Treating Our Patients Using Endodontic and Implant Restorations PPAC
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)
Treatment Numbers ď Ž
Implant placement at University of Minnesota 1997-2007 900 Patients
800 700 600 500
Implants
40% increase annually 1997-2007
400 300 200 100 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year
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 ď Ž 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 ď Ž 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
Success Criteria
Endodontic Success Criteria
3-year recall
Endodontic Success Criteria
Endodontic Success Criteria
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 ď Ž 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 ď Ž Two 3.75 x 18 implants
were placed on #9, 10 sites ď Ž Implants appear osseointegrated
Success Criteria - Implants Initial visit pt presented with provisional restorations
Esthetics case referred to Dr. Debra Johnson
Implants vs. Endodontics Success criteria Problem areas Who’s treating Publication bias Modern advances
Restorative Impact ď Ž 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
Restorative Impact
Restorative Impact
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 ď Ž With implant placement, 1 mm of bone is loss
during the first year of placement, with an additional 0.1mm annually. ď Ž Can vary with implant type/material
Bone Loss Around Implants 4
Bone Loss (mm)
3
2
1
0 0
1
2
3 Year
4
5
>
6
n=455 Error bars = S.E.M.
Cost to Patient ď Ž Analysis of 2005 insurance data concluded
that restored single-tooth implants cost 7590% more than similarly restored endodontictreated teeth
Cost to Patient ď Ž Analysis of 2005 insurance data concluded
that restored single-tooth implants cost 7590% more than similarly restored endodontictreated teeth ď Ž Post-treatment problems can increase this cost difference
Cost to Patient
Average Price ($$)
2000
1500
130% Increase
1000
500
0 Endodontic/Restoration
Implant/Restoration
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? ď Ž 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
Implant Prostho Endo
GPs or Students 0% 29% 63%
Specialists 87% 35% 29%
Who’s Treating?
Who’s Treating?
Who’s Treating?
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 ď Ž More likely to exist when a particular brand of
implant is studied. While endodontics is mostly generic. ď Ž 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
Case Selection
Case Selection – Fx #20
Case Selection
Case Selection
1-month recall
Case Selection
Case Selection
Case Selection
Case Selection
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 Endo/Implant:Survival proportions 1.0 0.9 0.8
Implant Endodontic
0.7 0.6 0.5
0
2
4
6
8
10
n=4477
Time Unpublished data from AAE Foundation - Bowles, Eleazer, Drum & Goodis 2008
Implants vs. Endodontics ď Ž Endodontic therapy should be given priority in
treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology.
Implants vs. Endodontics ď Ž Endodontic therapy should be given priority in
treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology. ď Ž Implants should be given priority in treatment planning for teeth that are planned for extraction
Implants vs. Endodontics ď Ž 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 CASE SELECTION CASE SELECTION
Conclusion ď Ž Functional survival rates are high for both
treatments
Conclusion ď Ž Functional survival rates are high for both
treatments ď Ž Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant
Conclusion ď Ž Functional survival rates are high for both
treatments ď Ž Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant ď Ž 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