presentation for dental specialists

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

0

100

200

300

400

500

600

700

800

900

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Implant placement at University of Minnesota 1997-2007

Implants

Patients

40% increase annually

1997-2007

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 CriteriaEndodontic Criteria 1956, Strindberg proposes stringent

radiographic criteria Strindberg LZ, 1956

Success CriteriaEndodontic 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 CriteriaEndodontic 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 CriteriaEndodontic 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

Initial visit pt presented with

provisional restorations

Success Criteria - Implants

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

0

1

2

3

4

0 1 2 3 4 5 6

Year >

Bon

e Lo

ss (m

m)

n=455 Error bars = S.E.M.

Cost to Patient Analysis of 2005 insurance data concluded

that restored single-tooth implants cost 75-90% more than similarly restored endodontic-treated teeth

Cost to Patient Analysis of 2005 insurance data concluded

that restored single-tooth implants cost 75-90% more than similarly restored endodontic-treated teeth

Post-treatment problems can increase this cost difference

Cost to Patient

0

500

1000

1500

2000

Endodontic/Restoration Implant/Restoration

Ave

rage

Pric

e ($

$) 130%Increase

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

GPs or Specialists StudentsImplant 0% 87%Prostho 29% 35%Endo 63% 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

Endo/Implant:Survival proportions

0 2 4 6 8 100.5

0.6

0.7

0.8

0.9

1.0

ImplantEndodontic

Time

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 SELECTIONCASE SELECTIONCASE 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