Endodontic Treatment Or Implants?

I am a periodontist who was fortunate to study periodontology in an era when our objective was to save the natural dentition, using every possible treatment at our disposal. This included endodontics, restorative dentistry and periodontics. This was done in a multidisciplinary way, utilizing the best that each could offer. I say this as an introduction as it is sometimes the only factor I can fall back on when faced with a difficult clinical decision. I am by no means an expert on endodontic treatment as a clinical procedure, but as I am often faced with pulpal pathology in periodontal cases, or lately, more and more with the question of extraction versus implants, I try to keep up to date on all aspects of endodontic treatment.
It is by no means possible to give a comprehensive review of the literature in this short column, and the opinions I express here are my own, based on more than two decades in practice, combined with evidence from the literature.
Dentistry has certainly changed over the last decades and I often find myself wondering where all our principles have gone. The discussions amongst colleagues and even from the teaching podiums at symposiums tend to be of the sentiment that if endodontic complications are present, or if periodontitis is diagnosed, then extraction is the best option and dental implants the natural choice of treatment. The motivation for such arguments is often the anecdotal; “Treatment of pulpal pathology or periodontitis will eventually fail, and implants are forever”
This is a debate that brings out the best and the worst that dentistry has to offer. I for one, am not always sure the end result is in the best interest of the patient and therein lies the dilemma; Are we as dentists not making decisions based on what is good for us and not what is good for our patients?
I think it is time that we visit our decision-making processes again, based on evidence before us and not on our limited field of interest/expertise, or even worse - what is good for our pockets.
Gordon Christensen1 covered the topic very well in his review for the American Dental Association, and although the views he expressed are, as he declared, his own personal opinion, it makes for excellent reading. Informed consent, one of the factors he addresses, has in my personal experience been managed such that the information given to the patient is often distorted, depending on whether the clinician is an endodontist / restorative dentist or a surgeon. Arguments such as “endodontic treatment will fail and although cheaper now, will cost more in the long term” are routinely used by surgeons, whereas the endodontist / restorative dentist might claim success rates published, but not use the same protocol to obtain biologic objectives, this being one of the most important aspect in successful endodontics treatment.2 Another very important factor determining the success of endodontic treatment is the restoration that follows it.3,4
That there will always be a debate about this, and a heated one at that, is a given, as both endodontics and implant dentistry benefit from continuously improving materials and techniques. One cannot be dogmatic in approaching this complex subject of implants versus endodontics, as there are just too many variables. What we do owe to our patients is to ensure that we stay abreast of all developments and calculate that into our decision making process.
Implant factors such as the position and size of the micro-gap as well as micro movement influence bone and soft tissue stability and therefore the sustainability of results.5,6 One should therefore not extrapolate findings from research of one product to the next. This, in my opinion, is plainly unethical.
I believe that, as surgeons, we have to show integrity in choosing our implant hardware, as not all implants are equal, just as all motor vehicles are not equal, and on the other hand, all endodontics treatment protocols are also not equal. The same arguments can be used in endodontics, such as the use of a microscope, the latest materials and an aseptic / sterile protocol.
We tend as clinicians to become very focussed on what we can do and then close our minds to what other disciplines in dentistry can offer as a solution to the same problem. To illustrate, I would like to use the following example, even if it does not include endodontic treatment.
How many of us would agree with the Cochrane Review that there is weak evidence that patients will be more satisfied with an implant retained prosthesis vs a soft tissue borne prosthesis after preprosthetic surgery?7 Probably very few, and yet I can testify to many satisfied patients that I treated with preprosthetic surgery to obtain better retention of the prosthesis, who then declined implant treatment as their main complaint of denture instability was totally eliminated. How often do we give this option to patients? I suppose one can argue that I have the luxury of working without the pressures of economic survival and therefore cannot compare with the private sector, but I have used both the above options in private practice as well. This is just one example of different treatment modalities that can be used for the same complaint, with the decision based on what is best for the patient, taking many factors into account such as finances, systemic health, main complaint and others.
I firmly believe that implants were never meant to replace viable natural teeth, but that the intention was, and should always be, to replace missing or hopeless teeth. What constitutes hopeless is something, which should be decided for each case on merit and not be a blanket decision for all patients, based on what our abilities are and what is good for our pockets. Endodontic treatment has become more predictable over the last few years and so has retreatment, and we should take careful note of this before condemning a tooth with pulpal/endodontic complications.
I hope that all our colleagues will be stimulated to read as much as possible on this very relevant issue, and to develop an objective way of looking at each new case, so that we may stay true to the Oath of Hippocrates – at least as far as “doing no harm” is concerned.

References
1.Christensen, GJ. Implant therapy versus endodontic therapy. J Am Dent Assoc 2006; 137: 1440-1443.
2.Peters, OA, Barbakow, F, Peters, CI. An analysis of endodontic treatment with three nickel-titanium rotary root canal preparation techniques. Int Endod J 2004; 37: 849-859.
3.White, SN, Miklus, VG, Potter, KS, Cho, J, Ngan, AY. Endodontics and implants, a catalog of therapeutic contrasts. J Evid Based Dent Pract 2006; 6: 101-109.
4.Doyle, SL, Hodges, JS, Pesun, IJ, Law, AS, Bowles, WR. Retrospective cross sectional comparison of initial nonsurgical endodontic treatment and single-tooth implants. J Endod 2006; 32: 822-827.
5.Hermann, JS, Buser, D, Schenk, RK, Schoolfield, JD, Cochran, DL. Biologic Width around one- and two-piece titanium implants. Clin Oral Implants Res 2001; 12: 559-571.
6.Hermann, JS, Schoolfield, JD, Schenk, RK, Buser, D, Cochran, DL. Influence of the size of the microgap on crestal bone changes around titanium implants. A histometric evaluation of unloaded nonsubmerged implants in the canine mandible. J Periodontol 2001; 72:1372-1383.
7.Coulthard, P, Esposito, M, Worthington, HV, Jokstad, A. Interventions for replacing missing teeth: preprosthetic surgery versus dental implants. Cochrane Database Syst Rev 2002: CD003604.

Andre van Zyl, MChD (OMP) (Stell). Head of Department of Periodontics & Oral Medicine, School of Dentistry, Faculty of Health Sciences, University of Pretoria, South Africa

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