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 Table of Contents  
Year : 2013  |  Volume : 3  |  Issue : 3  |  Page : 107-113

Endodontic therapy and restorative rehabilitation versus extraction and implant replacement

1 Department of Endodontics, Prince Sultan Military Medical City, Dental Clinics, Riyadh, Kingdom of Saudi Arabia
2 Department of Restorative Dental Sciences, Endodontic Division, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia

Date of Web Publication20-Nov-2013

Correspondence Address:
Abdelhamied Y Saad
Department of Restorative Dental Sciences, Endodontic Division, College of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11454
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5984.121502

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This investigation presents a chart that can assist clinicians, in general and endodontists, in particular, in making the right decision when they are deciding, which rout to take; endodontic treatment to save the natural tooth or extraction and osseointegrated implant. Systematic review of the literature was used to investigate success rates of both endodontic therapy and extraction of the tooth and placement of an implant, with the intent of determining the superior treatment modality. The results demonstrated that both treatment modalities produced nearly similar success rates, with implants generally showing slightly higher success rates. It was concluded that endodontic treatment should first be given to save compromised natural tooth before pursuing extraction and implant. A protocol to assist clinicians in making the right decision to endodontically save or extract the offending tooth and replacement of implant is presented.

Keywords: Endodontics, implant, outcome

How to cite this article:
Al Shareef AA, Saad AY. Endodontic therapy and restorative rehabilitation versus extraction and implant replacement. Saudi Endod J 2013;3:107-13

How to cite this URL:
Al Shareef AA, Saad AY. Endodontic therapy and restorative rehabilitation versus extraction and implant replacement. Saudi Endod J [serial online] 2013 [cited 2023 Feb 5];3:107-13. Available from: https://www.saudiendodj.com/text.asp?2013/3/3/107/121502

  Introduction Top

Endodontic treatment procedures have played a very important role in the retention and restoration to function of teeth affected by pulpal diseases or periapical pathosis. This can be achieved by the numerous treatment strategies in both non-surgical and surgical endodontics. These advances in modern endodontic practice have allowed the clinicians to provide greater range of treatment options to save teeth. On the other hand, the extraction of the teeth has generally been considered undesirable and as a treatment of last resort due to the limitation of alternative prosthodontic replacement such as bridges and removable prosthesis. Recently, implant replacement appear to be a new treatment modality to restore the non-restorable natural teeth which need extraction. This has led to consider that single tooth implant is a part of endodontic treatment programs.

Osseointegrated implants are a very technique-sensitive procedure. Currently, it is important to emphasize that this surgical technique is within the scope of endodontics. Therefore, endodontist who plan to incorporate this surgical technique into their practice should participate in advanced training programs in order to gain knowledge in (1) diagnosis, (2) treatment planning and (3) placement osseointegrated implants prior to implementing their use in clinical practice. This may be due to that the implant - supported restorations have become the most popular therapeutic option for professionals and patients for the treatment of total and partial edentulism.

This article presents a protocol or map road that can assist clinicians, in general, endodontists, in particular, in making the right decision when they are deciding which route to take; endodontic treatment to save the tooth or extraction and osseointegrated implant.

  Review of the Literature Top

Endodontic treatment

Endodontic treatment has a long history in management of teeth with pulp diseases and/or periapical pathosis. Endodontic therapy is presently widely prescribed by both endodontists and general dentists. The role of bacteria and bacterial infection in pulpal and periradicular diseases has been well-established. Recent years have also seen a new level of understanding of the physiologic as well as the pathologic process that are responsible for pulpal and periradicular diseases. Furthermore, dental field has shown some major technological and biological advances, resulting in development of innovative new treatment modalities in both non-surgical and surgical endodontics. [1]

One of the main objectives in the dental field is prevention of oral diseases and the preservation of the natural detention, frequently achieved by root canal therapy. The scope of endodontics include non-surgical treatment of teeth with diseased pulp and/or periapical pathosis, selective surgical removal of pathological tissues resulting from pulpal pathosis with or without using the operating microscope, management of traumatic injuries, bleaching of discolored teeth, retreatment of the teeth previously treated endodontically and treatment procedures related to coronal restorations by means of posts and/or cores involving the root canal space. In general, aim of endodontic therapy has been defined in terms of the prevention and/or elimination of apical periodontitis. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]

Outcomes of endodontic treatment

Several investigations have reported that multiple factors are involved in determining endodontic outcomes. They revealed that the risk of failure is higher when certain conditions are present. These include chronic periradicular infection or radiolucency, previous unsuccessful endodontic treatment, presence of multiple roots and co-existing periodontal disease. They added that re-treatment of teeth that have been previously treated endodontically seems to be often associated with poor outcomes. [11],[13],[14],[15] Others have stated that root canal therapy that is performed for the first time in a particular tooth has higher long-term tooth survival rate. [16],[17],[18] According to some investigators, the average survival rate of the teeth endodontically treated by the general dentist is ~89.7% after 5 years. Moreover, if the treatment is performed by a specialist, the success rate is increases to 98.1%. [19] Another investigator has revealed that the 10 years survival rate of teeth treated by root canal therapy performed by residents was 85.1%. [20] If a root canal-treated tooth presents persistent symptoms, retreatment of the affected tooth is a suitable option. However, the survival rate of retreated teeth is not as high compared with initial treatment, [16] especially when extensive periradicular lesions are present. [21] Friedman [22] comprehensively reviewed endodontic treatment outcomes from the second half of the 20 th century. With respect to initial endodontic treatment, he revealed that teeth without apical periodontitis were generally more successful than teeth with apical periodontitis. With respect to retreatment, he was generally more successful than initial treatment; and that in teeth with apical periodontitis, initial treatment was generally more successful than retreatment. With respect to surgery, he stated that surgery combined with root canal re-treatment was generally more successful (weighted average 80%) than surgery alone (weighted average 59%) on teeth with previously failed root canal treatment; and that optical surgery including retrograde filling was generally more successful than apicoectomy alone. [22] Stringberg's study [23] of up to 10 years reported a 93% success rate for endodontic therapy in teeth having vital pulps or necrotic pulp without apical periodontitis; an 88% success rate in teeth presenting with apical periodontitis; and an 84% success rate following retreatment in teeth presenting with apical periodontitis. Recent study reported an 88% success rate in teeth without apical periodontitis; a 63% success rate in teeth with diseased periapices and a 79% success rate in re-treatment cases. [24] In addition, a more recent investigation revealed success rate of 83% for vital pulp and 79% for non-vital ones. [25]

Implant therapy

Brånemark et al. [26],[27] and Schroeder et al. [28],[29] were the pioneer in osseointegrated implant. Implant dentistry has subsequently seen some major advances in used instrument and techniques, particularly in the past three decades. The shift toward improved esthetic and simplified use has resulted in the application of oral implants in the replacement of single teeth. According John et al. [12] who stated that the original protocol of delayed attachment of the overlying prosthesis has been replaced more or less immediate loading protocols, from the same day to 6 weeks following fixtures placement. They added that extraction and immediate placement of principles have been advocated to enable preservation of bone and soft-tissue contours with less post-operative complications. [12] However, Bader [30] reported that tooth sustention by reconstructive surgery and root canal therapy if indicated, may be a reasonable choice as opposed to extraction and implant therapy. He added that the predictability of implant fixtures as a long-term solution for edentulous areas has improved to the point where they have become the standard of care in many situations, in lieu of fixed prostheses. Moreover, the risk assessment for prognostic evaluation plays an important role in the decision making process. The clinical and systemic factors affecting the longevity of a tooth need be considered as well as location, bone quality and the amount and the condition of the patient's other teeth. [30] In addition, some investigators have stated that even with exiting new treatment options such as implant dentistry and the benefits offers to patients and practitioners, all due consideration should first be given to treatments aimed at preserving and storing compromised teeth before pursuing extraction and replacement. [31]

In certain situations implants may be considered a better therapeutic alternative than performing more extensive conservative procedures in an attempt to save or maintain a compromised tooth. Concomitantly, it is important to keep in mind that maintenance of the natural dentition in high function and acceptable esthetics remain the primary goal of any periodontal therapy. Prosthetic restorations cannot compete with a natural tooth regard to the physical, biomechanical and sensorial properties as well as proprioception and the adaptation under mechanical forces mediated by the periodontal ligament. [14],[31 ],[32],[33],[ 34] Avila et al. [14] in their extensive review presented with a color-coded system chart that can assist clinicians in making the right decision when they are deciding, which rout to take in order to save or extract a compromised tooth. They added that there is a large number of factors should be considered. These factors include initial assessment, periodontal disease severity, furcation involvement, etiologic and treatment factors, restorative factors and other determinants such as smoking habits, uncontrolled systemic condition and the clinician's experience.

First: Initial assessment (patient expectation and desire, treatment expectations, esthetics, finances, patient compliance and patient hygiene performance).

Second: Periodontal disease severity (probing depth, tooth mobility, recurrent periodontal abscess, amount of bone loss and bone defect morphology-vertical or horizontal).

Third: Furcation involvement (severity of furcation defects, interproximal bone level related to furcation entrance, root anomalies as enamel pearls and root groves, which hind plague and root resection to eliminate the cause and to provide a better environment).

Fourth: Etiologic and treatment factors (presence calculus, surgery that compromises bone dimension, recurrent periodontal disease, root proximity which may contribute in progression of periodontal disease and root canal therapy where the survival rate of endodontically retreated teeth is not as high compared to initial treatment).

Fifth: Restorative factors (carries, fractured and faulty restorations, crown/root ratio, determination of the need for a post/core and crown).

Sixth: Other determinants (smoking habits, uncontrolled systemic conditions, the use bisphosphonates that produce a reduction of bone turnover and inhibition of mineralization and inhibition of bone resorption and the clinician's experience.

Furthermore, Avila et al. were not included genetic determinants and age in their decision-making chart. [14] In addition, these factors were support previous factors stated by same authors who revealed that these factors should be considered in choosing between the implant and endodontic therapies. They concentrated on patient related issues (systemic and oral health as well as comfort and treatment perceptions), tooth and periodontium-related factors (pulpal and periodontal conditions, color characteristics of the teeth, quantity and quality of bone and soft-tissue anatomy) and treatment-related factors (the potential for procedural complications, required adjunctive procedures and treatment outcomes), radiation therapy, chemotherapy, hormone replacement therapy, Parkinson disease, multiple myloma and a human immunodeficiency virus - positive status. [35],[36],[37],[38]

In osseointegrated implants, sufficient bone with good quality should be available for placement of an implant. This bone and surrounding teeth are free from disease. It is also important to locate vital anatomic structure that can interfere with implant placement such as the inferior alveolar canal, mental foramen, maxillary sinus and approximating roots. Radiographic images are necessary to asses and identify bone quality and volume. Moreover, the faciolingual dimensions of residual bone should be measured using bone sounding and ridge mapping. With bone sounding, a periodontal probe and special bone calipers have been used for this purpose. Using a radiograph template, the selected radiograph is made and analysis. The cone beam tomogram and computed tomography scan are now used favorably compared with the accuracy of panoramic radiograph. [39],[40],[41] Extraction and immediate placement of single osseointegrated implants are now very predictable and have numerous advantages over delayed placement techniques. These advantages including maintenance of the existing gingival embrasure form and marginal contour, preservation of existing bone, reduced surgical procedure and shortened treatment time. [41],[42],[43],[44],[45]

Implant outcomes

Several investigators have demonstrated that when implant placed in an ideal position, with adequate prosthesis design and proper maintenance, it can achieve a success rate of 97-99%, with an outstanding long-term functional performance. [46],[47] Eckert et al. have reported a survival rate of 96% in 5 years survival rate. [48] Other investigations have reported 5 years implant survival rate of 95% and above. [49],[50] Haas et al. 10 years survival estimates of approximately 90%. [51] Interestingly, Torabinejad et al. have stated that success rates for implant-supported crown were higher than for root canal therapy were similar and superior to those of fixed partial denture. [52] Moreover, numerous prospective studies have performed and limited to single-tooth ITI implant-supported crowns. Brägger et al. have reported 90% success rate, [53] Levine et al. showed 95% survival rate, [54] Ferrigno et al. have demonstrated 91%, [55] Astrand et al. have stated 97%, [56] Lambrecht et al. demonstrated 99%, [57] while Fugazzotto et al. revealed 97%, [58] and Buser et al. reported 97%. [59] Furthermore, the American Dental Association's Council on Scientific Affairs reported high implant survival rate with regard to the single tooth implant. The council revealed survival rates ranging from 94.4% to 99%. [60]

In general, endodontic therapy with the use of recent instruments, equipment and dental devices as well as new techniques, enabling practitioners and endodontists to perform the endodontic therapy with greater precision and efficiency, fewer errors and better success rates than before. However, when this treatment modality is not possible, extraction and osseointegrated implants can be performed. The decision between retention of endodontically involved teeth versus extraction and implant replacement is a clinical decision that requires careful evaluation of all factors influencing the outcome of the proposed treatment. [61],[62],[63],[64],[65],[66] [Figure 1] demonstrating decision making a chart for endodontic therapy or extraction and implant.
Figure 1: Decision making chart for endodontic treatment or extraction and implant

Click here to view

  Discussion Top

The successful evolution of endosseous dental implants as a predictable replacement for missing teeth has had a positive impact on patient care. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] More challenging is the decision concerning whether or not to pursue endodontics for a tooth with a questionable prognosis or extract and use a single-tooth implant as a replacement. [61],[62],[63],[64],[65],[66] At this time, there are no randomized controlled outcomes studies comparing endodontic therapy with single-tooth implants. A synthesis of available evidence indicates that both primary root canal treatment and single tooth implants are highly predictable procedures when treatment is appropriately planned and implemented as stated by many previous works. [16],[17],[18],[19],[20],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60]

It was found that implants resist dental caries, periodontal diseases and restore structural deficiencies with high success rates. These findings were similar and confirmed by several previous investigators. [12],[14],[30],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60] On the other hand, natural teeth with intact coronal structure and reasonable root length with good surrounding alveolar bone are considered best candidates for traditional endodontic therapy, especially in instances in which the esthetic outcome is important to the patient. These data were parallel to and supported by several studies. [19],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[25] However, when a tooth is considered to be in a hopeless condition, extraction and immediate or delayed placement of implant is indication. [61],[62],[63],[64],[65],[66] Therefore, the decision to either maintain an endodontically involved tooth or do extraction and place an implant can be very complex issue and we feel that no generic answer to this clinical issue and every patient must be examined and evaluated on an individual basis to obtain long-term predictability of treatment outcome. Furthermore, according to some investigators who concluded that four conditions were found to improve the outcome of primary root canal therapy? These conditions include; (1) pre-treatment absence of a periapical radiolucency, (2) root filling with no voids, (3) root filling extending to 2 mm within the radiographic apex and (4) satisfactory coronal restoration. [66]

Finally, most current investigations indicated no significant difference in the long-term prognosis between restored endodontically treated teeth and single-tooth implants. We feel that every effort should perform to keep natural tooth as soon as the prosthetic restorability is good, the quality of bone is adequate besides the esthetic concerns and costs and patient preference. Therefore, endodontic therapy with adequate restoration represents a practical and economical way to preserve function in a vast majority of cases and that dental implants serve as a good alternative in selected in dications in which prognosis is poor. Moreover, some endodontic advanced education programs are now including implant training in their curriculum. Moreover, it is important to emphasize that the implant surgery is now within the scope of endodontics.

  References Top

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