Written by John West, DDS, MSD Thursday, 09 January 2014 10:29
If you are reading this article, you are probably a restorative dentist, prosthodontist, periodontist, oral surgeon, pediatric dentist, orthodontist, or endodontist. But there is one person who is not reading this article…the most important person of all…the person who chooses us for their care and grants us their trust to do the right thing and to treat them in their best interest…our patient. Our patients trust us to accurately diagnose and properly treatment plan options that are in their best interest, not our own. This article is not about implant versus endo; it is about health and longevity, optimal interdisciplinary outcomes, and right and wrong. I am biased. I am an endodontist, and I love teeth that can be predictably saved; however, we have lost our way.
As an endodontic educator and interdisciplinary clinician for more than 35 years, I have always been interested in the frequent questions that students ask. By far the most frequent question is, “How do you make the treatment result predictable?” Isn’t that is what it is all about? Predictability, predictability, predictability!
The implant versus endo pendulum has reached its apex (no pun intended). The world is moving back to teeth. What a surprise! Clinicians are starting to think again. Healthy teeth with proprioception that have a healthy bony and gingival architecture for optimal function and esthetics are the best that nature can offer. For the Frank Spear and John Kois educators/visionaries/esthetic clinicians of the world, the implant versus endo formula is simple: if the tooth under consideration for treatment has a predictable biology, structure, function, and esthetic prognosis, then restore it! If not, consider removal with an implant. Implants should be the last resort, not the first option of choice. We are still in the early stages of implant history and breakdown (crestal bone loss, peri-implantitis and peri-implantosteitis) can begin to show up after millions of chewing cycles. As with any developing technology, unforeseen problems usually begin to appear over time. Some of you may have attended the May 17, 2013, San Francisco conference entitled “Dental Implant Complications.” I personally have a friend who had an unrestorable tooth in the esthetic zone. He has had 3 implant-related surgeries so far; 3 episodes of bruising with swelling and pain; and more than one year in progress with still no end in sight for the eventual tooth. Without skilled hands and good intentions, outcomes can be even much worse, and those patients are popping up in offices all across America. Dentists made promises that they could not keep.
THE IMPORTANCE OF PROPER TREATMENT PLANNING
It is estimated that 570 million dental implant sites exist in American patients’ mouths if we froze all the numbers today. Like some endodontists who are “tunnel visioned,” tunnel-visioned implantodontists have fallen prey to treatment planning based on their needs, not the patient’s. However, many dentists dedicated to doing the right thing for their patients have discovered a properly diagnosed and treatment planned endodontically diseased tooth can be a better biologic, structural, functional, and esthetic choice. It was the father of preventative dentistry, the late Dr. Bob Barclay (Macomb, Ill), who was quoted saying that “dentistry makes patients worse at the slowest possible pace.” This means, if a tooth is restorable, restore it; if endodontically diseased, treat it with endodontics and then restore it.
Treatment planning is simple, predictable, cost-effective, and a huge value. Endodontic success is 100% minus x, where x is the dentist’s knowledge, skill, and willingness to perform at his or her best, which for most dentists begins by simply slowing down. Too often the endodontic treatment is more predictable than an implant and has a greater treatment value for the patient who is receiving your care. Consider an endodontically underfilled and unhealthy maxillary molar, for example. This tooth can be predictably saved with careful nonsurgical or surgical endodontic retreatment without a new restoration if microleakage is not present. The tissue and bone remain present and can be healthy.
IMPLANT VERSUS ENDODONTIC BIOLOGICAL AND STRUCTURAL EXAMPLES
A fee for endodontic treatment of a molar could be $1,500, and the treatment typically takes one to 2 visits with a 6-month postoperative appointment to validate healing. A restoration with cuspal coverage should follow. If previously crowned and no mi-croleakage, then simple: nonsurgical retreatment or surgical endodontic seal. If microleakage, then nonsurgical retreatment and new crown. Case done! On the other hand, implant replacement requires removal (fee No. 1), osseous and/or soft-tissue augmentation (fee No. 2), possible separate sinus lift augmentation (fee No. 3), implant placement (fee No. 4), 6-tissue healing time, and restoration (fee No. 5). Add it up, and you have the $7,000 tooth replacement. This may or may not be the best financial value for the patient, but it is a financial value for the specialist. So who wins? To me, it is not the patient and not the restorative dentist. For the restorative dentist, the patient has to leave the office and be treated by specialists. The patient has to follow a sequence protocol. The patient begins to feel that he or she is being torn apart. The patient may actually feel abandoned unless the restorative dentist takes the lead and plays the concerned and all-knowing quarterback. The restorative dentist must be the director. One must take ownership for the patient’s accurate consensus diagnosis, treatment plan, treatment sequencing, and treatment timing. Without a known plan and sequence, the patient is receiving multidisciplinary treatment versus a collaborative interdisciplinary treatment where all the interdisciplinary team knows what to do when. Meanwhile, the single endodontic treatment is well on its way to healing by the time the conditions for a predictable implant are even reached. To me, this maxillary first molar example illustrates treatment based more on the professional’s needs than the patient’s needs. The sustained success of a dentist is based on serving the patient’s needs, raising the patient’s dental IQ, and creating value. Many skill sets are required to remove and replace my maxillary molar example. There are 3 or 4 more chances for error due to the 4 separate steps for the maxillary molar implant. And finally, when a tooth is removed, human re-entry studies showed 11% to 22% vertical dimension change at 6 months and 29% to 63% horizontal dimensional change at 6 to 7 months.1
IMPLANTS VERSUS ENDODONTICS IN THE ESTHETIC ZONE
Let’s consider the case of a maxillary central incisor that has to match an adjacent maxillary incisor.
Once again, tooth removal is required, the bone shrinks both vertically and horizontally and must be replaced with bone, soft tissue, and bone factors; proper position of the implant must be executed and the implant must integrate, then a new res-toration must be placed. After all this effort to coordinate specialists in different offices, the endodontic retreatment is well on its way to healing and the esthetic tissue is where it needs to be. What would you actually do if it were your tooth? Remember, you can always do an implant, but is now the “right time”? You may feel it is not the right time if it were your tooth, so then why is it the “right time” when it is your patient’s tooth?
It is time to step back and take a deep breath. At least in these 2 patient examples, it is time for the dentist to present alternative treatment plans and evaluate the risks and benefits. If this process is done authentically, the answer to implant versus endo will stand tall. Your reputation for treatment based on patient needs spreads like wildfire and, before you know it, you will be the preferred choice of patients. The word gets out. When you are all finished with your career, this can be called your legacy. Implants are a wonderful thing when the endodontically diseased tooth cannot be predictably saved due to undersealed portals of exit, periodontal disease, or poor crown/root ratio (biology), unrestorable (lack of tooth structure to place an adequate ferrule), or unesthetic natural tooth result. Implants are not a wonderful thing when the endodontically diseased tooth could (and should) be retained.
The only constant in this world is change. As a simple example, first we had wide neckties, then thin ones, then wide ones again, then medium-wide neckties, then the pendulum swings again. I am sure that I am out of style right now! Styles, cars, clothes, shoes, etc, live and die on the swinging pendulum. We are at the knee of the curve of the tangential learning. If we can give a tooth life for even 5 more years, as long as it does not affect adjacent teeth or supporting tissues, dentistry will then be that much better at placing implants. We are also at the knee of the exponential curve of learning new technologies. It is estimated that we may be less than 15 years away from being able to actually grow a new genetically matched biologic tooth. Titanium implants could, in fact, get in the way by occupying the tooth bud site.
If I were to lose a front tooth tonight, I would find the best prosthodontic-perodontic team available to assess replacing my lost tooth. They would make a consensus diagnosis and treatment plan. However, if my tooth were damaged, restorable, periodontally sound (or could be made so), I want to keep my own tooth! And I have to believe that you would want the same.
Implant versus endo? In order to make the right choice for our patient, it is really simple: go look in the mirror and ask, “What would I do if it were me?” The answer to that question for you is the answer for that question for your patient…always!
- Tan WL, Wong TL, Wong MCM, Lang NP. A systematic review of post-extraction alveolar and soft-tissue dimensional change in humans. Clin Oral Implant Res. 2012;23(Suppl 5):1-21. doi: 10.1111/j.1600-0501.2011.02375.
Disclosure: Dr. West is the co-inventor of ProTaper Systems and WaveOne and Calamus System (DENTSPLY Tulsa).
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