Endodontics Continued »
as we attempt to compare both implants and endodontic treatment: • How can we compare both treatment modalities?
• In these comparisons, which performs better, endodontically treated teeth or implant-retained restorations?
• What is the cost and risk benefit to the patient of each treatment?
• How did the ‘turf war’ develop between the two camps?
Comparison of
endodontically treated teeth and implants Comparisons between both have been difficult due to the fundamental differences between the treatments them- selves and have traditionally only been based on longevity.
However, as Elemam and Pretty (2011) pointed out, both treatments differ in “the biological process, diagnostic modalities, failure patterns, and patients’ preferences”. Outcomes in dental literature
can broadly be classified into four categories: success, survival (with and without intervention) and failure. Traditionally, endodontic outcome studies have spoken in terms of success and failure, with little or no mention of survival of root filled teeth historically. These strict criteria have been maintained in many studies on outcome of endodontic treatment (Sjogren et al. 1990, Hoskinson et al. 2002, Ng et al. 2011). More recently, results in endodontic outcome studies have been dichotomised using both strict (success = complete radiographic healing and absence of signs/symptoms)
and lenient (success = reduction in size of periapical lesion and absence of signs and symp- toms) criteria (Friedman et al. 2003, Ng et al. 2007). Studies discussing the
survival rate of endodontically treated teeth are also now more commonly appearing in the literature (Salehrabi et al. 2004, Kim and Setzer 2013). While this may serve to alter the perception between both treatment modalities, it may also lead us further from the biological principles of endo- dontics and dentistry in general. Unfortunately, as Noyes (1922) outlined almost one hundred years ago: “We are not trained to think in terms of biological concepts but we are to act in mechanical procedures.” The shift in terms of our appraisal of the evidence merely acts to support this (Fig 2).
Direct comparisons: who wins? Despite these differences, direct comparisons between the two modalities have been made by some groups. Doyle (2006), in a 10-year study comparing single tooth implants and initial non- surgical endodontic treatment, found that both modalities had similar survival rates, while the incidence of post-operative complications requiring inter- vention was higher in the implant group. Levin (2013), in a recent
Fig 2a Fig 2
Radiographs showing healing of periapical lesion associated with tooth 22 following endodontic re-treatment
Fig 2b
systematic review comparing both, found that implant survival rates did not exceed those of compromised teeth, with implant failure rates recorded as high as 33 per cent in some studies. The conclusion that the decision
to extract and replace a tooth, as opposed to treating it, should be taken cautiously appears to be supported by the evidence. Setzer and Kim (2013) also compare reten- tion versus extraction and replacement, and draw very similar conclusions. A common misconception
related to the complications associated with implant therapy is that they are often of a minor nature and easily treated. Frequently, the pros- thodontic complications are minor and may include screw loosening or fracture or damage to the permanent restoration. However, a recent review
paper (Armas et al. 2013) high- lighted the fact that implant soft tissue complications are common, with peri-mucositis affecting up to 80 per cent (Zitz- mann and Berglundh 2008) and peri-implantitis affecting up to 56 per cent of subjects (Leon- hardt et al. 2003). Evidence suggests that peri-implant mucositis can be success- fully treated non surgically if detected early, whereas non- surgical therapy has not been shown to be effective for the treatment of peri-implantitis (American Academy of Periodontology paper on Peri-Implant Mucositis and Peri-Implantitis: A Current Understanding of Their Diagnoses and Clinical Implications, 2013). When making comparisons
Fig 3a Fig 3
Radiographs showing healing of periapical lesion associated with heavily restored tooth 25 following endodontic re-treatment and surgery
54 Scottish Dental magazine Fig 3b Fig 3c
with the interventions required following a ‘failed’ endodontic treatment, the necessity for surgical intervention is often presented as an undesirable follow on from the initial non- surgical treatment. However, as the evidence appears to demonstrate, this may also be indicated in a large number of implant cases. Also, outcomes following endodontic microsurgical procedures can be as high as 91.5 per cent (Rubinstein and Kim 2002), with anterior teeth in the maxilla having a better outcome (Song 2013) (Fig 3). This again highlights the need for caution before a
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