Oral Health Group
Feature

Tale of Two Specialties: The Endodontic/Implant Algorithm

May 1, 2007
by Kenneth S. Serota, DDS, MMSc


Change is a significant evolutionary tool provided it rests upon a solid and secure foundation. Innovations in materials and technologies occurring within the dental field are impacting powerfully on its art and science; however, dentistry, like all health care, is both a business and a profession. The pendulum swings that predicate trends and transitions within that nexus must be viewed from a macrocosmic perspective lest we fall prey to expediency in treatment recommendation and execution. There is an almost Faustian reliance on broad outcomes data, which in truth, may not be sufficiently specific to directly impact clinical decision-making.1,2

Rudiments and fundamentals are the abc’s of process. While the change from need dentistry to want dentistry is consistent with the societal trends championing botox, collagen, and silicone, it doesn’t necessarily reflect an enhanced awareness of the basic precepts of dental health by our client base. Their focus has been shifted away from masticatory harmony and equilibrated function to whitening in all its myriad applications. Nowhere is the disruption in the logical and sequential protocol to optimal dental health more evident that the trend to replace natural teeth with implants. At-risk patient cohorts3 may simply be encouraged to opt for virtual surgery and immediate function as an alternative to rehabilitative therapy.

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Implant-driven treatment planning can, if incorporated with vision, foster a melding of the specialties and offer patients a less confusing and fractionated approach to their dental care. Orthodontists are training to place mini implants for the purpose of anchorage. Endodontists can predictably retreat procedural failures;4 however, if these teeth are determined to be non-restorable, they can be replaced with osseo-integrated fixtures. Endo/ortho/ prosthetic treatment plans include modalities to grow bone where there was none and obviate aggressive bone harvesting procedures. Everything from enamel matrix derivatives to bone morphogenic proteins to stem cell research is directed toward cellular and structural reconstitution. The issue of who does what is not of consequence; what matters most is that we educate patients to understand their options and as a profession work to endlessly elevate the standard of care.

There are a myriad of problems in choosing between implant and endodontic therapies, as they differ profoundly. Different modes of outcome measurements frustrate direct comparison. The factors to be considered include patient-related issues (systemic and oral health, as well as comfort and treatment perceptions), tooth and periodontium-related factors (pulpal and periodontal conditions, color characteristics of the teeth, quantity and quality of bone, and soft-tissue anatomy), and treatment-related factors (the potential for procedural complications, required adjunctive procedures, and treatment outcomes). Long-term, large, clearly defined studies, with simple and clear outcome measures-for example, survival in combination with defined treatment protocols-are needed to measure the clinical performance of endodontic and implant therapies.5,6 Jan Lindhe has stated that implants are to be used to replace missing teeth, not teeth. The tragedy of using mathematical manipulation to provide accurate information for informed consent is that the cohort(s) used and the multivariate analysis derived may be altered to prejudice results.

The goal of preserving the natural dentition has long provided the foundation for clinical decision-making in dentistry. Current trends in implant dentistry have weakened this paradigm as many practitioners have moved quickly to adopt implant dentistry as a new standard of care; however, the rapidity of this shift is a cause for concern among others. Many short-term studies have reported favorable data supporting the growth of single-unit implant dentistry, but the lack of standardized outcome evaluations and broadly conceived dimensions of performance makes it difficult to compare these reports. Thus, even with the exciting new treatment options implant dentistry offers patients and practitioners, all due consideration should first be given to treatments aimed at preserving and restoring compromised teeth before pursuing extraction and replacement (Figs. 1A-F & 2A-B).

Based on selected follow-up studies, the chance of teeth without apical periodontitis to remain free of disease after initial endodontic treatment or those with apical periodontitis to completely heal after initial treatment or retreatment and the chance of teeth with apical periodontitis to completely heal after apical surgery is a lower percentage than demonstrated for implants; however, the chance for these teeth to be functional over time is 86 percent to 92 percent, which places them in the same strata as implants. The number of outcome predictors becomes literally arcane beyond the aforementioned obvious variables-intra-operative complications, number of roots, treatment technique, periodontal procedures required, ferrule size, etc.-and yet, all are predictable mainstream procedures.7-9 Expediency does not obviate their impact on success and thus the creation of a logical treatment planning algorithm becomes all the more relevant.

In a recent article on paradigm shifts reflecting dentistry’s future,10 a reputable educator reported polling audiences of dentists at continuing education programs as theoretical scientific evidence (“Hands up” if you’ve had root canal therapy and residual pain, sensitivity, or awareness of the presence of something untoward remaining associated with the endodontically treated tooth.) The same question posed to the same cohort in regard to those who had implant placement elicited no complaints. The presumption was that dentists seek out other dentists as care providers, thus the expectation that the results should reflect the highest standard of care. He summarized that the trend to remove endodontically suspect teeth and replace them with implants will continue.

The creation of a trend must have substantiation in objective fact, not subjective interpolation. One can only hope that the excesses of the pendulum swing to biomimetic replacement will reverse and dentistry will reframe yet again. The profession needs to revisit all aspects of treatment planning to create a more functionally integrated perspective. The specialties, and those areas with aspirations to be specialties, have operated independent of one another or at best with minimal linkage. The result has been a failed interdisciplinary approach, with the concept of comprehensive care relegated to fulfilling the art of dentistry, but not the biologic science. Nowhere is this more appalling than in the dismissal of endodontic success potential.11

Endodontics and implant dentistry are in continual experimental states of flux in regard to success predictors and treatment outcome protocols. Any procedure that can be validated by evidence-based science should be factored into comprehensive care. A rush to judgment and anecdotal, empirical bias must never replace case selection, treatment planning and ultimately respect for the healing capacity of a biologic organism. When the natural tooth can no longer be treated within predictable parameters, then the biomimetic option should be presented, taking into account all variables that impact upon its success rate (Figs. 3A-F). The choice is not between implants and endodontics, but between what is restorable and salvageable periodontally vs. implant replacement as an algorithm of functional success. The true decision is not between endodontics and implants, but greater accuracy in diagnosis of fractures of endodontically treated teeth, the success of crown lengthening procedures, and the success of periodontal therapy in regard to marginal periodontitis.

A treatment risk assessment algorithm is one of many tools that will optimize predictable clinical success. In order for the practitioner to successfully integrate any new treatment approach, it must represe
nt inclusion of the new; however, not at the expense of exclusion of the traditional. As such, endodontics and implantology must acknowledge and ultimately embrace the strengths each brings to the equation that creates dental health.

Dr. Serota is in private endodontic practice in Mississauga, Ontario. He is the founder of the cybercommunities ROOTS (www.rxroots.com) and IMPLANTS (www.rximplants.com). He can be reached at kendo@endo solns.com.

REFERENCES

1.White SN, Miklus VG, Potter KS, Cho J, Ngan AY. Endodontics and implants, a catalog of therapeutic contrasts. J Evid Based Dent Pract 2006 Mar;6(1): 101-9.

2.Tang CS, Naylor AE. Single-unit implants versus conventional treatments for compromised teeth: a brief review of the evidence. J Dent Educ 2005 Apr;69(4): 414-8.

3.Fouad AF, Burleson J. The effect of diabetes mellitus on endodontic treatment outcome: data from an electronic patient record. J Am Dent Assoc 2003; 134:43-51.

4.Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: the Toronto Study. Phases I and II: orthograde retreatment. J Endo September 2004; 30: (9):627-33.

5.Becker W. Immediate implant placement: treatment planning and surgical steps for successful outcomes. Br Dent J 2006 Aug 26;201(4):199-205.

6.Torabinejad M, Goodacre CJ. Endodontic or dental implant therapy: the factors affecting treatment planning. J Am Dent Assoc 2006 Jul;137(7):973-7.

7.Marquis VL, Dao T, Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: the Toronto Study. Phase III: initial treatment. J Endod. 2006;32(4):299-306.

8.Nair PN. Pathogenesis of apical periodontitis and the causes of endodontic failures. Crit Rev Oral Biol Med 2004 Nov 1;15(6):348-81.

9.Ichim I, Kuzmanovic DV, Love RM. A finite element analysis of ferrule design on restoration resistance and distribution of stress within a root. Int Endod J 2006;39 (6):443-52.

10.Christensen GJ. Current paradigm shifts in dentistry. Dentistry Today 2007:26(2):90-6.

11.Felton DA. Implant or root canal therapy: a prosthodontist’s view. J Esthet Restor Dent 2005;17(4):197-9.


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