Treating Our Patients Using Endodontic and Implant Restorations
Treating Our Patients Using Endodontic and Implant Restorations 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
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