ETHICAL CONSIDERATIONS
Dental practitioners have an obligation to provide the longest lasting, most cost-effective treatment that addresses the chief complaint of the patient and meets
A B
or exceeds patient expectations whenever possible. Advice to the patient and the treatment provided should be patient-centered, not based solely on dental insurance benefits or guided by the desires and exist- ing clinical experience of the practitioner. Practi- tioners should strive to present a balanced perspective
regarding alternative treatments. The capacity to achieve balance requires practitioners to be familiar with both treatments. It is difficult to objectively pre- sent alternative treatment options when an individual has only substantive clinical experience with one option.
A B
Figure 7 A, Patients with thick biotype gingiva and teeth in esthetic zones are good candidate for dental implants. B, Patients with thin biotype gingiva and teeth in esthetic zones are good candidate for root canal treatment.
A
B
Figure 8 A, Mandibular molar region has good bone quality for implant placement. B, Maxillary molar region with poor quality bone is not ideal for dental implants.
PATIENT COMFORT AND PERCEPTIONS
The studies that have focused on the pretreatment anxiety of patients seeking root canal treatment are inconclusive. Whereas some note no difference between root canal treatment and extraction,56,57 others58report higher anxiety levels in patients being considered for randomized controlled trial (RCT). A lack of data exists about examining pretreatment anxiety of patients seeking implant treatment. The most similar treatment that has been studied is extrac-
tion. However, patients presenting for extraction are often in pain, as are those presenting for root canal treatment. This may have the effect of raising the anxiety levels of both these patient populations.
The question of pain associated with treatment has been analyzed to some degree in implant literature, although not to the same extent as in the endodontic literature. Andersson et al.59 found that 88.2% of subjects gave positive responses to the question of implant treatment being pain-free, with 70.6% giving a ‘‘Yes’’ response along with 17.6% stating, ‘‘Yes, with doubt.’’ Watkins et al.,60on the other hand, observed a mean pain score of 22.7 out of 100 in 333 subjects seeking RCT, with an additional score of 19.9 noted ‘‘unpleasantness.’’ Of significance, 20% of the endo- dontic cohort reported to the appointment in pain. One prospective study61 focused on implant compli- cations and found that 92% of the subjects felt the number of complications was acceptable. No endo- dontic study was found to have evaluated this ques- tion.
PROCEDURAL COMPLICATIONS
Root canal treatment can sometimes be associated with procedural accidents (Figure 10A). These mishaps can occur during different phases of root canal treatment.62 Some of these accidents can have a negative impact on the outcomes of root canal treatment.63–65Studies have shown that the apical extension of root canal filling materials as well as quality of obturation can affect the prognosis of root canal treatment.33,66
As with root canal treatment, complications can occur with dental implants. Surgical implant complications Figure 9 Retaining teeth through root canal treatment and bleaching
without ceramic crowns in esthetic zones may be esthetically advanta- geous over placing implant crowns that are difficult to match to adjacent teeth.
A B
Figure 10 Root canal treatment or implant placement can sometimes be associated with procedural accidents. Examples are A, furcation perforation in a maxillary molar; B, a large hematoma following implant surgery.
include hematomas (Figure 10B), echymosis, and neurosensory disturbance.54Inflammation and/or pro- liferation of gingiva as well as soft tissue fenestration/ dehiscence can occur following implant placement. Early implant loss can occur as a result of failure of the implant to integrate with the bone. Mechanical compli- cations of implant placement include screw loosening, screw fracture, prosthesis fracture, and implant frac- ture.54 Minor complications such as screw loosening are easily corrected, whereas major complications such as fenestration/dehiscence can result in clinical failure.
ADJUNCTIVE PROCEDURES REQUIRED
A number of adjunctive procedures can be performed in high-risk root canal treatment or placement of an implant and crown. Saving some teeth with significant decay or periodontal disease may require crown lengthening through surgery or orthodontic extrusion as well as periodontal disease therapy. In light of high success rates with dental implants, the value of such procedures needs to be reevaluated.
Lack of bone prior to placement of an implant may require bone grafting or distraction osteogenesis, sinus grafting, and ridge augmentation. These highly difficult technical procedures are expensive, unplea- sant, and time consuming.
COST OF TREATMENT
According to the data collected by the American Dental Association (Jack Brown, personal commu- nication) through its Services Rendered Survey that yield national and subnational estimates of fees for general practitioners (GPs) and specialists for each CDT4 code, the initial cost of an extraction, endo- steal implant, abutment, and crown is approximately $2,850 and does not vary substantially whether a GP, an oral surgeon, or a periodontist provides the surgical care. On the other hand, the costs of an anterior root canal treatment provided by a GP with a resin-composite restoration, and a molar root canal treatment provided by an endodontist followed by an amalgam build-up and a porcelain fused to high noble metal crown are approximately $743 and $1,765, respectively. This simple analysis does not include consultation fees and pre-operative radio- graphs that may vary from simple periapical views to cone-beam tomography and CT scan for implant placement. Additional separately charged procedures such as surgical guides (stents) or provisional restorations may also be necessary. Retention of a periodontally sound tooth through root canal treat- ment clearly has tremendous cost benefit and cost-
effectiveness in comparison with any alternative where the tooth is lost.
TREATMENT OUTCOMES
Clinical and radiographic examinations are the most common procedures used to determine outcomes of root canal therapy. Examination of the data regarding success and failure of root canal treatment shows significant variability in material composition, treat- ment procedures, and evaluation criteria. Some stu- dies use recognized evaluation methods, such as the periapical index.67 The periapical index relies on the comparison of the radiographs with a set of five radiographic images representing a radiographically healthy periapex (score 1) to a large periapical lesion (score 5). Another evaluation method that has been used in several studies is the system suggested by Halse and Molven,68who place radiographic findings in one of the following groups: (1) success, where there in no visible periapical lesion; (2) uncertain, where there is an uncertain finding such as an existing increased width of the periodontal ligament space; and (3) failure, where there is a pathologic finding such as a periapical radiolucency. The shortcomings of these methods of evaluation are that they deter- mine ‘‘success’’ strictly on the basis of radiographic findings. As early as 1966, Bender and coworkers69 noted that radiographic interpretation is often subject to personal bias and that a change in angulations can often give a completely different appearance to the lesion, making it appear either smaller or larger. It has also been shown that different observers may not agree on what they see in a radiograph, and in fact the same observer may disagree with himself if asked to review the same radiograph some time later.70
Based on the results of studies published since 1996, the American Dental Association Council on Scientific Affairs reports high implant survival rates for various clinical situations.39 With regard to the single-tooth implant, the Council’s evaluation of 10 studies involving over 1,400 implants shows survival rates (without giving length of time) ranging from 94.4% to 99%, with a mean survival rate of 96.7%. High mean survival rates were also reported for partially edentulous patients with implant FPDs. This report states that immediate loading of implants does not lower the survival rates, with three studies reporting survival rates ranging from 93.5% to 95.6%.39 In a systematic review of clinical implant studies, Creugers and associates71 predicted a 4-year survival rate of 97% for single implants. In another paper, Lindh et al.72 performed a meta-analysis of
implant studies involving partially edentulous patients. They reported a success rate of 97.5% after 6 to 7 years for a single-implant crown.
In a recent systematic review, Torabinejad et al.21 compared the outcomes of endodontically treated teeth with those of single dental implant-supported crown, FPD, and no treatment following extraction. Success data in this review consistently ranked implant therapy as being superior to endodontic treatment, which in turn was ranked as being superior to fixed prostho- dontic treatment (Table 1). At 97%, long-term survival was essentially the same for implant and endodontic treatments and was superior to extraction and replace- ment of the missing tooth with a FPD. Iqbal and Kim73 have reported similar findings when they compared the survival of restored endontically treated teeth with implant-supported restorations.
ALTERNATIVE TREATMENTS
The treatment options following unsuccessful initial root canal treatment are re-treatment and/or endodontic sur- gery. In two separate searches, investigators at Loma Linda University searched for clinical articles pertaining to success and failure of nonsurgical and surgical re-
treatment, and assigned levels of evidence to these studies. Their first search, related to nonsurgical re- treatment, resulted in the identification of 31 clinical studies and 6 review articles.74The success rate of non- surgical re-treatment ranged between 40% and 100%. Based on the literature, it appears that the success rate is very high in teeth without periapical lesions and when the cause of failure is identified and corrected properly.74 Their second search, pertaining to success and failure of periapical surgery, located many clinical studies, most of which were case series.75The success rate of surgical endo- dontics varied from 31% to over 90%. The significant differences in the techniques, materials, and methods of evaluation make it very difficult to compare these studies. Most recent studies using new materials and techniques report high success rates for endodontic surgery.76–79
Considering factors involved in treatment planning for patients who have been afflicted by oral diseases or traumatic injuries, decision to keep a tooth through root canal treatment or periodontal therapy, or extraction and placement of a fixed or partial denture, or an implant supported restoration, should be based on scientific evi- dence. Ideally one should strive to preserve the biologic environment, while maintaining or restoring long-term esthetics, comfort, and function for the patient.
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Table 1 Pooled and Weighted Survival and Success Rates of Dental Implants, Root Canal Treatment, and Three Unit Bridges 2–4, 4–6, and Over 6 Years
Success Survival 2–4 years
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