, I felt compelled to comment and elaborate on some of the assertions made in those articles.

Dr.Serota states that the purpose of his paper “is to ensure that all variables in the treatment planning equation are understood and given equal weight in the comprehensive care decision making process”. However, one cannot overlook the fact that there is an inherent bias by an endodontist in favour of treating a tooth endodontically rather than recommending an extraction and subsequent implant placement.


As an associate/locum general dentist who has done a substantial number of root canals in many different offices here in Ontario and overseas for the past 20+ years, I have noticed a disturbing situation (which I intend to discuss in greater detail) when it comes to making a decision,by either a GP or an endodontist, whether to save a tooth endodontically or extract and replace it by implant/C&B/denture.

Dr.Serota states that, “…treatment outcome studies have been egregiously abused by those wishing to diminish the value of reengineering natural teeth. Many studies have categorized teeth with caries, fractures, periodontal involvement and poor coronal restorations as negative endodontic outcomes.”

I would like to suggest that many “negative endodontic outcomes” are the result of poor treatment decision-making in the first place. Personal experience, anecdotal evidence from GPs and endodontists, dental journal articles and editorials have led me to question the wisdom of saving teeth at almost any cost. Rather than” pointing fingers” elsewhere to account for negative endodontic outcomes, maybe endodontists should take more initiative in deciding when and where endodontic treatment is appropriate rather than unquestioningly following directions on a dentist’s referral slip.

On several occasions, I have heard endodontists say that many of the teeth they have treated or re-treated had poor prognoses restoratively and should have been extracted instead. My question is “Why do endodontists not convey that concern to their referring dentist?” Is it fear of alienating the referring GP by questioning his/her diagnosis, financial self-interest, abrogation of responsibility for what happens to the treated tooth once the patient leaves the office, etc?

The corresponding question to GPs is, “Why do we insist on trying to endodontically treat teeth with dubious long-term prognoses?” I have seen dentists either fail to do a cost/benefit analysis when it comes to deciding between endo versus extraction or fail to consider the patient’s general dental health, IQ, financial constraints, etc. There are sometimes issues around financial self-interest, short-sighted treatment-planning, etc. Too often, we disregard the patient’s perspective on saving a tooth and decide that we as dental professionals know the “right treatment”.

Both GPs and endodontists have sometimes been complicit in recommending endodontic treatment in situations where extraction (and future implant/C&B/denture) would have been a better choice.

However, having said the above, it is the endodontist (in cases of referral) who is the “gate-keeper” or ultimate decision-maker whether to proceed with treatment/retreatment/periapical surgery. It should be incumbent upon them to shoulder some of the responsibility for the future long-term outcome of the tooth. A realistic appraisal of a tooth’ potential lifespan and a willingness to say to a patient or referring dentist that “I believe it would be better to extract this tooth than to attempt to save it endodontically” is what is necessary.

I believe the above approach would reduce the potential for “egregious abuse of treatment outcome studies” by reducing the number of “negative endodontic outcomes”.

Dr. Leon Freudman

Toronto, ON