1. Treating Our Patients Using Endodontic and Implant Restorations

2. 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 1996 - 300,000-428,000 annually, 2000 - 910,000 annually future annual growth rate - 18.6% (Millenium Research Group)

3. Treatment Numbers 40% increase annually 1997-2007

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

5. 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.”

6. 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

7. 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

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

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

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

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

12. 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

13. 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

14. 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

15. Success Criteria

17. Endodontic Success Criteria 3-year recall

18. Endodontic Success Criteria

20. 12-month recall

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. 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

28. 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

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

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

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

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

33. 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

34. 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

35. 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

36. Restorative Impact

39. 22-month recall

40. 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

41. 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

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

43. Cost to Patient Analysis of 2005 insurance data concluded that restored single-tooth implants cost 75- 90% more than similarly restored endodontic- treated teeth

44. Cost to Patient Analysis of 2005 insurance data concluded that restored single-tooth implants cost 75- 90% more than similarly restored endodontic- treated teeth Post-treatment problems can increase this cost difference

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

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

47. 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

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

49. 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%

50. Who’s Treating?

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

55. 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

56. 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

57. 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

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

59. 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

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

61. 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…

62. Case Selection

65. Case Selection – Fx #20

66. Case Selection

67. 1-month recall

68. Case Selection

72. 13-month recall

73. 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

74. 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

75. 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

76. 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

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

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

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

80. 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

81. 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

82. Implants vs. Endodontics CASE SELECTION

83. Conclusion Functional survival rates are high for both treatments

84. 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

85. 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