Treating Our Patients
Using Endodontic and
Implant Restorations
PPAC
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)
Treatment Numbers

Implant placement at University of Minnesota 1997-2007
900
Patients
800
Implants
700
600
500
40%
increase
annually
1997-2007
400
300
200
100
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Treatment Considerations
 “Treatment planning for
the future: Endodontics,
fixed partial dentures –
or implants?”
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.”
Implants vs. Endodontics
 The Academy of Osseointegration’s 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
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
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Apples vs. Oranges
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Success Criteria
Endodontic Criteria
 1956, Strindberg proposes stringent
radiographic criteria
 Strindberg LZ, 1956
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
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 Strindberg’s
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
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 Strindberg’s
dated criteria.
 Fristad and colleagues showed the potential
for late radiographic healing.
 Fristad, Molven and Halse, 2004
Success Criteria
Success Criteria
Endodontic Success Criteria
3-year recall
Endodontic Success Criteria
Endodontic Success Criteria
Endodontic Success Criteria
12-month recall
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 Strindberg’s
dated criteria.
 Fristad and colleagues showed the potential
for late radiographic healing.
 Success or Survival?
 Iqbal MK, Kim S, 2007
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
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
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
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
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.
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
Success Criteria
 The Academy of Osseointegration’s 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
Success Criteria
 Success or Survival?
 Iqbal MK, Kim S, 2007
Success Criteria - Implants
 Two 3.75 x 18 implants
were placed on #9, 10 sites
 Implants appear
osseointegrated
Success Criteria - Implants
Initial visit pt
presented with
provisional
restorations
Esthetics case referred to Dr. Debra Johnson
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Restorative Impact
 Lazarski et al examined over 110,000
endodontic cases, and found teeth that were not
restored were significantly more likely (>4 X) to
undergo extraction.
 Lazarski et al 2001
Restorative Impact
 Lazarski et al examined over 110,000
endodontic cases, and found teeth that were not
restored were significantly more likely (>4 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
Restorative Impact
 The Academy of Osseointegration’s 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
Restorative Impact
Restorative Impact
Restorative Impact
Restorative Impact
22-month recall
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
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
Bone Loss Around Implants
4
Bone Loss (mm)
3
2
1
0
0
1
2
3
Year
4
5
>
6
n=455 Error bars = S.E.M.
Cost to Patient
 Analysis of 2005 insurance data concluded
that restored single-tooth implants cost 7590% more than similarly restored endodontictreated teeth
Cost to Patient
 Analysis of 2005 insurance data concluded
that restored single-tooth implants cost 7590% more than similarly restored endodontictreated teeth
 Post-treatment problems can increase this
cost difference
Cost to Patient
Average Price ($$)
2000
1500
130%
Increase
1000
500
0
Endodontic/Restoration
Implant/Restoration
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Who’s 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
Who’s Treating?
 Of 13,047 identified studies, 147 articles from
the endo, prosth and implant literature were
systematically reviewed.
 Torabinejad, et al, 2007
Who’s Treating?
 Of 13,047 identified studies, 147 articles from
the endo, prosth and implant literature were
systematically reviewed.
 Torabinejad, et al, 2007
Implant
Prostho
Endo
GPs or
Students
0%
29%
63%
Specialists
87%
35%
29%
Who’s Treating?
Who’s Treating?
Who’s Treating?
Who’s Treating?
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
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
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
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
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Modern Advances
 Both Iqbal and Kim’s 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
Modern Advances
 Implants
 New implant shape/design
 New surface modifications
 New implant-abutment
interfaces
 Immediate loading
 Mini implants
 Etc…
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…
Case Selection
Case Selection
Case Selection
Case Selection – Fx #20
Case Selection
Case Selection
1-month recall
Case Selection
Case Selection
Case Selection
Case Selection
Case Selection
13-month recall
Implants vs. Endodontics
 The Academy of Osseointegration’s 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
Implants vs. Endodontics
 The Academy of Osseointegration’s 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
Implants vs. Endodontics
 The Academy of Osseointegration’s 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
Implants vs. Endodontics
 “…in periodontally sound teeth having pulpal
and/or periradicular pathosis, root canal
therapy resulted in…equal outcomes (97%)
to extraction and replacement of the missing
tooth with an implant.”
 Torabinejad, et al, 2007
Implants vs. Endodontics
 “No difference in the survival rates between
the two treatment modalities.”
 Iqbal MK, Kim S, 2007
Implants vs. Endodontics
n=4477
Unpublished data from AAE Foundation - Bowles, Eleazer, Drum & Goodis 2008
Implants vs. Endodontics
 Endodontic therapy should be given priority in
treatment planning for periodontally sound
single teeth with pulpal and or periradicular
pathology.
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
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
Implants vs. Endodontics
CASE SELECTION
CASE SELECTION
CASE SELECTION
Conclusion
 Functional survival rates are high for both
treatments
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
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