Making The Right Move:

The concept of deciding between saving a tooth (ie, performing endodontics) and placing a

substitute (ie, performing implant placement and restoration) hinges on several aspects of deci-

sion-making that are linked indisputably to the specific clinical situation at hand. Unfortunately,

some segments of the dental profession—whether marketers, manufacturers, lecturers, or oth-

ers—have pitted one specialty against the other as being better or worse for patients in the long

run. As a result, the public and even some clinicians are encountering the plethora of the mixed

and controversial messages and potentially opting to put the cart before the clinical horse.

Any controversy between endodontics and implants is primarily economic and more artifi-

cially manufactured than exists in reality, believes Richard E. Mounce, DDS, an endodontist

based in Vancouver, WA. In essence, there is not nor should there be any competition or contro-

versy between endodontics and implants, he says.

“There are clear indications for endodontic therapy and clear indications for implant thera-

py,” Mounce explains. “Rarely are these treatment options so evenly weighted that when consid-

ered side by side (as to their advantages and disadvantages) that there should be a ‘competition’

or ‘controversy,’ most especially when the patient’s best interest is put first.”

e Right Move:

By Allison M. DiMatteo, BA, MPS

PlanningYour Clinical

Strategy

Mike Murphy, senior category managerfor implants and bone grafting for TulsaDental Specialties, has observed the de-bate within the industry as to whether en-dodontic treatment is the best option forthe patient versus extraction or implants.Although the sides disagree, he says thereare some individuals or organizations thatclaim that endodontic treatment is even-tually doomed to fail and that implantsoffer a better, more favorable outcome.

“We think this is simply not true as ageneral rule. The fact is both treatment op-tions have high success rates and compa-rable ones at that. The decision that mustbe made involves the probability for suc-cess of an endodontic treatment for eachindividual case, not as a general rule,”Mur-phy emphasizes. “At the end of the day, itis all about what is best for the patientswhen diagnosing and planning treatment.The clinician should responsibly make

that determination and reach the properdecision—along with the patient and thereferring general practitioner—not indus-try experts or manufacturers quoting in-complete or suspect data.”

According to Ali Nasseh, DDS, MMSc,clinical instructor at Harvard UniversitySchool of Dental Medicine, what is tak-ing place and contributing to controver-sy is a comparison of apples and oranges,whereas the most important consideration

should be what is of the most value to thepatient. He elaborates that usually whatpatients care the most about are health,function, and esthetics. However, consid-eration of “value” must take into accountthe manner in which the profession valuesthe natural dentition, Nasseh says.

“Is it only a matter of function and es-thetics, or do we really value our own bi-ological tissues in a deeper, more mean-ingful way? If an implant or a root canalhas the same 90% success rate in a givensituation, it’s obviously reasonable to saythat a root canal is the more logical ap-proach, since it involves saving our ownbiological tooth,” Nasseh proposes. “Butwhat if an implant is 90% successful anda root canal is 80% successful in a givensituation? Are we to merely make deci-sions based on numbers, or does the in-trinsic value of our own tissues andpreserving them account for anything?We need to come to terms with thesenon-tangible factors as a profession be-cause we’ve spent the past 60 years con-vincing patients that they should pre-serve their own teeth and not think ofthem as dispensable.”

Dennis Brave, DDS, and Kenneth A.Koch, DMD, co-founders of Real WorldEndo, being endodontists, see the firstchoice as trying to save the natural denti-tion, if possible. This makes sense fromdifferent perspectives, including tissuemanagement, they say. If the tooth forsome reason is not restorable, that’s an-other issue; then you have the option ofan implant.

Robert A. Levine, DDS, clinical asso-ciate professor in post-graduate perio-dontics, perio-prosthesis, and implan-tology at the University of PennsylvaniaSchool of Dental Medicine, speaking as aperiodontist, notes that clinicians shouldalways try to save teeth. “I think there isnothing that is better than a tooth,” heexplains. “However, when a tooth appears

124 INSIDE DENTISTRY—JULY/AUGUST 2008

“At the end of

the day,

it is all about

what is best

for the

patients when

diagnosing

and planning

treatment.”

(Circle 102 on Reader Service Card)

126 INSIDE DENTISTRY—JULY/AUGUST 2008

to be non-restorable for whatever reason,then an implant is a very good alternative.”

According to Jon Julian, DDS, a privatepractitioner in McPherson, Kansas, whoperforms both endodontic and implantprocedures, any controversy that there isprobably arises when there is a case thatis not straightforward, such as difficultiesin performing a restoration on an endo-dontically treated tooth (eg, a tooth thathas been fractured). In such instances, the

clinician now has to make a judgment call.In the past, that judgment has gone to-ward endodontic treatment, he explains.

“I believe the reason for this is becausemost of the diagnosing of the tooth’scondition has been done by general den-tists, and it’s only been just recently—within the last 5 years—that more generaldentists are starting to refer out for im-plants,” Julian observes. “Clinicians havegone to great lengths to perform a root

canal, to perform heroic dentistry and re-store a tooth, where maybe it wasn’t indi-cated and perhaps an implant would havebeen more appropriate.”

Further, Julian suggests that any issuessurrounding an endodontics vs implantsdebate most likely stem not from initial,beginning stage root canal therapies.Rather, he says the issue occurs when atooth that has been treated with a rootcanal is having a problem and the ques-

tion is whether to retreat that tooth withendodontic surgery in order to save it, orextract it and place an implant.

But again, it’s a matter of diagnosing thespecific case and making proper decisionsin the treatment-planning process. Thismonth, Inside Dentistry explores this sup-posed controversy and provides informa-tion and insight to help readers betterunderstand the issues they may face whendeciding between saving a tooth with en-dodontics and extracting it and placingan implant as a substitute.

Keith D. Rossein, DDS, president of Inter-national Dental Consultants and the edi-tor/publisher of Implant News & Views,commented that the question of choos-ing between endodontics and implants isan improper one. The only way to have im-plant dentistry is if the tooth is removed.“So, the questions are really, ‘When canyou save the tooth with endodontics?’and ‘When should it be extracted and animplant placed?’”he says.“As a general rule,it’s always better to save the tooth, in myopinion, if you can.” See Some Questionsto Ask When Determining Whether to Savea Tooth, page 128.

According to Gregori M. Kurtzman,DDS, MAGD, DICOI, a key question toask when determining whether or not toproceed with endodontics is, “Is the toothrestorable as is?” He explains that it does-n’t matter that the canal system withinthe tooth can be instrumented and obtu-rated if the tooth cannot be predictablyrestored and maintained in the long term.

Restorability is determined by what isleft of the tooth following removal of de-cay and any existing restorative material,Kurtzman elaborates, offering several ques-tions to help with this determination. Canthe new restoration’s margins be placedcoronal to the crestal bone and not violatebiological width? In multi-rooted teeth,is the remaining tooth structure internal-ly in the furcation area thick enough toprovide structural strength to the remain-ing tooth? Are cracks apparent internallyin the tooth that may increase the chanceof structural failure of the tooth?

“Deciding which plan to recommendand follow must take these factors intoaccount and examine which treatment hasthe best prognosis, keeping the patient’shealth and lifespan into account,” Kurtz-man explains. “If a tooth can be restoredwithout compromise to adjacent teeth,then it is better to maintain the naturaltooth due to the proprioception that im-plants do not have.”

Robert A. Horowitz, DDS, clinical as-sistant professor in the departments ofperiodontology and implant dentistry,

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INSIDE DENTISTRY—JULY/AUGUST 2008 127

biomaterials, and biomimetics at NewYork University College of Dentistry, re-calls seeing a number of patients recentlywith catastrophic fractures of the maxil-lary premolars. When an upper premolartooth fractures below the gingival level,once the pulp chamber is exposed, savingthe tooth would require endodontic ther-apy, crown lengthening, fabrication of apost, and then placement of a crown res-toration, he explains.

“All of these are procedures that aredone routinely. However, teeth that haveundergone endodontic therapy are oftenmore brittle and more likely to fracturein the long run,” Horowitz says. “Addingthat risk to a tooth that has already frac-tured and—if you have to eliminate someof the hard and soft tissue support of thattooth by performing a crown lengthen-ing procedure—leaving a greater crown-to-root ratio and more chance of mobilityof the tooth, you have an even greaterchance of fracture of the tooth.”

Further, if the tooth is fractured facial-ly and clinicians need to remove boneand gingiva, then an esthetic compro-mise could result, Horowitz notes. If thetooth fractures interproximally, bone orgingiva may need to be removed from anadjacent tooth, which could lead to func-tional or esthetic problems, or could po-tentially even open furcations and putthe adjacent tooth at greater risk, he says.

“When you take these factors into ac-count, sometimes even if a non-restoredor restored tooth has fractured that hasnot yet had endodontic therapy, it may bein the patient’s best interest to preservethe maximal bone and gingival support,extract the tooth, augment the site, andplace an implant,” Horowitz suggests.

Kurtzman says that natural teeth canbe modified to improve restorability bymoving the crestal bone in relation tothe restoration’s margin and permittinga restorative ferrule to be placed. Doingso may involve osseous crown lengthen-ing. However, the drawback to this ap-proach is that surgically, bone needs to beremoved mesial and distal to the toothrequiring crown lengthening. In multi-rooted teeth, this may create furcationexposure leading to periodontal issues,difficult home care, and loss of the toothlong term, he adds.

An alternative to crown lengtheningwhen additional tooth structure is need-ed to place a ferrule is forced orthodonticeruption. This permits treatment of onlythe tooth in question, with no periodontalcompromise, and it works well in teethwith sufficient root length that can afforda change in the crown-to-root ratio, Kurtz-man explains. As with crown lengthening,this can create issues in multi-rooted teeth,since the forced eruption may expose thefurcation area, he says.

Internal cracks also compromise thestructural integrity of the tooth and maybe warning signs to ultimate failure ofthe tooth under function. If these cracks do

not extend across the pulpal floor or intothe roots, then restoration of the toothwith a bonded core and full-coverage res-toration may offer good long-term results,Kurtzman says.

However, when even after endodon-tic treatment the tooth remains symp-tomatic, this may indicate deeper struc-tural issues than are visually appreciated,and extraction and replacement with animplant is the more prudent treatment

(Circle 105 on Reader Service Card)

“a key question to ask

when determining whether or not

to proceed with endodontics is,

‘Is the tooth restorable as is?’”

choice with better predictability, Kurtz-man emphasizes.

Further, Michael Sonick, DMD, a pri-vate practitioner and lecturer, notes thateven when endodontic therapy is success-ful, it usually requires a crown restorationon that area that may need to be redone atsome point. He says that according topublished data, the average crown lastsonly approximately 7 to 10 years before itmust be replaced on a natural tooth be-cause it usually decays. When placed onan implant, decay is not an issue.1

“Dentists should understand that en-dodontics must be performed with theultimate restoration in mind. When per-formed properly—and that’s the key thing,when performed properly—endodonticsand endodontically treated teeth can haveas excellent a long-term prognosis as im-plants,” Koch explains. “You have to per-form endodontics in such a way that youcan really successfully enhance the long-term retention of the tooth.”

When viewed objectively, 99.9% of thetime there is a best choice for the patient,explains Mounce. This “best choice”shouldbe a decision made by the patient afterbeing fully informed of the risks and ben-efits of each procedure. If bias, empiri-cism, economics, and opinion are takenout of the treatment planning, each pro-cedure (ie, endodontics or implants) hasa set of predictors for success (and failure)that are quite well-defined, he says.

“Abide by the principles that govern op-timal execution of the service, and successand healing are very predictable,” Mouncesuggests.“In the most general terms, mostpatients, when faced with the costs, time,and treatment requirements, will opt tokeep their natural teeth if possible.”

It’s that “if possible” question that be-comes important. According to Kurtzman,if a tooth that has had a previous endodon-tic treatment can be retreated convention-ally and the tooth is restorable with goodosseous support, then endodontic retreat-ment is the treatment of choice. But whenan endodontically failing tooth will requireapical surgery or has a periodontal fac-tor that has led to support issues, then amore prudent long-term prognosis maybe found with extraction and implantplacement, he says.

“Financial decisions also play a factorin these cases,” Kurtzman says. “Shouldthe patient invest in endodontic retreat-ment, which, as with all treatment options

clinicians offer, does not have a 100%success rate, or use those funds towardthe more predictable treatment of im-plant placement?”

Currently Murphy estimates that thecost for molar endodontics ranges from$1,200 to $1,400 without any restoration(eg, crown). A single implant placementwithout any restoration or laboratoryfees is estimated at about $2,000, he says.

“There are a number of issues sur-rounding an implant that are not prob-lems faced with the restorative effort of anatural tooth. Some implants will requirea sinus lift, tissue grafting, or bone aug-mentation (many times multiple proce-dures), in order to give them the bestchance of success. These are all, in gener-al, added to the fees that a patient has todeal with when they’re choosing an im-plant,” Brave explains. “I think it’s ratherclear that under normal circumstanceswhen an implant includes these adjunc-tive procedures, it’s going to be consider-ably more expensive than endodontictreatment and restoration of that endo-dontically treated tooth.”

According to Horowitz, the entire treat-ment planning and diagnosis area is gray,with no black or white; the prognosis ofa tooth is different depending on the ageof the patient, the patient’s caries index,the gingival and bone support, and thepatient’s periodontal susceptibility. Butone thing remains clear: the need for dis-closure as far as predictability of endodon-tic therapy or implant therapy in termsof esthetics, restoration, potential need forretreatment, and anatomy (eg, proximityto the inferior alveolar canal).

“I think probably the most importantitem when you’re interviewing patientsregarding treatment possibilities is togive them the options that are availableto them, along with the prognoses andvarious success rates,” believes Sonick.“What I don’t like to see are treatmentsbeing successful for a short period of timeand then saying, “Well, we can get a fewyears out of something and then we’llconsider the options.” I like to go forthand give the patient the option of doingsomething that would have a very, veryhigh long-term success rate.”

Levine notes that regardless of the prog-nosis of the tooth, clinicians still need topresent patients with all of their otheroptions, such as a three-unit bridge, en-dodontics, or an implant.“I think the cli-nician needs to guide the patient as to whatis in their best interest long-term,” he says.“In a tooth that’s mobile, has a short rootlength, that is missing a lot of the soundtooth structure, that needs a surgical crown-lengthening procedure and has goodapical bone for an implant, those are goodindications to do an implant.”

Nasseh echoes the comments of oth-ers, noting the importance of informing

?Some Questions to Ask

When Determining Whether to Save a Tooth

?Some Questions to Ask

When Determining Whether to Save a Tooth

In developing this feature presentation, several Inside Dentistry editorialboard members provided background and insight into the issues and ques-tions surrounding the topic of when to save a tooth with endodontic treatmentand when to consider extraction and placing an implant. The questions thatresulted from their input appear below.

However, significant to determining whether a tooth can be saved or not isusing a team approach to diagnosis, something that Robert A. Levine, DDS,believes is imperative to the process. The team, he says, is comprised of thepatient, general practitioner, oral surgeon, periodontist, endodontist, andrestorative dentist.

“Unless it’s very clear cut, I want the opinion of my colleagues,” Levine empha-sizes.“I never make the decision alone if I have any questions about apical peri-odontitis, tooth mobility, a crown-to-root ratio problem, or insufficient toothstructure. These are things we look at collectively to determine if the tooth canbe saved or not be saved.”

Additionally, Ali Nasseh, DDS, MMSc, notes that decisions regarding endo-dontic treatment cannot be made without full knowledge. For this reason, healso believes that a team approach involving the periodontist, endodontist, andoral surgeon enables clarification of any limitations to treatment and develop-ment of the best solution for the patient.

“Ultimately, it’s about the patient and making the right decision that serveshis or her purposes in the long run based on their value system,” Nasseh says.“The decision about what to do should be based on the principle of saving thepatient’s oral tissues and dentition using ideally minimally invasive procedures.If we abide by these basic principles, we should develop the right answer forwhat’s best for any given patient.”

Questions to Ask

• Is the tooth periodontally involved?• Can you complete the root canal successfully?• Would there be sufficient tooth structure remaining to restore the tooth and

ensure structural support/integrity?• Is the tooth restorable as is or does it require periodontal surgery (ie, crown

lengthening to restore the tooth)?• If crown lengthening is necessary, will it have a major impact on the bony

support, periodontal status, and esthetics of the adjacent teeth?• Is this an endodontic retreatment?• If so, what will be done differently to provide for better success and progno-

sis of the tooth?• What is the prognosis of the endodontic treatment? If the prognosis is

guarded or marginal, is an implant more predictable?• What is the caries susceptibility of the patient? Are they taking any medications

causing dry mouth and generalized root caries with Sjögren-like symptoms?• What is the periodontal status of the teeth in the arch?• How important is the affected tooth to the overall case? A compromised

tooth can affect a full-mouth rehabilitation and, in such instances, placingan implant may be more appropriate.

128 INSIDE DENTISTRY—JULY/AUGUST 2008

1 Priest G. Predictability of soft tissue form around single-tooth implant restorations. Int JPeriodontics Restorative Dent. 2003;23(1):19-27.

a Misch CE. The importance of dental implants. Gen Dent2001;49(1):38-45.

130 INSIDE DENTISTRY—JULY/AUGUST 2008

patients of the possibilities down the lineof one modality versus the other, and mak-ing a decision based on what’s good for thepatient in the long term.“What I’ve foundis oftentimes dentists may make decisionsfor patients without spending enough timeasking questions to find out what it is that’simportant to them,” he says.

After elaborating on the benefits andrisks of the different treatment options, it’simportant to give patients a list of thingsthey should consider when they maketheir decision, Sonick explains. The firstthing might be cost (ie, what are the dif-ferences in cost between an implant anda crown and endodontics?) What are theshort-term costs and the long-term costs?

The second consideration might be es-thetics, he says, and the third considera-tion might be prognosis (ie, long-term vsshort-term). Finally, Sonick suggests thatpatients consider any pain that may beassociated with the options presented.

“I find that very few patients are evergiven an opportunity to make a decision intheir own healthcare. Most of them just goalong with what the doctor has suggestedto them,” Sonick has observed.“Sometimesit’s better to let the patient make those de-cisions because then they can get what’smore appropriate for them. You have todisclose to the patient all of the optionsthat are available to them regardless ofwhat your personal feelings may be.”

When looking at success rates for eitherimplants or endodontic treatments, it’simportant to emphasize that both typesof dentistry demonstrate success. Bothtypes of treatments have caveats and cau-tions, and to compare the failures ratesof the two types of treatments is to com-pare apples and oranges, our intervieweessuggest. Some studies are retrospective,

examine only certain symptoms or presen-tation criteria, and inclusion criteria maynot be universal.

Levine comments that there are notenough studies of endodontically treatedteeth versus teeth that have been restoredwith implants in which the researchersexamined similar teeth (ie, single-toothimplants, single-rooted tooth root canals).Further, it’s not clear if the teeth havebeen restored with a crown, what type ofpost was done, or whether there was anyapical disease remaining. In past studies,it has been hard to trust in the resultspresented, he suggests.

“We really need, number one, a studythat is going to compare exactly what I

In the areas of endodontics and implant dentistry, bothhave excellent technologies and proven techniques thatachieve high comparable success rates, according to ourinterviewees. Available materials and practice protocollend themselves to predictability in the clinical practice.The advancements and developments that have occurredin both arenas ultimately benefit patient care by enhanc-ing treatment comfort and long-term prognosis.

EndodonticsWhile others may have their own beliefs about the optimalmethods for endodontic treatment and may championthose methods, Richard E. Mounce, DDS, believes that thehighest endodontic success can be accomplished with asurgical operating microscope, unconditional use of therubber dam, achievement and maintenance of apical paten-cy, rotary nickel titanium instrumentation, ultrasonicallyactivated bactericidal irrigation with a combination ofsolutions, smear layer removal, warm bonded obturation,and early coronal seal. He further notes that these shouldbe applied in an environment where 1) the patient has beenfully informed of the risks and benefits of treatment and2) treatment is performed with adequate time to optimizeall variables.

“With the advent of nickel titanium rotary files, ultra-sonics, better magnification and light sources, the surgicaloperating microscope, and greater advancement in sur-gical techniques and materials, teeth today that we oncethought were not treatable have been able to undergovery routine procedures in today’s dental clinic,” explainsJim Tinnin, DDS.“All of those developments have openeda lot of doors for people that before would have just hadteeth extracted.”

According to Kenneth A. Koch, DMD, co-founder ofReal World Endo, in the past and even currently, there havebeen different endodontic techniques for shaping thecanal, and these produce either a constant tapered shapedor a variable tapered shape, dependent upon the differentinstrumentation systems available. Going forward, Kochbelieves professionals will move toward a more conser-vative shape at the top of the canal in order to help preservethe integrity of the tooth.

“The preservation of that radicular dentin is going toenhance the long-term retention of the endodonticallytreated tooth,” Koch believes. “As a result, you’re going tosee more use of a constant taper preparation that allowsanyone doing endodontics the ability with irrigationprotocol to satisfy all of the biologic requirements in

such a way that it enhances the long-term retention ofthe tooth.”

Dennis Brave, DDS, co-founder of Real World Endo,elaborates that endodontics today is about choosing todo minimally-invasive techniques that do not destroy toothstructure, but which maintain the structural integrity ofthe tooth. This follows through from instrumentation allthe way to obturation and restoration, he says.

ImplantsPrimarily a clinical endodontist and not an implant sur-geon or restorative dentist, Mounce’s knowledge of theadvancements in implants is based on the literature andextensive discussions with other colleagues. A recent recip-ient of implants himself, he says he was reassured by thefact that his periodontist used an ICAT during the treat-ment planning and execution of his surgery, as well asthe fact that there are many systems that can provideexcellent clinical results.

“With the application of CT scans and cone beamtechnology to the diagnosis and treatment planning processhas allowed my treatment of patients that years ago weren’ttreatable,” Tinnin says.“We, as clinicians, enjoy higher suc-cess rates with implants because of these technologies,and patients have options based on a modality that is goingto last them a lifetime.”

Tinnin adds that implant case planning and engineer-ing is now more of a prosthetically driven function ratherthan a bone-driven function. Using guided stents and bonegrafting materials that are available today, the techniquesand science behind implantology have been enhanced tothe extent that these treatment opportunities are muchbetter for patients, he says.

In recent years, the category of narrow-body implantshas changed the manner in which patients with congen-itally missing lateral incisors (eg, extremely small max-illary space usually filled by orthodontic movement) ormissing mandibular incisors are treated, explains KeithD. Rossein, DDS. These very thin, very narrow implants(ie, anywhere from 1.8 mm to 2.5 mm in diameter) havebeen accepted for long-term use, giving clinicians anoption to place a fixed implant-supported restorationfor patients with these types of missing teeth.

Further, Robert Horowitz, DDS, who performs exten-sive research on implant surfaces and bone regeneration,adds that other advancements in implants include theirdesign and surface technology. Newer surfaces improvethe stability and speed of osseointegration. In terms of

placement techniques, bone grafting in sockets, sinuses,and ridges has also been improved. Enhancements suchas predictable bone regeneration enable surgeons to grafta deficient alveolar site and replace the missing volumewith living, vital bone, not just non-resorbable scaffolds.

BRIDGING THE GAPJon Julian, DDS, a private practitioner who performs bothendodontic and implant procedures, personally tries toavoid bridgework whenever possible and instead placesingle-tooth implants. However, he notes that if a patientdecides that a bridge is their choice, rather than an im-plant, then he will provide it.

“A root canal treated tooth may have more difficultydown the road depending on what it’s supporting. If thattooth is going to support a large span bridge, it may fail,”Julian says.“Implants have no carious failure rates and do notfracture. So, over an extended period of time, the lifetime ofthe patient, the option for a root canal is a good conservativechoice, but the implant probably has a higher success rateover the lifetime of the patient compared to a bridge.”

According to Keith D. Rossein, DDS, because a toothwon’t ever be as strong as it was once it’s been treatedendodontically, such teeth may not be good choices forabutment teeth or a bridge since too much stress may beplaced on it.

“There are a lot of reasons to believe that a single-toothimplant now is better or longer-lasting and will do thepatient more service over a long period of time comparedto a three-unit bridge,” explains Rossein. “Over a 10-yearperiod of time, bridges have been shown to develop re-current decay at the edge of the abutment crowns, porce-lain fractures, periodontal problems, and cement failure.a

This doesn’t take into account that in the area where thetooth is now missing, the pontic area, that bone is contin-uing to resorb because there is no tooth.”

Rossein adds that when bridges are used to replace amissing tooth, the abutment teeth used to anchor thefixed prosthesis are often “virgin” teeth that are—or atleast were—fairly strong. However, he notes that oncethey’ve been prepared, the damage is done.

“When you place the single-tooth implant, you’re nottouching the abutment teeth,” Rossein explains. “Also,you’re continuing to stimulate the bone properly so youdon’t have bone resorption in that particular area.”

mentioned regarding teeth that have beenrestored with a root canal, that have noapical disease, that have been crowned,versus an implant in the same mouth orin somebody else’s mouth over the sameperiod going for 5 years or 10 years,” Le-vine suggests. “I think that’s where you’llhave some value.2”

Julian has observed high success ratesfor both endodontics and implant thera-pies in his 30 years of experience, but henotes that the treatment plan should boildown to what is in the best interest of thepatient. What is in the best interest of thepatient should be based on clinical deci-sions, the experience of the doctor, andthe patient’s desires.

“I don’t think a study is going to give usclarity,” Julian says.“I think the research isbeneficial, but clinical dentistry requiresjudgment and decisions based on myriadfactors that research doesn’t always address.”

Anecdotally, Horowitz has observedthe survival rates of dental implants inthe literature to be much higher than thesurvival rates of endodontically treatedteeth, especially if the endodontically treat-ed teeth have a periapical lesion, whichoften predisposes them to failure or theneed for retreatment. In particular, hecites a 1997 report by Hepworth and Fried-man in which the authors state that ifthere is a periapical lesion on a previously

endodontically treated tooth, the successrate of the retreatment is only 66%.3

Sonick notes, however, that the successrate for initial root canal therapy approxi-mates 90% to 95% if no apical periodonti-tis is present, especially for single-rootedteeth. An investigation at the Universityof Toronto by Farzaneh and colleaguesshowed that the presence of apical peri-odontitis lowers the success rate by 10%to 15% or so and lowers the success rate to80% over 4 to 6 years, he explains. If a toothneeds retrograde treatment for periapi-cal lucencies, the predictability drops evenfurther, increasing the chance of failure,he says.4,5

“As I mentioned, there are widely dif-ferent criteria being used to measure thesuccess rates of implants and root canaltreatment,” Levine says.“Because the stud-ies that do exist are 5, 10, or more years old,things have changed so much. Until wehave better studies, it’s difficult to comparethe success rates of the two modalities.”

According to James M. Tinnin, DDS,MSD, a diplomate of the American Boardof Endodontics in private practice in Fay-etteville, Arkansas, there are studies avail-able, and there have been for quite sometime, showing the treatment success ratesof both modalities. Unfortunately, someimplant manufacturers misrepresent theendodontic success rates, he says.

“For example, in the literature from1977 to 1989, there are some 35 articlesthat use a criteria for implant success bywhich the implant is still in the mouth,where usually criteria for endodonticsuccess is more on a histological basis,along with radiological data and patient’ssymptoms,” Tinnin explains. “It’s a morescientific approach.”

He notes that some implant researchersare starting to move in such a direction, butthat there are still implant studies in whichsome failures (eg, patient comfort, dam-age to the adjacent teeth, violations of themaxillary sinus) have been considered sep-arately. When failures are removed fromthe start, the “successes”are going to appearbetter, Tinnin says.

“Success rates in implant studies andsuccess rates in endodontic studies havevery different criteria as to what is consid-ered a success,” reiterates Koch. “In myopinion, there are indications for bothtreatment modalities, but the research in

magazines is skewed toward implants. Idon’t want dentists to forget all of the ex-cellent benefits that endodontic therapycan offer their patients.”

According to Nasseh, over the past 50years, there have been approximately 50or 60 outcome studies in endodontics witha range of successes, anywhere from 60%up to nearly 100%. Therefore, when peopleare trying to make a point for implants,they tend to pick those studies with thelowest success rates, he says.

“If you were to just compare survivalof a tooth, then a recent, very large epi-demiological study on root canal therapythat included about 1.4 million endodon-tically treated teeth across a population of1.12 million people in the United Statesshows that 97% of teeth that were treatedendodontically were still in the mouthafter eight years6,” Nasseh says. “Survivalwas the criteria for the study, which isbasically the same criteria used in implantstudies. Only 3% of those endodonticallytreated teeth were extracted and, of those,

2 Iqbal MK, Kim S. For teeth requiring endodontic treatment, what are the differences in out-comes of restored endodontically treated teeth compared to implant-supported restorations.Int J Oral Maxillofac Implants. 2007;22(Suppl):96-116. From: State of the Science on ImplantDentistry, Consensus Conference Proceedings.

3 Hepworth MJ, Friedman S. Treatment outcome of surgical and non-surgical management ofendodontic failures. J Can Dent Assoc. 1997;63(5):364-371.

4 Farzaneh M, Abitbol S, Lawrence HP, Friedman S. The Toronto Study. Treatment outcome inendodontics—the Toronto Study. Phase II: initial treatment. J Endod. 2004;30(5):302-309.

5 Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: the Toronto study.Phases I and II: Orthograde retreatment. J Endod. 2004;30(9):627-633.

6 Salehrabi R. Endodontic treatment outcomes in a large patient population in the USA: An epi-demiological study. J Endod. 2004;30(12):846-850.

Dennis Brave, DDSCo-founderReal World Endo®info@realworldendo.com

Robert A. Horowitz, DDSClinical Assistant ProfessorDepartments of Periodontology andImplant Dentistry,Biomaterials and BiomimeticsNew York University College of DentistryPrivate PracticeScarsdale, New Yorkrahdds@optonline.net

Jon Julian, DDSPrivate PracticeMcPherson, Kansasjk@mcphersondentalcare.com

Kenneth A. Koch, DMDCo-founderReal World Endo®info@realworldendo.com

Gregori M. Kurtzman, DDS,MAGD, FACD, DICOIPrivate General PracticeSilver Spring, MarylandDrimplants@aol.com

Robert A. Levine, DDSClinical Associate Professor inPost-Graduate Periodontics,Perio-Prosthesis and ImplantologyUniversity of Pennsylvania School of DentalMedicine, Philadelphia, PA

Private Practice, Pennsylvania Center for DentalImplants ad PeriodonticsPhiladelphia, PALevineDDSPC@aol.com

Richard E. Mounce, DDSPractice Limited to EndodonticsVancouver, WashingtonRichardMounce@MounceEndo.com

Mike MurphySenior Category ManagerImplants and Bone GraftingTulsa Dental Specialtiesmmurphy@dentsply.com

Ali Allen Nasseh, DDS, MMScClinical Instructor,Harvard University School of Dental MedicineClinical Director,MicroSurgical EndoEndoman@MSEndo.com

Keith D. Rossein, DDSPresident, International Dental ConsultantsEditor and Publisher, Implant News & Viewskrossein@optonline.net

Michael Sonick, DMDFairfield County Implants and Periodontics, LLCFairfield, CTmike@sonickdmd.com

James M. Tinnin, DDS, MSDDiplomate, American Board ofEndodontics Private Endodontic PracticeFayetteville, Arkansashogendo@aol.com

THEInside Look FROM…THEInside Look FROM…

Issue after issue, the feature presentations in Inside Dentistry deliver coverage ofthe relevant and thought-provoking topics specifically affecting the dental profes-sion, as well as oral healthcare in general. The publishers and staff could not bringthe underlying concerns surrounding these timely issues to the forefront withoutthe insights shared by our knowledgeable and well-respected interviewees. Fortheir collective generosity of time and perspectives, we extend our sincere gratitude.

132 INSIDE DENTISTRY—JULY/AUGUST 2008

“...regardless of

the prognosis

of the tooth,

clinicians

still need to

present patients

with all of their

other options...”

a great majority was not restored. So it’spossible that they were extracted becauseof the lack of restoration.”

Further, Nasseh points to another study—one conducted at the University ofMinnesota—that suggests that the suc-cess rates for non-surgical endodontictreatment and single-tooth implants arethe same.7 However, he notes that whatthis study also showed was that implanttherapy demonstrates a longer time tofunction and higher incidence of post-operative complications than endodon-tic treatment.

“When failures do occur, you cannotblame the root canal procedure itself forthe failure,” Nasseh emphasizes.“Researchhas demonstrated that in cases of endo-dontic failure, a large percentage of themhave been performed below the standardof care.8,9 Therefore, in my opinion, whenendodontics are performed properly ac-cording to the standard of care and usingmodern techniques, the treatments havea very high success rates.”

When taken in the context of what thepatient needs rather than the modalitiesthat a dentist does, the decision aboutwhether to save a tooth or extract it andplace an implant as a substitute becomes ispretty simple, believes Tinnin. “In today’sclinical practice, there are very, very feweither/or situations,” he says.“If a diagno-sis is correct, both modalities (ie, endon-dontics or implants) enjoy a very highdegree of success. Each patient must beevaluated on a case-by-case basis and notcategorized as an implant or an endodon-tic treatment option.”

Further, although it’s been noted thatadditional studies are needed to help de-termine when and to what extent certaintreatment modalities are appropriate andsuccessful, they cannot provide the skilland technical care needed to carry out animplant placement or a root canal to thehighest level, emphasizes Mounce. An ex-cellent final result is ultimately a functionof sound treatment planning and optimaltechnical service.

“While comparing implants versus en-dodontics on a Meta analysis or literaturebasis has a place and provides some gui-dance, the procedure has to be planned andcarried out correctly, irrespective what thesuccess or failure studies might show,”Mounce says.

“We think endodontics and implantsare equally terrific. But whichever mo-dality of treatment is chosen, we hopethat the clinician performs it in such a

way that it enhances the long-term prog-nosis,” Koch explains. “In terms of endo-dontics, we think right now that the persondoing root canals has to be very cogni-zant not to remove an excessive amountof coronal, radicular dentin.”

In the end, conservation and preser-vation of nature should—wheneverpossible—be the goal. “The natural toothis the best implant, and no material wehave today meets the gold standard of

the healthy, natural tooth. But as withthe natural tooth, every treatment weperform today also has a life cycle, andit eventually needs to be replaced,” ex-plains Tinnin. “It is our mission as clini-cians to properly diagnose, treatmentplan, and perform treatment to thehighest level of care. The longer we canextend this life cycle, the healthier thepatient is and the more economical atreatment has become.”

7 Doyle SL, Hodges JS, Pesum IJ, et al. Retro-spective cross sectional comparison of ini-tial nonsurgical endodontic treatment andsingle-tooth implants. JOE. 2006;32(9):822-827.

8 Sjögren U, Figdor D, Persson S, Sundqvist G.Influence of infection at the time of rootfilling on the outcome of endodontic treat-ment of teeth with apical periodontitis. IntEndod J. 1997;30(5):297-306.

9 Sundqvist G, Figdor D, Persson S, Sjögren U.Microbiologic analysis of teeth with failedendodontic treatment and the outcome ofconservative re-treatment. Oral Surg OralMed Oral Pathol Oral Radiol Endod. 1998;85(1):86-93.

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