Tuesday, September 16, 2008

Root Canal or Implant?

The latest version of Inside Dentistry (July/August 2008, volume 4, number 7) has a very interesting cover story by Allison M. DiMatteo BA, MPS. As an endodontist, I have been watching this debate develop for quite some time. I think it is important to determine what is behind this effort to pit one dental specialty against another.

This particular article seeks the opinion of endodontists and periodontists alike. All sides agree that implants are a great way to replace missing teeth. There is consensus that there is value to retaining natural teeth. The disagreement seems to come from the debate about when to remove a tooth in order to place an implant.

There are some who argue that implants are more successful than endodontically treated teeth. This is despite the evidence that shows that implants and endodontically treated teeth have similar, almost identical success rates.

Richard Mounce DDS, an endodontist, points out that the only controversy between endodontics and implants is "primarily economic and more artificially manufactured than exists in reality...There are clear indications for endodontic therapy and clear indications for implant therapy. Rarely are these treatment options so evenly weighted that when considered side by side (as to their advantages and disadvantages) that there should be a 'competition' or 'controversy', most especially when the patient's interest is put first".

According to Gregori M. Kurtzman DDS, "as a general rule, it is better to save a tooth...if you can". Restorability is the key factor in determining when a tooth needs to be removed. Ability to get a good margin, not violate biological width, cracks, strength of furcation, crown:root ratio etc. are all important factors in determining the restorability of the tooth. An endodontically treated tooth with a poor restoration, will generally not have long term success.

However in the same article, Dr. Kurtzman goes on to questions the success rates of endodontic surgery, and even the value of endodontic retreatment. Dr. Kurtzman points out that the financial investment into retreatment, like all treatment options which does not have 100% success rate, may be better made in a more predictable treatment of an implant.
That argument shows lack of understanding and appreciation for modern microscopic endodontic therapy.

I routinely recommend implant therapy for patients. What concerns me as a specialist is to see the marketing techniques and lack of proper endodontic evaluation during the treatment planning of implant cases. All of our mailboxes are full of marketing journals filled with clinical cases of implant placement.

Here is an example of two cases in the same issue of Inside Dentistry p.104-108.


This case is described as a "peri-apically involved maxillary incisor resulting from a failed root canal." Treatment options were reviewed and informed consent was obtained. Based on the patient's desire to reduce trauma and treatment time, it was decided to perform immediate implant placement. First of all, failed root canal is not an accurate diagnosis. The radiograph does not show the peri-apex. As best as we can tell the periodontal ligament looks fairly normal at the periapex. Was retreatment an option discussed? If it was, would it not be considered "less truamatic" than extraction and immediate implant placement? Not to mention the ability of a natural tooth to retain the crestal bone levels. Unless this tooth has a vertical fracture, of which there is no evidence, endodontic retreatment is a better option.

Another case from the same article shows a 27 year old female with a "symptomatic maxillary left lateral incisor with a history of endotherapy with a core build-up and crown". Active infection was noted with perilous fistula and exudate at the gingival margin. The prognosis of this tooth was deemed "hopeless".

Again, the endodontic evaluation of this tooth is incomplete. The anterior "bite-wing" type film certainly shows a normal crestal bone level, however, it is impossible to evaluate the endodontic therapy and is not a sufficient pretreatment radiograph. The conclusion that this tooth has a "hopeless" is premature.

Inadequate endodontic evaluation seems to be commonplace in many of the published clinical cases and those marketing dental implants. As mentioned above, there should be little controversy regarding endodontics and implants. Our specialties should not be pitted against one another, but should work together to meet the needs of our patients.

Sources:

DiMatteo, A. "Making the Right Move: Planning Your Clinical Strategy", Inside Dentistry, July/August 2008. p122-133.

Malek, M. "Done in a Day: Immediate Tooth Replacement with Definitive Prosthesis", Inside Dentistry, July/August 2008. p104-108.

26 comments:

Periapex said...

Thanks for this post. I'm hoping that a lot of internet dental patients find it so that they can make a more informed decision about their treatment options that what they may have been led to believe.

paul said...

Not so easy...It is difficult to compare outcomes when in reality one option (re-treatment) will possible delay the ultimate outcome and thus have more bone loss...poorer cosmetics...poorer hygiene vs. the immediate extraction and implant which will maintain bone height and soft tissue. If you were looking at apico surgery...or 2nd or 3rd re-treatment in your 30's(while you still have the bone and only looking at a 10 year survival rate, would you want a more permanent solution??? It is the loss of time that becomes an issue. Because now if the RCT fails...would we not have been better off with plan B. Just stirring the pot!!! I'm not an endo hater...Just love the controversy. Can't wait to see the K-flex files in my car tires tomorrow night.

Jason J. Hales D.D.S., M.S. said...

Thanks for the comment. Are you making the assumption that retreatment will ultimately fail? If you are, then I think you need to reconsider. In the few studies taht there are directly comparing outcomes of single tooth implants and endodontics, the success rates of both are comparable. Whenever I do a retreatment, I try to figure out the reason for failure. Many times it is a missed canal, inadequte cleaning and shaping etc. These are easily rememdied with proper treatment. Inadequate endodontic treatment is the problem. The solution is proper endodontic treatment, not extraction.

What would you do if this was your tooth?

Thanks for stirring the pot! These are the discussions that we need to have!

Periapex said...

It's funny (or not)that I hear the exact same stuff from dentists whose endo work is consistently poor and ends up failing more often than not. Of course an implant would be a better way for a patient to spend their money in that office.

Javier Pascual Irigoyen said...

Great post Dr. Halles

North Bethesda Dentist said...

You have to look at this from visual and financial point of view. Sure dental implant is more expensive than root canal, but how about possible future maintenance of dental crown(to protect tooth) and durability? On the other side you should consider time for healing of dental implant. So if you time and financial crunch- root canal otherwise- dental implant.

Anonymous said...

Please help me. I've now had 3 root canals on the same tooth. I still have pain in the tooth and its getting worse. What can I do?

Jason J. Hales D.D.S., M.S. said...

Dear Anonymous,
Its very difficult to say what is going on with your tooth without being able to evaluate it. It should not be bothering at this point.
I would recommend that you visit an endodontist ASAP.
You can find one near you:
www.aae.org

Anonymous said...

I have been told that because I have a wood post, a root canal retreatment is almost impossible. Have you had any experience with root canal retreatments and posts?

Jason J. Hales D.D.S., M.S. said...

Dear Anonymous,
Go and see your local endodontist.
I have never heard of a wooden post. We routinely retreat teeth with posts. Posts are typically made of steel, carbon fiber or gold.
Seek another opinion

Anonymous said...

I have an appointment for a root canal in two days. I have 6 implants (lower) and have also had root canals in the past. This is an upper single-root tooth that is already capped. The cap fell off and the back of the tooth is rotted--all black and gross looking. The adjacent two teeth toward the back are also capped and not in great shape (deep pockets). The teeth adjacent toward the front have a 5-tooth bridge covering 4 teeth and bridging a missing tooth.

My new dentist says he can do the root canal rather than sending me to a specialist. He says it's simple because it's a single root. He'll put in a post and then I'll get a new cap. I'm concerned. All my teeth are capped and this is the second time a cap has come off and the tooth was rotted underneath. I have had dental problems my whole life from when I was 3. I am now 60. My old dentist retired and this guy isn't even 30. The old dentist would never do a root canal himself but always referred out. Maybe it's more common for general dentists to have training in doing root canals now than in the past. I'm just nervous. Please advise. Thanks.

implanty said...

I think there would be no such issues if endo retreatment with post cost same as implant placement surgery. Dentist would have no incomes incentives. But well there is other thing to consider it is much more easier to insert an implant than to retreat a tooth. I am not sure but if I was a patient I would probably choose an implant instead of sitting on a chair for 3 hours just to negotiate a canal.

Jason J. Hales D.D.S., M.S. said...

Implanty,

Interesting points. Retreatment is less expensive & less time to function. Treatment time is much shorter when done with a microscope as well.

Implanty said...

Jason

What I noticed from my clinic and after having conversation with my colegues root canal retreatment fails in around 50% of cases after 2-3 years, no matter if you use microscope or not. Of course this concerns cases with symptomathic badly root canal treated teeth (not the ones you can see on the x-ray with missed canal only, giving no problems for the patient). I think this is caused by the fact that even the very small dentin tubules are infected in such problematic teeth and as you know there is no way to desinfect them reliably. Of course you can do apiectomy but well in my opinion this just postpones extraction in time. So the question is do you want to retreat a tooth and lose a patient when problem occures once again. I don't, so I always try to convince a patient to go for an implant. Of course this is my point of view but well it works in my hands, and even if my patient doesn't want an implant and I do root retreatment and if it fails I don't loose this patient, we do the implant then.

Anonymous said...

I'm reading your blog Dr. Jason and your passion for the subject is palpable.Unfortunately, I'm just not sure the majority of endodontists {and I've seen quite a few :(...,} across the country, thrive on the challenge of solving individual cases. Kudos to you.

Paul L Caputo, DDS said...

The upper lateral incisors have such small root and they normally function with the lower cuspids. In my opinion nothing is better than a natural tooth, but if an upper lateral incisor restored with an endo, post & core and crown fails, the best treatment option is implant dentistry. Paul L Caputo, DDS www.DentalImplantsCost.us

Joe Stuart said...

I think a very important consideration is the age of the patient. A younger individual that ops for root canal treatment has a greater chance for failure over time than an older person. At the same time we cannot be sure if a dental implant will stay in for four to six decades. Just a thought.

Janos Sz├ęcheny said...

Thank you for this. I am currently debating between retreating a crown on my back molar that has been retreated once already or just doing the implant. The endodontist gave me a 50% chance of success and that I should do the implant, but if it were his tooth, he'd fiddle with the retreat. The implant specialist told me it would be a fairly simple implant, although I'd need a bone graft. I'd like to keep my tooth, but my insurance is quite good right now and covers much of the cost of implants, so I'm tempted to go ahead and do that, especially if I'll have to take it out in 20 years anyway.
I'm still totally undecided, but this discussion among professionals really helps me to understand the debate. At the least, knowing there is such a debate among professionals makes me feel better that I cannot decide myself!

Stan said...

I'm 66 and have an abscessed pre-molar that had rct and a cap 25 years ago. Went to my dentist (who does implants) and was told rct retreatment had a 50% failure rate and the implant-cap was my best option. I had agreed and he injected anesthetic. 15 minutes later, prior to the extraction I commented on the amount of $$ that had already gone into the tooth. Shortly thereafter, after giving me Amoxicillin he said he'd do the extraction in a week. Then on my way out I learned the implant-cap would be a $2700 cost out of my pocket! I'm guessing even he felt that $4K for one tooth is a little much.
GREAT discussion and I'm glad I found this.

tooth crown said...

Your content is incredible! Thank you for researching and making this topic plain to your readers. Your article is a very welcome change of pace from others I’ve been reading.

Anonymous said...

I'm periodontal patient. My periodontist, who is resident in famous university, and his professors don't trust the root canal process. I was recommended to do implant only. However, after extract many teeth, I am wondering that is implant the right answer because some dentists said I should keep the teeth as many as possible.

Jason J. Hales D.D.S., M.S. said...

Dear Anonymous,

I would suggest you go see the endodontist at the famous university. Ask him if the tooth is savable. A natural tooth is always better than an implant - unless the root is fractured or the tooth has severe periodontal disease (very mobile) Ask your periodontist for a referral to an endodontist for a second opinion.

bcking2000 said...

I'm a healthy 47 year old male. My upper central incisor (#9) was struck (trauma). It cracked vertically to the gum line, and then cracked horizontally to the lateral edge (resulting in an inverted "L" shaped fracture).

My general dentist first tried applying a layer of bonding, which appeared to be acceptable both aestetically and structurally.

6 weeks later, severe pain started to develop. I went back to my dentists and he said that there is no sign of infection, but that the pain is likely from the nerve dying. We agreed that we should go with either a root canal + crown, or implant + crown.

As a mechanical engineer, I'm leaning towards the implant, because it seems more "fool proof", especially considering that the extisting tooth has been structurally compromised down to the gumline.

But the one thing that still has me second-guessing the implant option is that endodontists and periodontists both seem to universally agree that "It's better to save the tooth whenever possible."

So I have to ask: WHY???

Why is it "better to save the natural tooth" if it is subject to future decay (in particular at the base of the crown) and is also subject to brittleness following the root canal?

As a mechanical engineer, I like the prospect of an inert metal or zirconium implant that is not subject to these potential future modes of failure.

Please share your insights in the context specific to my situation descibed above. Much appreciated. Thank you.

Jason J. Hales D.D.S., M.S. said...

Dear BCKING2000

Thanks for your comment. The short answer is that a natural tooth has a periodontal ligament which attaches the root to bone. This ligament has important function such as proprioception (sensation) and helps to maintain the bone. It is kind of like a shock absorber for the tooth.

The implant on the other hand, has no ligament. The implant is directly fused to the bone. An implant lacks proprioception and the "shock absorber" qualities and other functions that are provided by the periodontal ligament.

This ligament is the main differenct between teeth and implants and is too often overlooked in the discussion regarding implants.

Check out some other posts:

http://www.theendoblog.com/2012/06/root-canals-and-dental-implants-rest-of.html

http://www.theendoblog.com/search/label/Periodontal%20Ligament

http://www.theendoblog.com/search/label/Implant

Anonymous said...

Hi,

I had a root canal and then apicoectomy on one of my front teeth. Reading your blog I am beginning to doubt the skill of the endodontist who performed the treatments. For one, she did not, as you do, "try to figure out the reason for failure" of the root canal, and she does not use a operating microscope.

Are there a few questions to ask of a new endodontist to make sure I find a better one?

thanks for the advice.

Alex Stephen said...

I just sent your post to my web contacts as I agree with most of what you're saying here and the way you've presented it is awesome.
dentist in Markham