All Things Considered

Fundamental Elements

One guiding principle of decision-making in dentistry is to maximize health while minimizing risk. Accordingly, the decision to pursue endodontic treatment or to extract a tooth and replace it with an implant should be predicated on a thorough risk analysis of each patient's individual circumstances. Practitioners' levels of education and experience factor in heavily; however, the decision can still be difficult to make, especially in cases in which the success and survival rates of both options are about equal. A recent retrospective comparison of patients who received both nonsurgical root canal treatments and single-tooth implants found that both treatments demonstrated a 95% survival rate at a mean 7.5-year follow-up.¹ And although research has shown that properly treated teeth with significantly reduced periodontal support are able to support extensive fixed prostheses for long-term periods with survival rates close to 90%,² systematic reviews have indicated that the 10-year survival rate of dental implants is approximately 96%.³ The decision to save or replace is further complicated by a variety of patient-specific factors that play roles in the success rates of both implants and root canal procedures, including the location in the alveolar arch, the type of restoration, occlusion, bone quality, the presence of systemic medical conditions, patient age, lifestyle issues such as tobacco use, and more.⁴

"The most difficult situations are the ones in which both procedures will present their own set of challenges," says Allen Nasseh, DDS, MMSc, a clinical instructor of postdoctoral endodontics at the Harvard University School of Dental Medicine and private practitioner in Boston, Massachusetts. "Deciding relative risk combines the analysis of two different specialists; therefore, it is necessary to work as a team as well as to maintain excellent communication and the pillars of professionalism."

When considering which approach is more appropriate regarding factors such as function, esthetics, and patient comfort, dentists should be fully aware of all of the possible long-term complications of both endodontic treatment and implant therapy. "The general practitioner is like the quarterback," explains Rebekah Lucier Pryles, DMD, an assistant clinical professor of endodontics at the Tufts University School of Dental Medicine and a private practitioner in White River junction, Vermont. "By and large, the decision rests on the general practitioner, but we are practicing dentistry in an era of shared information, so his or her decision is informed by specialists like myself who will confirm, ‘Yes, that endodontic prognosis is an appropriate solution for this particular case.'" In addition, factors such as the number of adjunct and additional treatments that will be required, the number of appointments necessary, the time needed prior to delivery of the final restoration, the number of prescribed medications involved, and the cost of the treatment should be a part of the conversation and ultimately the decision. Although the techniques and materials used in both endodontic and implant therapy have significantly evolved, the research still fails to support a clear consensus on the general preference of one approach over the other. The decision should be made at the individual patient level, and the decision-making process should involve each patient's individual presentation and circumstances.

Determining Best Practices

Because the decision to attempt to save a tooth is based on patient-specific factors in every circumstance, best practice is more about being guided by principles than following dogma. There are many key indications that can sway a practitioner toward either endodontic or implant therapy. "When there is inadequate bone level or support, if the patient exhibits heavy bruxism, or if the patient has medical limitations that preclude a surgical approach," explains Nasseh, "those are all indications in favor of endodontics." Root canal treatments to save compromised teeth has been shown to have a high success rate when performed by both endodontists and general practitioners.⁵ Furthermore, research suggests that a significantly higher percentage of patients would rather opt for endodontic treatment to preserve their natural teeth than have them extracted and replaced with implant-supported restorations.⁶ "Although teeth have a special sentimental value to many patients who want to save their natural dentition," says Nasseh, "I believe that it's always best to try to preserve what's natural and ours rather than simply electing to replace our parts with artificial counterparts for the sake of efficiency or convenience."

Alternatively, for some practitioners, advances in the field of dental implantology have changed their perspective regarding trying to save the teeth of patients who are indicated for implants and express a preference for them. "For years, conventional dentistry has tried to do everything that it could to preserve the natural tooth at all costs," notes Paul Petrungaro, DDS, MS, a diplomate of the International Congress of Oral Implantologists and private practitioner in Chicago, Illinois. "But nowadays, there's a patient consideration to be assessed regarding saving a tooth versus saving time and money. In 2022, we are able to remove the tooth, place the implant, and basically have a quick, worry-free resolution with long-term success." Part of the success of modern implant treatment can be attributed to the improved accuracy and predictability achieved through digital workflows, which have enabled surgeons to more effectively and accurately plan implants and their restorations in three dimensions, create surgical guides, and when indicated, place and immediately restore implants in one session.⁷

Clinicians' specific experiences within their own practices can also influence their opinions regarding the salvageability of teeth. "We see a lot of pediatric patients in my practice," says Pryles. "And in those cases, we may give a lot more thought to retaining something that's more complicated in order to facilitate healthy growth and development of the jawbone."

In cases that require endodontic re-treatment to save teeth, the cause of the failure factors heavily into the assessment of whether such an approach is appropriate. "Most of my practice is taking on failed root canal patients," explains Petrungaro. "If the issue is just with one tooth and it's surrounded by healthy, unrestored teeth, then why not try to keep it. But over time, with multiple failed root canals in a patient, there may be a critical connection between the failures and the individual's overall health."

A comprehensive patient risk assessment should include an evaluation not only for the potential for future caries and periodontal disease but also for any systemic or other conditions that could influence the success of treatment. "We must look at the patient as a whole, consider his or her comorbid oral diseases, and assess the best option for each particular case," says Pryles.

The Impact of New Developments

In simple cases, the decision of whether to attempt to save a tooth with endodontic treatment or to extract and replace it can be made between general practitioners and their patients. However, in more complicated cases, a conversation between specialists may provide more informed guidance on how best to proceed. "We have to consider how new dentists are being taught in school," suggests Petrungaro. "How can dental schools, in four years, cover all the advancements that dentistry has experienced during the past 10 years?" Because outcomes will largely be influenced not only by technology but also by how clinicians will use it, education is critical. This is leading more and more dentists to complete a practice residency upon graduation and is further impetus for collaboration among specialists. According to the American Dental Association, approximately 35% to 40% of dental students pursue advanced education in residency programs.⁸ Ultimately, the delivery of superior patient care is the main motivating factor in the decision-making process of all dental practitioners, but as techniques, materials, and technologies continue to evolve, so will the conversation on best practices.

Advancements in materials have improved the efficiency and long-term success of endodontic treatment. "With bioceramics began a new era of efficiency in endodontics," explains Nasseh. "Although these cements have excellent success rates like traditional cements, they are also significantly more biocompatible and have permitted the development of substantially less complicated obturation and surgical techniques as a result of their unique properties." In addition to increased biocompatibility, bioceramic endodontic materials are advantageous in that they are nontoxic, dimensionally stable, and most importantly for endodontic procedures, bioactive.⁹

Advances in technology have benefited both endodontic and implant therapies. For example, cone-beam computed tomography (CBCT) has improved diagnosis, case selection, and treatment planning by identifying issues that conventional periapical radiography could not. "My practice now has a fully digital workflow, which means that I can use CBCT scans to create digital images that allow patients to have more input in the process, helping to decide the preferred size, shape, and color of their restorations," says Petrungaro. "Digital workflows have really catapulted the immediate implant field to the next level."

For endodontics, a digital workflow incorporating 3D endodontic treatment planning software can help in the simulation of complex treatments,¹⁰ and CBCT and optical scan data can be used to design and 3D print small endodontic microsurgery guides to help facilitate guided osteotomy and root resection.^10,11 During the past few decades, digital radiography, CBCT, and scanning technologies have revolutionized dentistry. But in the future, innovations in techniques, diagnostic technologies, and materials will continue to improve upon the success of endodontic and implant treatments, so it's imperative that both general practitioners and specialists stay up to date with the literature to inform their decision-making processes. "New research is published every single month by reputable sources," notes Pryles, "We need to stay on top of the latest and best information out there—through journal articles and continuing education courses—so that we can ensure that our patients have all the latest and best information."

Finding the Right Answer

The decision to maintain a compromised tooth through endodontic and restorative treatment or to extract it and replace it with an implant and an implant-supported restoration remains one that is based on patient-specific factors as opposed to research demonstrating the superiority of one approach over the other. Due consideration should be given to the restorability of the tooth in question, as well as the esthetic implications, clinical complexity, position of the tooth in the arch, the general systemic health status of the patient, and the patient's overall procedural preference, among other factors.¹² In addition, the selection of a particular approach may be influenced by the practitioner's education, experience, and preferences. Endodontic therapy and implant therapy should not be viewed as competing alternatives but rather as complementary treatment options, each of which can provide the correct solution when used in the appropriate patient situation. "One of our main goals should be to create realistic expectations for our patients by inquiring about their priorities for their mouths and their limitations in achieving them," emphasizes Nasseh. "This is the best way that we can help them make the best decisions for their own healthcare."

Clinical Resources

Interested in peer-reviewed content focused on endodontics and implantology? Browse Inside Dentistry's extensive online library of clinical articles.

ENDODONTICS

Fiber-Reinforced Composite Post and Core Techniques

Daniel H. Ward, DDS

Examine the progression of endodontic posts from earlier cast metal versions to more modern fiber-reinforced options and learn about their advantages in different situations.

History-Centered Diagnosis

Brooke Blicher, DMD, and Rebekah Lucier Pryles, DMD

Diagnosing endodontic disease requires the careful compilation of subjective and objective data. The information obtained from patients during the subjective examination enables differential diagnosis and guides the clinical and radiographic examinations.

Pulpal Diagnosis and Treatment

James Bahcall, DMD, MS; Qian Xie, DDS, PhD; Mark Baker, DDS; and Steve Weeks, DDS

This article explores the types of pulpal nerves and their function, discusses sensibility and vitality testing, presents the current pulpal diagnostic terminology, and proposes an updated system of pulpal diagnosis and treatment terminology.

IMPLANTOLOGY

Tooth Replacement in the Maxillary Posterior

John R. Francis,
DDS, MS

A case report demonstrates the favorable outcomes that can be achieved from restoratively driven, guided implant placement with a surgical guide fabricated using CBCT data and implant planning software.

Repairing an Apical Lesion Around a Dental Implant

Timothy Kosinski, DDS, and Stephanie
Tilley, DMD

Explore options for treatment and their efficacy, review the different types of dental lasers and their applications, and examine how a soft-tissue diode laser can be used to decontaminate the surfaces of infected implants and their surrounding sites.

Full-Mouth Rehabilitation With Fixed, Implant-Supported Prostheses

Abdulmohsin Alhashim, BDS, MSD; Ronald L. Harris, DDS; Ahmed Zaher, BDS, MSD; and Barry D. Hammond, DMD

In this case report, implants that were improperly placed due to a lack of preoperative treatment planning are removed and replaced to enable a full-mouth rehabilitation with screw-retained, implant-supported fixed prostheses.