Editor’s Note: Co-author of this month’s column is Dr. Ken Serota, who has a private practice for endodontics and implantology in Mississauga, Ontario, Canada (www.endosolns.com).
There are those who challenge the value of root canal therapy, particularly retreatment, as a viable treatment option. Unfortunately, the success rates for implant therapy, while appearing from a cursory viewpoint to be statistically higher than root canal therapy, have more to do with the protocols and analytic tools used to determine success than with reality. Any comparison must be meaningful, exacting, standardized, and direct.
Multiple treatment outcome studies must be performed to arrive at valid correlations between cumulative survival and functional success rates in implant and endodontic modalities. The implant modality, in spite of success rate claims, is subjective to investigatory interpretive flux.
Dental implant survival as compared to endodontic success rates must be assessed under a variety of clinical conditions and prognostic variables, such as length, well size, implant coating, sinus lift necessity, and timing of implant placement relative to tooth extraction. Simply put, exacting success rate evidence that reflects clinical reality does not yet exist for implants.
In our clinical opinion and judgment, the best implant is a natural tooth. When endodontics is not feasible because a natural tooth cannot be restored, we are fortunate to have another option (implants) when determining how a patient’s function and esthetics can be restored. The question is not really implants versus endodontics, but rather improving endodontics continuously to provide patients with the highest possible retention of their natural teeth, and then have implants available as a fallback.
Dental service mandates that treatment plans include risk assessment algorithms to ensure that sophisticated reconstructive procedures are predictable. The success rates of primary treatment, retreatment, and microsurgical retreatment are as significant as those for implants. Given the disparity between the implant and endodontic retreatment literature - and the lack of databased results and contraindications for the use of one or the other - treatment planning is a daunting and complex endeavor.
Thus, an algorithm is needed to provide clinicians with a risk assessment prognosis analysis in treatment planning to resolve this conundrum since a lack of standardized outcome evaluations makes it difficult to compare accurately literature. Currently, the authors are writing such an algorithm.
Endodontics and implant dentistry are in continual states of flux in regard to success predictors and treatment outcome protocols. Any procedure that can be validated by evidence-based science should be factored into comprehensive care. Expediency, rushing to judgment, and empirical bias must never replace case selection, treatment planning, or respect for the healing capacity of an organism. When the natural tooth no longer can be treated within predictable parameters, then the next option should take into account all variables that impact success. The real decision is not between endodontics and implants, but greater accuracy in diagnosing fractures of endodontically treated teeth, the success of crown lengthening procedures, and the success of periodontal therapy in regard to marginal periodontitis.
A risk assessment algorithm is one of many tools that will optimize predictable clinical success. Successfully integrating a new treatment approach must not be done at the expense of the traditional.
Two issues are not often mentioned in this debate. First, virtually all of the success-failure studies in endodontics are retrospective and not prospective. Second, these studies do not reflect the advances that have been made in endodontic treatment (surgical microscopes, improved irrigation protocols, rotary nickel titanium instruments, improved appreciation of canal anatomy), and the complexity and capability of new obturation materials to be bonded (RealSeal, SybronEndo, Orange, Calif., and Resilon, Resilon Research, Madison, Conn.). The latter will impove long-term success by reducing coronal microleakage. Using outmoded research parameters (treatment performed by dental students) to measure success and failure is simply disingenuous.
We welcome your questions and feedback.
Dr. Richard Mounce lectures globally and is widely published. He is in private practice in endodontics in Portland, Ore. Among other appointments, he is the endodontic consultant for the Belau National Hospital Dental Clinic in the Republic of Palau, Korror, Palau (Micronesia). He can be reached at Lineker@aol.com.