Treating Our Patients Using Endodontic and Implant Restorations

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Treating Our Patients Using Endodontic and
Implant Restorations
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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)

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Treatment Numbers

40 increase annually 1997-2007
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Treatment Considerations

• Treatment planning for the future Endodontics,
  fixed partial dentures or implants?

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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.

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Implants vs. Endodontics

• The Academy of Osseointegrations 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

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Implants vs. Endodontics

• 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

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Implants vs. Endodontics

• Success criteria
• Problem areas
• Whos treating
• Publication bias
• Modern advances

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Apples vs. Oranges

• Success criteria
• Problem areas
• Whos treating
• Publication bias
• Modern advances

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Implants vs. Endodontics

• Success criteria
• Problem areas
• Whos treating
• Publication bias
• Modern advances

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Success Criteria

• Endodontic Criteria
• 1956, Strindberg proposes stringent radiographic
  criteria
• Strindberg LZ, 1956

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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

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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 Strindbergs
  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

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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 Strindbergs
  dated criteria.
• Fristad and colleagues showed the potential for
  late radiographic healing.
• Fristad, Molven and Halse, 2004

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Success Criteria
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Success Criteria
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Endodontic Success Criteria
3-year recall
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Endodontic Success Criteria
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Endodontic Success Criteria
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Endodontic Success Criteria
12-month recall
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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 Strindbergs
  dated criteria.
• Fristad and colleagues showed the potential for
  late radiographic healing.
• Success or Survival?
• Iqbal MK, Kim S, 2007

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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

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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

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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

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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

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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.

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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

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Success Criteria

• The Academy of Osseointegrations 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

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Success Criteria

• Success or Survival?
• Iqbal MK, Kim S, 2007

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Success Criteria - Implants

• Two 3.75 x 18 implants were placed on 9, 10
  sites
• Implants appear osseointegrated

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Success Criteria - Implants
Initial visit pt presented with provisional
restorations
Esthetics case referred to Dr. Debra Johnson
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Implants vs. Endodontics

• Success criteria
• Problem areas
• Whos treating
• Publication bias
• Modern advances

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Restorative Impact

• Lazarski et al examined over 110,000 endodontic
  cases, and found teeth that were not restored
  were significantly more likely (gt4 X) to undergo
  extraction.
• Lazarski et al 2001

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Restorative Impact

• Lazarski et al examined over 110,000 endodontic
  cases, and found teeth that were not restored
  were significantly more likely (gt4 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

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Restorative Impact

• The Academy of Osseointegrations 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

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Restorative Impact
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Restorative Impact
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Restorative Impact
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Restorative Impact
22-month recall
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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

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Bone Loss Around Implants

• With implant placement, 1 mm of bone is loss
  during the first year of placement, with an
  additional 0.1mm annually.
• Can vary with implant type/material

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Bone Loss Around Implants
Bone Loss (mm)
n455 Error bars S.E.M.
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Cost to Patient

• Analysis of 2005 insurance data concluded that
  restored single-tooth implants cost 75-90 more
  than similarly restored endodontic-treated teeth

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Cost to Patient

• Analysis of 2005 insurance data concluded that
  restored single-tooth implants cost 75-90 more
  than similarly restored endodontic-treated teeth
• Post-treatment problems can increase this cost
  difference

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Cost to Patient

130 Increase
Average Price ()
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Implants vs. Endodontics

• Success criteria
• Problem areas
• Whos treating
• Publication bias
• Modern advances

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Whos 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

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Whos Treating?

• Of 13,047 identified studies, 147 articles from
  the endo, prosth and implant literature were
  systematically reviewed.
• Torabinejad, et al, 2007

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Whos Treating?

• Of 13,047 identified studies, 147 articles from
  the endo, prosth and implant literature were
  systematically reviewed.
• Torabinejad, et al, 2007
• GPs or
  Specialists
• Students
• Implant 0 87
• Prostho 29 35
• Endo 63 29

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Whos Treating?
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Whos Treating?
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Whos Treating?
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Whos Treating?
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Implants vs. Endodontics

• Success criteria
• Problem areas
• Whos treating
• Publication bias
• Modern advances

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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

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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.
• Torabinejad, et al, 2007

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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

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Implants vs. Endodontics

• Success criteria
• Problem areas
• Whos treating
• Publication bias
• Modern advances

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Modern Advances

• Both Iqbal and Kims 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

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Modern Advances

• Implants
• New implant shape/design
• New surface modifications
• New implant-abutment interfaces
• Immediate loading
• Mini implants
• Etc

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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

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Case Selection
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Case Selection
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Case Selection
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Case Selection Fx 20
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Case Selection
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Case Selection
1-month recall
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Case Selection
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Case Selection
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Case Selection
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Case Selection
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Case Selection
13-month recall
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Implants vs. Endodontics

• The Academy of Osseointegrations 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

74
Implants vs. Endodontics

• The Academy of Osseointegrations 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

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Implants vs. Endodontics

• The Academy of Osseointegrations 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

76
Implants vs. Endodontics

• in periodontally sound teeth having pulpal
  and/or periradicular pathosis, root canal therapy
  resulted inequal outcomes (97) to extraction
  and replacement of the missing tooth with an
  implant.
• Torabinejad, et al, 2007

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Implants vs. Endodontics

• No difference in the survival rates between the
  two treatment modalities.
• Iqbal MK, Kim S, 2007

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Implants vs. Endodontics

n4477
Unpublished data from AAE Foundation - Bowles,
Eleazer, Drum Goodis 2008
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Implants vs. Endodontics

• Endodontic therapy should be given priority in
  treatment planning for periodontally sound single
  teeth with pulpal and or periradicular pathology.

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Implants vs. Endodontics

• Endodontic therapy should be given priority in
  treatment planning for periodontally sound single
  teeth with pulpal and or periradicular pathology.
• Implants should be given priority in treatment
  planning for teeth that are planned for extraction

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Implants vs. Endodontics

• 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

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Implants vs. Endodontics

• CASE SELECTION
• CASE SELECTION
• CASE SELECTION

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Conclusion

• Functional survival rates are high for both
  treatments

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Conclusion

• Functional survival rates are high for both
  treatments
• Endodontic treatment on a hopeless tooth is just
  as unethical as extracting a restorable tooth and
  replacing it with an implant

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Conclusion

• Functional survival rates are high for both
  treatments
• Endodontic treatment on a hopeless tooth is just
  as unethical as extracting a restorable tooth and
  replacing it with an implant
• 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