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Root Canal or Implant?

Posted Sep 22 2008 10:30am
The latest version of Inside Dentistry (July/August 2008, volume 4, number 7) has a very interesting cover story by Allison M. DiMatteo BA, MPS. As an endodontist, I have been watching this debate develop for quite some time. I think it is important to determine what is behind this effort to pit one dental specialty against another.

This particular article seeks the opinion of endodontists and periodontists alike. All sides agree that implants are a great way to replace missing teeth. There is consensus that there is value to retaining natural teeth. The disagreement seems to come from the debate about when to remove a tooth in order to place an implant.

There are some who argue that implants are more successful than endodontically treated teeth. This is despite the evidence that shows that implants and endodontically treated teeth have similar, almost identical success rates.

Richard Mounce DDS, an endodontist, points out that the only controversy between endodontics and implants is "primarily economic and more artificially manufactured than exists in reality...There are clear indications for endodontic therapy and clear indications for implant therapy. Rarely are these treatment options so evenly weighted that when considered side by side (as to their advantages and disadvantages) that there should be a 'competition' or 'controversy', most especially when the patient's interest is put first".

According to Gregori M. Kurtzman DDS, "as a general rule, it is better to save a tooth...if you can". Restorability is the key factor in determining when a tooth needs to be removed. Ability to get a good margin, not violate biological width, cracks, strength of furcation, crown:root ratio etc. are all important factors in determining the restorability of the tooth. An endodontically treated tooth with a poor restoration, will generally not have long term success.

However in the same article, Dr. Kurtzman goes on to questions the success rates of endodontic surgery, and even the value of endodontic retreatment. Dr. Kurtzman points out that the financial investment into retreatment, like all treatment options which does not have 100% success rate, may be better made in a more predictable treatment of an implant.
That argument shows lack of understanding and appreciation for modern microscopic endodontic therapy.

I routinely recommend implant therapy for patients. What concerns me as a specialist is to see the marketing techniques and lack of proper endodontic evaluation during the treatment planning of implant cases. All of our mailboxes are full of marketing journals filled with clinical cases of implant placement.

Here is an example of two cases in the same issue of Inside Dentistry p.104-108.


This case is described as a "peri-apically involved maxillary incisor resulting from a failed root canal." Treatment options were reviewed and informed consent was obtained. Based on the patient's desire to reduce trauma and treatment time, it was decided to perform immediate implant placement. First of all, failed root canal is not an accurate diagnosis. The radiograph does not show the peri-apex. As best as we can tell the periodontal ligament looks fairly normal at the periapex. Was retreatment an option discussed? If it was, would it not be considered "less truamatic" than extraction and immediate implant placement? Not to mention the ability of a natural tooth to retain the crestal bone levels. Unless this tooth has a vertical fracture, of which there is no evidence, endodontic retreatment is a better option.

Another case from the same article shows a 27 year old female with a "symptomatic maxillary left lateral incisor with a history of endotherapy with a core build-up and crown". Active infection was noted with perilous fistula and exudate at the gingival margin. The prognosis of this tooth was deemed "hopeless".

Again, the endodontic evaluation of this tooth is incomplete. The anterior "bite-wing" type film certainly shows a normal crestal bone level, however, it is impossible to evaluate the endodontic therapy and is not a sufficient pretreatment radiograph. The conclusion that this tooth has a "hopeless" is premature.

Inadequate endodontic evaluation seems to be commonplace in many of the published clinical cases and those marketing dental implants. As mentioned above, there should be little controversy regarding endodontics and implants. Our specialties should not be pitted against one another, but should work together to meet the needs of our patients.

Sources:

DiMatteo, A. "Making the Right Move: Planning Your Clinical Strategy", Inside Dentistry, July/August 2008. p122-133.

Malek, M. "Done in a Day: Immediate Tooth Replacement with Definitive Prosthesis", Inside Dentistry, July/August 2008. p104-108.

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