The ‘great debate’ on whether dental implants replace the need to perform endodontic treatment has been raging for years. It has been the subject of a number of review articles. These articles attempt to compare success rates and survival rates of dental implants and endodontically treated teeth; the general consensus is that both treatments have high success rates.
In the beginning
The ‘great debate’ began as a result of modern implant studies which showed that they had very high success or survival rates. It was fuelled further by the rising cost of modern endodontics, which requires surgical microscopes and nickel titanium rotary files.
In countries where insurance claims are common and trauma has resulted in fracture of the upper incisors. An insurance company might legitimately ask, is better to perform root canal treatment and place post crowns or simply place dental implants? Which of these two options will last longer? This is a totally healthy and rational debate to have.
Unfortunately with all the statistics, spin and advertising around: many operators have taken this common clinical situation and extrapolated it. To the point where some consider a molar tooth with a carious pulp exposure to warrant extraction and replacement with an implant! It is this extrapolation which is the problem with the ‘great debate’. Long before we start comparing the success rates and survival rates from implant and endodontic studies: the practical issues into performing either treatment must be considered for each individual patient. By understanding these practical issues to begin with, only then we can help our patients make the best decision.
PRACTICAL ISSUES
PATIENT FACTORS
Age
The chronological age of the patient will often dictate what treatment they prefer with dental age being as important as chronological age. The full development of the maxilla and mandible should have occurred before implants are considered. If implants are placed before the end of the growth phase, they will remain in place and the bones will change their position.
An advantage of root canal treatment is that the natural dentition and periodontal ligament are maintained, allowing it to be performed at any stage of development. The orthodontic situation of the patient is often overlooked by many operators. There is little point in performing root canal treatment on a tooth which may require extraction to prevent crowding later. If it is possible that extraction of the tooth will allow replacement by a sound permanent successor then the timing of extraction is very important and a consultation with an orthodontist is warranted.
Oral hygiene
The oral hygiene of the patient is important for maintenance of both root canal treated teeth and dental implants. Implants should never be prescribed as a replacement for natural teeth in a patient with poor oral hygiene. Periodontal disease of implants known as peri-implantitis is a common cause of implant failure. It is a reason why extraction of periodontally involved teeth and immediate replacement by implants are rarely successful long term, unless the patient’s oral hygiene can be improved. In patients with chronic periodontal disease the loss of supporting bone may be such that implant placement is complicated.
Before either root canal treatment or implant placement is undertaken the patient’s oral hygiene should be of a good standard.
Medical history and systemic health of the patient
Placement of dental implants involves surgery and as a result any medical conditions which compromise healing such as: smoking, diabetes and nutritional deficiency, will make implant survival less likely. The bone density of the patient should also be optimal and conditions that affect this, such as osteoporosis will decrease the chance of implant survival. There are also numerous medications which have an affect on the bone and these may also compromise implant placement. Patients who have compromised mobility are less likely to wish to attend the multiple visits required for implant placement.
The systemic health of the patient may have a role in healing of periapical disease after root canal treatment however there is no sound evidence on this.
Occlusion and habits of the patient
One area many operators completely overlook when it comes to the ‘great debate’ is that many of our natural teeth have multiple roots. The advantage of having multiple roots is to distribute the forces from the opposing teeth to the bone via the periodontal ligament. Having a single implant fixture in an upper molar site means there is less surface area with which to distribute force. As a result the forces on this single fixture are higher than those on the multi rooted tooth which preceded it. Titanium is a very strong metal but can be fractured by the forces with which many patients can apply to their teeth.
The patient’s occlusion and parafunctional habits should be thoroughly assessed before implants are considered. It may be necessary to provide protection of the implant by way of a splint. Many patients are resistant to wearing splints and this should be discussed before treatment is carried out.
Biotype
In patients with a thin gingival biotype the titanium implant fixture may be visible through the thin gingival tissues after placement. Patients with triangular shaped anterior teeth also present an aesthetic problem as regards implant crown placement. Often the extraction of the tooth and the associated bone loss makes preservation of the interdental papilla almost impossible. In order to compensate for the loss of interdental bone a square shaped crown is necessary to avoid a large black triangle. In certain cases the result may be aesthetically unacceptable; especially in patients with high expectations.
It may be preferable in these patients to undertake root canal retreatment or apical surgery to treat these teeth, if there is a good chance of success. These aesthetic considerations are of prime importance and need to be discussed with the patient before treatment is commenced.
Patient expectations
Patients who have psychological problems or unrealistic expectations are difficult to satisfy. Some patients feel dental implants will be the same as having new teeth and will not tolerate the disparities between their previous tooth and the implant.
In these cases if it is feasible, it may be easier to maintain their natural tooth by performing endodontic treatment. As with all patients they should be made fully aware of the risks involved in performing root canal treatment or implant placement, as well as the advantages and disadvantages of the treatment decision. The patient can then make an informed decision.
CLINICAL FACTORS
Site
The site of implant placement often has a bearing on implant survival. Certain sites such as the anterior region of the mandible are more favourable for implant placement. It is also important to examine the anatomy in the region of proposed placement. Sites with lack of bone height or nearby nerves may require extra treatment if an implant is planned.
In the hands of a specialist the anatomical site is of little consequence with endodontic treatment.
Space
It is recommended that there is a space between implants of 4-7 millimetres. This prevents necrosis due to blood supply impairment. It also allows the patient to carry out oral hygiene procedures. The distance between a natural tooth and an implant should not be less than 3 millimetres. If these spaces are not present then it may be necessary to create them by orthodontic treatment. The need for more pretreatment can unnecessarily complicate treatment if the possibility of doing root canal treatment is more straightforward.
Neighbouring teeth
As implant placement requires sound bone any apical disease or severe periodontal disease in the neighbouring teeth is likely to complicate implant integration. This need to treat the neighbouring teeth may delay implant placement. In situations where the delay is undesirable another treatment option may be required.
An advantage of endodontic treatment is that treatment can be carried out immediately at the same time on the neighbouring teeth.
CONCLUSION
The ‘great debate’ is far simpler than some would have you believe. Both endodontic treatment and dental implants have their risks and benefits. They are treatment modalities available in the arsenal of the modern dental surgeon intended to prevent a patient’s need for removable prostheses or bridge work. They are treatments designed to compliment one another. One is not intended to make the other irrelevant. If a tooth is restorable the first choice must be endodontic treatment but if the tooth is unrestorable the best replacement currently available is a dental implant.
So the next time you are deciding on performing root canal treatment or placing an implant, before you start quoting your patient ‘success’ rates from a multitude of studies. Take a step back, examine the patient, look at the entire dentition, consider the practical issues of the particular individual and ask yourself what is the ‘success rate’ for an implant or endodontic treatment for this patient? Because the patient may look interested in the ‘success’ rates; but what they are most interested in is whether the chosen treatment will be successful for them.