Treating Our Patients Using Endodontic and Implant Restorations

Treatment Numbers Endodontic and implant restorations are performed daily by dentists and specialists For endodontic treatment, estimates for the year 2000 were 30 million endodontic procedures annually (ADA) Estimated number of patients receiving endosseous implants , ,000 annually, ,000 annually future annual growth rate % (Millenium Research Group)

Treatment Numbers 40% increase annually

Treatment Considerations “Treatment planning for the future: Endodontics, fixed partial dentures – or implants?”

Treatment Considerations “The success rate of non-surgical root canal treatment is unclear within the endodontic literature.” “…(endodontics) in general practice, the success rate can be 64% to 75%.” “Endodontic therapy may extend the life of the tooth but very little is known on the extent of tooth longevity.”

Implants vs. Endodontics The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”  Iqbal MK, Kim S, 2007

Implants vs. Endodontics Furthermore, in response to an ADA Foundation request for proposals Torabinejad, et al, conducted a systematic review of the clinical, psychosocial, and economic outcomes of endodontics, implants and FPDs.  Torabinejad, et al, 2007

Implants vs. Endodontics Success criteria Problem areas Who’s treating Publication bias Modern advances

Apples vs. Oranges Success criteria Problem areas Who’s treating Publication bias Modern advances

Implants vs. Endodontics Success criteria Problem areas Who’s treating Publication bias Modern advances

Success Criteria Endodontic Criteria 1956, Strindberg proposes stringent radiographic criteria  Strindberg LZ, 1956

Success Criteria Endodontic Criteria 1956, Strindberg proposes radiographic criteria Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised  Bender IB, Seltzer S and Soltanoff W, 1966  Van Nieuwenhuysen JP, et al, 1994  Fristad I, et al, 2004  Gutmann JL, 1992  Seltzer S, 1988

Success Criteria Endodontic Criteria 1956, Strindberg proposes radiographic criteria Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised However, some studies still use Strindberg’s dated criteria.  Allen R, Newton C and Brown C, 1991  Sundqvist G, et al, 1998  Sjogren U, et al, 1990  Farzaneh M, Abitbol S and Friedman S, 2004

Success Criteria Endodontic Criteria 1956, Strindberg proposes radiographic criteria Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised However, some studies still use Strindberg’s dated criteria. Fristad and colleagues showed the potential for late radiographic healing.  Fristad, Molven and Halse, 2004

Success Criteria

Endodontic Success Criteria 3-year recall

Endodontic Success Criteria

12-month recall

Success Criteria 1956, Strindberg proposes radiographic criteria Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised However, some studies still use Strindberg’s dated criteria. Fristad and colleagues showed the potential for late radiographic healing. Success or Survival?  Iqbal MK, Kim S, 2007

Success Criteria Success or Survival? The definition of “success” for dental implant studies is often implant survival Unlike implants and FPDs, RCTs aim to cure existing disease  Weiger, et al, 1998

Success Criteria Success or Survival? Unlike implants and FPDs, RCTs aim to cure existing disease Thus, RCT studies measure both the healing of existing disease and the occurrence of new disease.  Torabinejad, et al, 2007

Success Criteria Success or Survival? It has been suggested that implant success criteria are not routinely applied in much of the implant outcomes literature  Salinas and Eckert, 2007

Success Criteria Success or Survival? “In essence, the use of lenient success criteria in implant studies may translate to higher success rates, while stringent criteria employed in root canal prognostic studies may lead to lower success rates.”  Watson, et al, 1999  Johnson, et al, 2000  Wennstrom, et al, 2005

Success Criteria In order to establish comparable comparisons, it is critical that the same outcome measure is used to assess both endodontic and implant procedures.

Success Criteria In order to establish comparable comparisons, it is critical that the same outcome measure is used to assess both endodontic and implant procedures Due to these differences in meanings of success, it is probable survival rates “will permit less biased, albeit less informative, comparisons.”  Doyle, et al, 2006  Eckert and Wollan, 1998  Creugers, et al, 2000  Torabinejad, et al, 2007

Success Criteria The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”  Iqbal MK, Kim S, 2007

Success Criteria Success or Survival?  Iqbal MK, Kim S, 2007

Success Criteria - Implants Two 3.75 x 18 implants were placed on #9, 10 sites Implants appear osseointegrated

Initial visit pt presented with provisional restorations Success Criteria - Implants Esthetics case referred to Dr. Debra Johnson

Implants vs. Endodontics Success criteria Problem areas Who’s treating Publication bias Modern advances

Restorative Impact Lazarski et al examined over 110,000 endodontic cases, and found teeth that were not restored were significantly more likely (>4 X) to undergo extraction.  Lazarski et al 2001

Restorative Impact Lazarski et al examined over 110,000 endodontic cases, and found teeth that were not restored were significantly more likely (>4 X) to undergo extraction. The restoration of an endodontically treated tooth is considered a major determinant of its survival.  Vire DE, 1991  Siqueira JF, 2001  Hoen MM, Pink FE, 2002  Salehrabi R, Rotstein I, 2004  Aquilino SA, Caplan DJ, 2002  Sorensen JA, Martinoff JT, 1985

Restorative Impact The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”  Iqbal MK, Kim S, 2007

Restorative Impact

22-month recall

Restorative Impact The restoration of an endodontically treated tooth is considered a major determinant of its survival. More prosthetic complications with implants.  Goodacre CJ, et al, 2003  Iqbal MK, Kim S, 2007  Doyle et al 2006

Bone Loss Around Implants With implant placement, 1 mm of bone is loss during the first year of placement, with an additional 0.1mm annually. Can vary with implant type/material

Bone Loss Around Implants Bone Loss (mm) n=455 Error bars = S.E.M.

Cost to Patient Analysis of 2005 insurance data concluded that restored single-tooth implants cost % more than similarly restored endodontic- treated teeth

Cost to Patient Analysis of 2005 insurance data concluded that restored single-tooth implants cost % more than similarly restored endodontic- treated teeth Post-treatment problems can increase this cost difference

Cost to Patient Average Price ($$) 130% Increase

Implants vs. Endodontics Success criteria Problem areas Who’s treating Publication bias Modern advances

Who’s Treating? Historically, implants placed by specialists, while many endodontic studies were conducted on patients treated by dental students.  Aquilino SA, Caplan DJ, 2002  Bergman B, et al, 1989  Dammaschke T, et al, 2003  Lynch CD, et al, 2004  Mentink AG, et al, 1993

Who’s Treating? Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were systematically reviewed.  Torabinejad, et al, 2007

Who’s Treating? Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were systematically reviewed.  Torabinejad, et al, 2007 GPs or Specialists Students Implant 0% 87% Prostho 29% 35% Endo 63% 29%

Who’s Treating?

Implants vs. Endodontics Success criteria Problem areas Who’s treating Publication bias Modern advances

Publication Bias More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic.  Schnitman PA, Shulman LB, 1979  Iqbal MK, Kim S, 2007  Andersson B, et al, 1998  Brocard D, et al, 2000  Deporter DA, et al, 1998

Publication Bias More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic. Furthermore, 13% of the implant studies had an evaluator that was different than the operator, while 88% of the endo papers had independent evaluators.  Torabinejad, et al, 2007

Publication Bias More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic. Furthermore, 13% of the implant studies had an evaluator that was different than the operator, while 88% of the endo papers had independent evaluators “… the authors' results confirm the presence of publication bias in implant dentistry literature…”  Moradi DR, et al, 2006

Implants vs. Endodontics Success criteria Problem areas Who’s treating Publication bias Modern advances

Modern Advances Both Iqbal and Kim’s as well as Torabinejad and colleagues’ systemic reviews were conducted “using material from previous decades and therefore reflect the treatment approaches prevalent at that time.”  Iqbal and Kim, 2007

Modern Advances Implants New implant shape/design New surface modifications New implant-abutment interfaces Immediate loading Mini implants Etc…

Modern Advances Implants New implant shape/design New surface modifications New implant-abutment interfaces Immediate loading Mini implants Etc… Endodontics NiTi instrumentation Apex locators Surgical operating microscope Digital radiography Materials: MTA, MTAD, Resilon DNA hybridization, PCR, etc… Etc…

Case Selection

Case Selection – Fx #20

Case Selection

1-month recall

Case Selection

13-month recall

Implants vs. Endodontics The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”  Iqbal MK, Kim S, 2007

Implants vs. Endodontics The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.”  Iqbal MK, Kim S, 2007 AND

Implants vs. Endodontics The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry entrusted Iqbal and Kim to systematically “review clinical studies of the survival of single-tooth implants and endodontically treated and restored teeth and to compare the results.” Furthermore, in response to an ADA Foundation request for proposals Torabinejad, et al, conducted a systematic review of the clinical, psychosocial, and economic outcomes of endodontics, implants and FPDs.  Torabinejad, et al, 2007

Implants vs. Endodontics “…in periodontally sound teeth having pulpal and/or periradicular pathosis, root canal therapy resulted in…equal outcomes (97%) to extraction and replacement of the missing tooth with an implant.”  Torabinejad, et al, 2007

Implants vs. Endodontics “No difference in the survival rates between the two treatment modalities.”  Iqbal MK, Kim S, 2007

Implants vs. Endodontics n=4477 Unpublished data from AAE Foundation - Bowles, Eleazer, Drum & Goodis 2008

Implants vs. Endodontics Endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology.

Implants vs. Endodontics Endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology. Implants should be given priority in treatment planning for teeth that are planned for extraction

Implants vs. Endodontics The decision to treat a compromised tooth endodontically or replace it with an implant must be based on factors other than treatment outcome – since the outcomes are similar.  Iqbal and Kim 2008

Implants vs. Endodontics CASE SELECTION

Conclusion Functional survival rates are high for both treatments

Conclusion Functional survival rates are high for both treatments Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant

Conclusion Functional survival rates are high for both treatments Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant Since outcomes are similar with either treatment, decisions should be based on other factors such as restorability, costs, esthetics, potential adverse outcomes and ethical factors