ENDODONTICS VS

SINGLE-TOOTH IMPLANT

CURRENT CONTROVERSIES

DR AMIEN KHAN (GROUP LEADER), DR RHIDWAAN HAFFAJEE,

DR GRETHE KOEN,

DR NITUS VAN TONDER,

DR COLLIN VEERAN,

DR JAMES WALKER.

Dental Implant evolution over 40 yrs resulted in reliable & predictable treatment options

for missing teeth (Iqbal & Kim, 2008).IT include single-tooth replacement, an alternative to RCT for the compromised tooth

(Iqbal & Kim, 2008).

RCT is important in the retention and restoration of function of teeth affected by pulp and peri-apical disease (Pradeep & Rajesh, Jan-Jun 2013).

Recent paradigm shift in IT thinking is that it is equal or better RCT. (Toskos & DiBernardo, 2013). Recent

Decision making to retain & restore a compromised tooth or to remove & replace is still uncertain.

a dilemma/controversy (Thomas & Beagle, May 2006)The clinical decision could be consistent and easy with sufficient supporting evidence for

guidelines with universally accepted recommendations. Current trends are to retain teeth as long as possible.

IT is touted as equal or superior to preservation of compromised teeth with RCT.

With most cases the choice is obvious - if the tooth is intact, RCT should be performed (DiMatteo, July/ August 2008).

Dentist proficiency is a concern

INTRODUCTION

RCT - the prevention or elimination of apical

periodontitis by creating a fluid tight seal at the peri-apical area.

IT - The replacement of a missing tooth. This can be delayed or immediate placement/loading.

RCT & IT

Treatment objectives:

To rehabilitate oral function To a lesser degree improve aesthetics.

Treatment should: Address the patient’s main concern, Show longevity, Be cost effective Be based on scientific evidence, Preserve the biological environment Restore aesthetics and function.

(Torabinejad & Goodacre, July 2006)

Decision making: IT or RCT?

Retention of the compromised tooth is possible with RCT and a coronal restoration or

Extraction and replacement with IT

(Sharma & Nair, 2012)

Current Controversy:

Function

RCT

Endodontically treated teeth function like normal intact teeth.

(Morris, et al., 2009)

IT

Lacks periodontal ligament

Lower maximum bite force

Reduced chewing efficiency

Smaller occlusal contacts.

Complications

RCT Retreatment, Apical surgery Extraction RCT failure rate

IT Biological, Technical Mechanical More maintenance and

follow up

Advancement in instrumentation & materials Greater predictability Cost-effective compared to IT Conservative/non-invasive Important option in systemically compromised

patients Success rate comparable to IT

(Cobankara & Belli, August 2011)

Factors in favour of RCT

Poor outcome of RCT compared with IT ‘success’

rates Concerns over durability of weakened inherent

structure of a RCT tooth supported by a coronal restoration.

Implant fixture is a better foundation for restorative dentistry than a RCT tooth.

Implant restoration ‘may require’ less follow up compared to endodontics (this in itself may be controversial)

(Iqbal & Kim, 2008)

Factors in favour of IT

A surviving implant is that which is still

retained in the oral cavity A successful implant is has:

absence of clinical symptoms, no signs of inflammation, limited marginal bone loss (not > 0.2 mm after

the 1st year of function. (Pjetursson, et al., 2004)

Success criteria:

RCT success rate over 5 years of 81%. IT average survival rate of 96.7% Many report equal success rates of 97% for IT

& RCT. (Thomas & Beagle, May 2006)

Success Rates

1. Survival Rates2. Outcome of non-surgical retreatment & endodontic

surgery3. Patient Factors4. Health5. Para-functional Habits/Bruxism6. Treatment duration7. Aesthetics8. Soft tissue management9. Finances10. Clinician’s proficiency and preference11. Risk factors of Treatment

Factors that play a role in treatment planning:

Continuous alveolar bone growth Aesthetic concern particularly in single tooth

restorations Gingival recession over years Possible susceptibility to periodontal and peri-

implant disease

(Cobankara & Belli,August 2011)

RCT better than IT:

Teeth with prior RCT & persistent peri-apical lesions can

be saved with non-surgical retreatment or endodontic surgery.

A systematic review of re-surgery report a failure rate of 38%. (McCord & Grant, 2000)

Outcomes of non-surgical retreatment and endodontic surgery

Consent Patient's Perception of Treatment Age Health Condition Treatment duration Aesthetics Soft tissue management Finances Clinician’s proficiency and preferenceBoth RCT & IT improve quality of life by alleviation of pain, improved function, aesthetics, speech and patient satisfaction

Patient concerns

When treating a compromised tooth, factors to be

considered include prosthodontic, endodontic & periodontal factors.

With questionable longevity extraction may be the better alternative. (Dehalli & Mounce, May 2001).

The type of restorations on a RCT teeth & success of coronal seal influence long-term retention of the teeth compared to RCT on its own (Cobankara & Belli, August 2011).

Risk factors of Treatment

Site

Anatomy of the site is important. (Muskant, 2009) Little consequence with endodontics (Ikram, 2011)

Space Space between implants and other structures to be considered RCT is generally straight forward. (Ikram, 2011)

Neighbouring teeth Treatment of neighbouring teeth may delay IT. RCT and neighbouring teeth can be treated at the same time (Ikram, 2011)

Clinical Factors influencing IT vs RCT

A compromised tooth is defined as impaired structure or

pathology, with disorders that impair the ability of the tooth to function properly without some type of restoration.

End-stage is defined as a pathologic or structural deficiency that cannot be repaired with reconstructive therapies, including RCT & continues to show pathological changes as well as clinical dysfunction

(Iqbal & Kim, 2008), (Cobankara & Belli, August 2011), (Christensen, 2006).

Compromised vs End stage

Coronal Restorations and the outcome of a RCT

tooth & single-tooth implant

Influence of a Coronal Restoration on the outcome of RCT?

Risk of extraction decreases up to 4x with coronal restoration placed.

Comparison of outcome of coronally restored RCT teeth and single-tooth

implant.

Analyzed data showed no difference in long-term outcome between the 2 modalities. Both showed high survival rates >94%. (Iqbal & Kim, 2008),(Ikram, 2011)

Are there more complications in implants?

(Doyle, et al., 2006), reported that dental implants had a 5 x greater number of complications compared to restored RCT teeth.

Do outcome assessments reflect technology in evolution? Evidence that with new technology, advancement in electronic apex locators, operating microscopes & materials such as therma-fill,gutta-percha core and MTA, these all have improved the safety and accuracy of RCT. (Toskos & DiBernardo, 2013)

If apical periodontitis persists or develops after root canal treatment then what treatment procedure should be recommended? Reported radiographic success rates of studies with modern microscopic surgical endodontic procedures often are greater than 90%. (Stoumza, 2005)

Can immediate implants be placed in sockets where teeth were extracted because of apical periodontitis? Apical periodontitis does not significantly alter implant osseo-integration with a 90% survival rate of implants reported after immediate insertion after tooth removal. (Siegenthaler, et al., 2007) Is RCT preferred in patients with poor quality of bone?

Failure rates in Type IV bone is approximately 35%. Quality of bone is an important consideration when treatment planning for implants (Mombelli & Cionca, 2006).

(Christensen, 2006), advised that if bone density/area is problematic or there are anatomical structures present, then RCT should be considered.

Other questions to be asked.

Indemnity

Indemnity & IT

IT account for 7-8% of claims annually & is on the increase.

Practitioners are driven by manufacturer’s claims

The majority of claims with RCT is due to incomplete obturation. (Kelleher, 2010)

Indemnity & RCT

Treatment should be a solution with patient consent, that

will universally offer the best long term prognosis. (Stoumza, 2005)

According to (Stoumza, 2005), there are 2 distinct phases in decision making: o 1)Evaluate the evidence to “save or not to save”,o 2)Evaluate the feasibility of the “what if” scenario.

Modification of the treatment path must be allowed as the treatment develops.

How do we decide on a specific treatment modality?

Each clinical situation is unique and different. Both RCT & IT have benefits and risks, they complement each other as treatment options. IT is a useful alternative in replacement of teeth with poor prognosis. The optimal treatment plan must incorporate the best available evidence together with

specific factors & the patient's desires and needs. Patient & clinical factors determine if RCT or IT should be done. There is no perfect treatment planning guide to help with decision making. The ultimate goal of both RCT & IT is to help and facilitate rehabilitation of the patient's

natural dentition & restore function and aesthetics. There is a great degree of differences in studies reporting outcome measures and criteria

for success. As current controversy continues even with a plethora of clinical evidence for and against

endodontic and implant treatment "TO SAVE OR NOT TO SAVE?" - is still the question that beckons!

Conclusion

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References cont.

Any questions?