Root Canal Treatment in the Era of Implants

ROOT CANAL TREATMENT IN THE ERA OF IMPLANTS

ROOT CANAL TREATMENT IN THE ERA OF IMPLANTSOne of the fundamental goals of dentistry is the retention of a patients natural dentition in a disease-free state.

The use of surgical and nonsurgical endodontic treatment has historically been a key ingredient in the attainment of this goalExtraction is often seen as a treatment choice of last resort as a result of limited restorative options and nancial considerations.

With the emerging eld of implant dentistry gaining acceptance, the prevailing opinions on treatment planning for diseased teeth are changingMany practitioners consider the single-tooth implant as a reasonable alternative to the preservation of the natural dentition.

Thus, a practitioner is faced with a fundamental dilemma

Should a tooth be retained through nonsurgical endodontic treatment, or should it be extracted and replaced with an implant-supported crown ?Treatment should be patient-centered, not be based only on dental insurance benefits and not be guided solely by the desires and clinical experience of the practitioner.

It must be based on scientific evidence, and ideally it should preserve the biological environment while maintaining or restoring esthetics, comfort and function.Do Implants and Endodontic Treatment Have theSame Indications?When dental implants were first introduced by Brnemark in 1977, they were envisioned as a replacement for missing teeth and

indicated for patients who might otherwise have received removable prosthesisCreugers et al demonstrated that an assortment of single-tooth implants (n459) achieved a 4-year survival rate of 97%.

However, the study also reported that approximately 20% of single-tooth implants were associated with some sort of postoperative complication, ranging from abutment screw retightening to crown remake.Creugers NH, Kreulen CM, Snoek PA, de Kanter RJ. A systematic review of singletoothrestorations supported by implants. J Dent 2000;28:209 17.Lindh et al performed a meta-analysis of implant studies involving partially edentulous patients and reported a success rate of 97% after 67 years for a single implant crown.

Data in table indicate that 28% of the teeth extracted and replaced with single-tooth implants were endodontically treated.

The actual reason for extraction of these endodontically treated teeth was not stated.

Only a small percentage (9%) of endodontically treated teeth are lost as a result of true endodontic failure (Vire DE. Failure of endodontically treated teeth: classification and evaluation. J Endod 1991;17:33842.).

The loss of the endodontically treated tooth is because of multiple types of failure, including

prosthetic failure (59.4%), periodontal failure (32%) andendodontic failure (9%) In several studies many cases with post-treatment apical periodontitis were extracted and replaced with implants, without resorting to alternative treatment modalities such as retreatment and periapical surgery.

Contrary to the preponderance of evidence, the presence of apical periodontitis is increasingly being used to recommend tooth extraction and immediate implant placement 26% of teeth replaced by implants suffered from dental trauma. In one of the studies, teeth with horizontal root fractures constituted 16% of teeth replaced with single tooth implants .

However, it should be recognized that the use of implant therapy in intra-alveolar root fractures is unwarranted because most pulp tissue remains vital under these conditions .

Furthermore, a majority of these horizontal fractures do not require any intervention, whereas many others respond favourably to endodontic treatmentROOT CANAL TREATMENT INDICATIONS causative factors of root canal treatment performed at a postgraduate endodontic program indicated that approximately60% - treatments were necessitated by caries, 19% -restorative failures, 13%- post-treatment apical periodontitis, and 6%- dental trauma both root canal treatment and single-tooth implants are increasingly being offered to a similar patient population.indications for dental implants begin to conflict with the indications for endodontic therapy, there is a need for development of guidelines so that the patient is provided with sufficient information to select the optimal procedure for their particular treatment plan. What Factors Influence Prognosis of Endodontic andImplant Treatments?It has been suggested that the restored single-tooth implant is a viable alternative in treating a compromised tooth with a poor prognosis.

To discuss treatment of compromised teeth, a compromised tooth must be differentiated from an end-stage tooth failure.

A compromised tooth defined as a complex clinical syndrome that can result from any structural or pathologic disorder that impairs the ability of the tooth to function properly without some type of restoration.

Currently, the strategies for achieving this objective include placement of prosthetic restorations and possibly various endodontic treatments (nonsurgical root canal treatment, retreatment, or periradicular surgery).

Similarly, an end-stage tooth can be defined as a pathologic state or structural deficiency that cannot be successfully repaired with reconstructive therapies, including root canal treatment and retreatment, and continues to exhibit progressive pathologic changes and clinical dysfunction of the tooth.

Strategies for treating end-stage tooth failure include- extraction and restoring function with placement of a fixed or removable prosthesis or an implant-supported restorationTreatment NumbersEndodontic and implant restorations are performed daily by dentists and specialistsFor 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

40% increase annually1997-2007The 18.6 % increase is just an estimate. For example, from 1997 to 2007, we see a 40% annual increase in implant placements at the University of Minnesota. However, the number of implants per patient did not significantly change over the 10-year period.24Pie chart illustrating the outcomes of 1,463,936 root canal-treated teeth with an eight-year follow-up. Data is from Delta Dental insurance database and represent patients from all 50 states of the United States. (Source: Salehrabi and Rotstein. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. Journal of Endodontics 2004; 30(12):846-50.

Implants vs. EndodonticsSuccess criteriaProblem areasWhos treatingPublication biasModern advances

26When comparing these two treatment modalities there are five aspects of the literature that should be taken into account.Apples vs. OrangesSuccess criteriaProblem areasWhos treatingPublication bias Modern advances

27Of course the challenge is that in the literature its like apples and oranges; there is a veritable dearth of articles directly comparing the two treatment modalities.Implants vs. EndodonticsSuccess criteriaProblem areasWhos treatingPublication bias Modern advances

Success CriteriaEndodontic Criteria1956, Strindberg proposes stringent radiographic criteriaStrindberg LZ, 1956

absence of clinical symptoms and periapical pathology with a normal, intact periodontalligament and lamina dura surrounding the apex.29Strindberg proposed a one-year timeframe that required COMPLETE radiographic resolution for it to be considered a success.Success CriteriaEndodontic Criteria1956, Strindberg proposes radiographic criteriaBeginning in 1966 and since, many authors suggest radiographic criteria is ill advisedBender IB, Seltzer S and Soltanoff W, 1966Van Nieuwenhuysen JP, et al, 1994Fristad I, et al, 2004Gutmann JL, 1992Seltzer S, 198830However, there are definite limitations to such a criteria as these authors have discussed. It doesnt account for an asymptomatic patient with a functioning tooth not to mention the potential for delayed radiographic healing.Success CriteriaEndodontic Criteria1956, Strindberg proposes radiographic criteriaBeginning in 1966 and since, many authors suggest radiographic criteria is ill advisedHowever, some studies still use Strindbergs dated criteria.Allen R, Newton C and Brown C, 1991Sundqvist G, et al, 1998Sjogren U, et al, 1990Farzaneh M, Abitbol S and Friedman S, 2004Success CriteriaEndodontic Criteria1956, Strindberg proposes radiographic criteriaBeginning in 1966 and since, many authors suggest radiographic criteria is ill advisedHowever, some studies still use Strindbergs dated criteria.Fristad and colleagues showed the potential for late radiographic healing.Fristad, Molven and Halse, 200432As mentioned earlier there is evidence of delayed healing. In fact, Fristad and colleagues showed radiographic healing as late as 20 to 27 years after RCT.Success Criteria

33According to Strindberg and some of the articles we just discussed this #10 would not be considered a success. However the tooth is asymptomatic and fully functioning. In factSuccess Criteria

34this was how the tooth presented prior to retreatment.Endodontic Success Criteria

3-year recall35And in fact the first image we saw was from the 3-year recall. In a clinical practice, by most measures this would be considered a success. Especially if we take into account the findings of Fristad et al this tooth is well on its way to radiographic resolution.Endodontic Success Criteria

36HERES ANOTHER EXAMPLE Heres a case with a periapical lesion on the mesial root as well as what appears to be a void/cotton under the access repair material. Failure? Certainly according to Strindberg, not a success.Endodontic Success Criteria

37However, heres the pre-op of the caseEndodontic Success Criteria

12-month recall38So while, yes, there is still a temporary in place, the patient was ashamed she had not followed up, I would still call this a success. Given the bony healing and the patient is asymptomatic and functioning well on glass ionomer temporarySuccess Criteria1956, Strindberg proposes radiographic criteriaBeginning in 1966 and since, many authors suggest radiographic criteria is ill advisedHowever, some studies still use Strindbergs dated criteria.Fristad and colleagues showed the potential for late radiographic healing.Success or Survival?Iqbal MK, Kim S, 200739All of which begs the question: should we be looking at Success, or is Survival a better benchmark?Success CriteriaSuccess or Survival?The definition of success for dental implant studies is often implant survivalUnlike implants and FPDs, RCTs aim to cure existing diseaseWeiger, et al, 1998Albrektsson et al proposed criteria for implant success in 1986 that included-absence of mobility, absence of peri-implant radiolucency, absence of signs and symptoms, loss of marginal bone of less than 1.5 mm duringthe first year after insertion of the prosthesis and less than 0.2 mm annual bone loss thereafter, and a minimum 10-year retention rate of 80%.Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy ofcurrently used dental implants: a review and proposed criteria of success. Int JOral Maxillofac Implants 1986;1:1125.Success CriteriaSuccess or Survival?Unlike implants and FPDs, RCTs aim to cure existing diseaseThus, RCT studies measure both the healing of existing disease and the occurrence of new disease.Torabinejad, et al, 2007

Success CriteriaSuccess or Survival?It has been suggested that implant success criteria are not routinely applied in much of the implant outcomes literatureSalinas and Eckert, 200743Meanwhile on the implant side of the equation there is question about the consistency of the results.Success CriteriaSuccess 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, 1999Johnson, et al, 2000Wennstrom, et al, 200544Thus you are more apt to see leniency in the implant literature, while stringency is the trademark of the endodontic literature.Therefore, studies evaluating survival as anoutcome measure will, by definition, providegreater measured magnitudes than studies with healing/success as an outcome measure. Moreover, the conclusion of healing/success versus nonhealing/failure might be influenced by the sampling time.Success CriteriaIt remains difficult to compare the success rates because of differing methodologies and definitions of successDue to these differences in meanings of success, it is probable survival rates will permit less biased, albeit less informative, comparisons.Doyle, et al, 2006Eckert and Wollan, 1998Creugers, et al, 2000Torabinejad, et al, 2007Success CriteriaSuccess or Survival?Iqbal MK, Kim S, 2007

47to be a little tongue in cheek, this patient is asymptomatic and the tooth is still being retained. Based on some of the criteria published in the implant literature you could call this a success/survival.Success Criteria - ImplantsTwo 3.75 x 18 implants were placed on #9, 10 sitesImplants appear osseointegrated

Lets turn things around for a moment and look at Success and Survival when it comes to implants. Here are two implants that obviously appear osseointegrated and thus surviving

Initial visit pt presented with provisional restorationsSuccess Criteria - ImplantsEsthetics case referred to Dr. Debra JohnsonHowever, the determination of success isnt quite as clear cut when we look at the bigger picture.Implants vs. EndodonticsSuccess criteriaProblem areasWhos treatingPublication bias Modern advances

Restorative ImpactLazarski 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 200151At this point in time it is pretty well understood that a proper restoration following RCT is a must.Restorative ImpactLazarski 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, 1991Siqueira JF, 2001Hoen MM, Pink FE, 2002Salehrabi R, Rotstein I, 2004Aquilino SA, Caplan DJ, 2002Sorensen JA, Martinoff JT, 198552At this point in time it is pretty well understood that a proper restoration following RCT is a must.Are there any studies comparing the outcome of Coronally restored root canaltreated teeth and Single-tooth implants?Restorative ImpactThe Academy of Osseointegrations 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

Which again, is why the AO specified in their mandate, restored teeth.

The outcome demonstrated no difference in the long-term outcome between these 2 treatment modalities.

This systematic review concluded that the decision to treat a tooth endodontically or to replace it with a singletooth implant should be based on criteria other than long-term outcomeof the 2 treatment modalities because the 2 treatments produce similar outcomes.A recent retrospective study compared the survival of single-tooth implants in 196 patients with a case-matched 196 patients who received conventional root canal treatment followed by coronal restoration .

.Although both groups exhibited high overall survival rates(94%), it should be noted that nearly 18% of implants required some type of post-treatment intervention (eg, lost screws) and that this group required significantly (P .001) more subsequent dental treatment than endodontically treated teeth.

Restorative Impact

60Heres an example of what I would consider a technically well-done RCT, but the patient reported discomfort at this, the 12 mrc. As you can see, whats left of the original temporary has collapsed.Restorative Impact

61This is now the retreated tooth, with a somewhat more substantial glass ionomer (triage) temporary in place. Yes, cotton has been replaced under the temporary per the restoring dentists request. Otherwise, a permanent core would have been placed at the time of obturation, at no charge if need be, based on the patients history of poor follow-up.Restorative Impact

62Another example of poor follow-up. Heres an immediate post-op film of RCT #19, complete with cotton under a glass ionomer temp (triage) again, cotton placed per restoring dentists request.Restorative Impact

22-month recall63And here we are at almost the 2-year point, and while the glass ionomer has held up well the margins of the original restoration have leaked and you can now see evidence of recurrent decay in the chamber.Restorative ImpactThe restoration of an endodontically treated tooth is considered a major determinant of its survival.More prosthetic complications with implants.Goodacre CJ, et al, 2003Iqbal MK, Kim S, 2007Doyle et al 2006

Bone Loss Around ImplantsWith 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

Bone Loss (mm)n=455 Error bars = S.E.M.Cost to PatientAnalysis of 2005 insurance data concluded that restored single-tooth implants cost 75-90% more than similarly restored endodontic-treated teethPPAC INFO, NEED REFERENCESCost to PatientAnalysis of 2005 insurance data concluded that restored single-tooth implants cost 75-90% more than similarly restored endodontic-treated teethPost-treatment problems can increase this cost difference PPAC INFO, NEED REFERENCESMoiseiwitsch and Caplan conducted a cost-benefit analysis of endodontic treatment versus single-tooth implants and found that a restored implant costs approximately 70%400% more than an endodontically treated tooth restored with a crown.

Christensen et al found that an implant-supported crown cost about twice that of an endodontically treated tooth restored with a crown.

For implant therapy the cost of the extraction, implant placement, implant abutment, and porcelain fused to metal crown For endodontic treatment the cost of the root canal procedure, post and core, and porcelain fused to metal crown.

. Doyle et al demonstrated that patients receiving implants required 5 times more postoperative interventions compared with those receiving endodontic careCost to Patient

Average Price ($$)130%Increase

These numbers were generated in an university setting, but still demonstrate a marked difference between the two treatment options.Function and Psychological FactorsEndodontically treated teeth -maintain the original proprioceptive mechanisms of the natural tooth,

Implants - lack a periodontal ligament and the ability to perceive functional loads as well as the shock-absorbing function of the periodontal ligamentTrulsson reported that patients who lack information from periodontal receptors, such as implant patients, show an impaired fine motor control of the mandible.

Klineberg and Murray proposed osseoperception as the sensory mechanism for implants and postulated that the sensory and motor capabilities do not appear to match those of dentate individuals.

Schulte also found that the propriception of natural teeth at biting and chewing loads cannot be substituted by ankylotic retained implants.

Torabinejad et al revealed the resultant inferior esthetics and psychological trauma associated with tooth loss, such as self-image, were cited as factors for these inferior psychological outcomes. Esthetics plays a key role in a patients satisfaction and is the most frequent problem with implants in the anterior region .

The esthetic gingival response to a single-tooth implant will depend on the tissue biotype .

Thin scalloped tissue will react poorly to surgery and recede, whereas

Thick flat tissue will respond by inflammation without recession

Another difficult clinical situation to manage is the replacement of 2 adjacent anterior teeth with implant restorations.

Implants must be placed a minimum of 3 mm apart to preserve the interdental bone between the implants. in many clinical situations this might result in the loss of the interdental papilla, creating a black triangle with anunesthetic appearanceImplants vs. EndodonticsSuccess criteriaProblem areasWhos treatingPublication biasModern advances

Whos Treating?Historically, implants placed by specialists, while many endodontic studies were conducted on patients treated by dental students.Aquilino SA, Caplan DJ, 2002Bergman B, et al, 1989Dammaschke T, et al, 2003Lynch CD, et al, 2004Mentink AG, et al, 1993Whos Treating?Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were systematically reviewed.Torabinejad, et al, 2007

Whos 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%80Torabinejad and colleagues showed quite a disparity in operator skill level across the literature.Whos Treating?

81While there are many very skilled general practitioners, a case like this merits an objective assessment of ones skills prior to proceeding with treatment.Whos Treating?

82for if one of the canals goes untreated, the patient will have a much poorer prognosis.Whos Treating?

83Furthermore we all have our strengths and weaknesses. And to quote inspector Callahan a good man knows his limitations. This is how the patient presented to our office after both an initial RCT and a subsequent retreatment by the same practitioner.Whos Treating?

84This was our final film.These data suggest that the success rates of root canal treatment studies might be negatively biased as a result of the experience level of those performing a majority of the treatments compared with implants..Implants vs. EndodonticsSuccess criteriaProblem areasWhos treatingPublication bias Modern advances

Publication BiasMore likely to exist when a particular brand of implant is studied. While endodontics is mostly generic.Schnitman PA, Shulman LB, 1979Iqbal MK, Kim S, 2007Andersson B, et al, 1998Brocard D, et al, 2000Deporter DA, et al, 1998

Publication BiasMore 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, 2007Publication BiasMore 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 literatureMoradi DR, et al, 2006

Torabinejad et al found the quality of root canal treatment studies to be higher than implant studies, which consisted of case series analyses 64% of the time.Implants vs. EndodonticsSuccess criteriaProblem areasWhos treatingPublication bias Modern advances

Modern AdvancesImplantsNew implant shape/designNew surface modificationsNew implant-abutment interfacesImmediate loadingMini implantsEtcEndodonticsNiTi instrumentationApex locatorsSurgical operating microscopeDigital radiographyMaterials: MTA, MTAD, ResilonDNA hybridization, PCR, etcEtc92In technological terms, modern endodontics can be considered as advanced as implant dentistry Iqbal and Kim. Granted, it is difficult to assess the extent to which these improvements have affected the most current success rates of RCT. However, with the advent of widely accepted single implants treatment, now that we have an alternative where there wasnt one before, there are fewer questionable RCTs being performed. (often referred to as herodontics). Thus better case selection will result in better endodontic success/survival rates.Case Selection

93DR BOWLES, THIS IS THE CASE (NAMES CHANGED TO PROTECT THE UNINFORMED) THAT FIRST LIT A FIRE UNDER ME ABOUT IMPLANTS AND THE QUESTIONABLE TREATMENT PLANNING BEING DONE OUT THERE. IT MAY BE TOO STRONG OF A MESSAGE FOR THE GENERAL POPULACE, BUT IVE LEFT IT IN CAUSE ITS EASIER TO DELETE THAN ADD. This patient originally presented to a periodontist with buccal swelling adjacent to #4 and 5 (her daughter was being seen for an implant, and it was a convenient appt.) By patient report, the periodontist informed her that the RCT was failing (#5) and that #4 also had a RCT and would probably fail, so subsequently recommended extractions and implants #4 and 5). Fortunately, the patient had previously been seen in our office (for a different tooth) and self-referred for a second opinion. Obviously, #4 was in fine shape and #5 was indeed failing, due to untreated canal space thus rendering a good prognosis.

Case Selection

94This is the retreatment post-op image. Not only did the patients swelling and symptoms resolve, she saved her existing crowns, money and most importantly her own teeth.Case Selection

95Another example of a poor restorative prognosis, due to decay in the furcation, that even the worlds best RCT wont help.Case Selection Fx #20

96This next case, diagnosed as a necrotic #20 had a coronal fracture evident, but no significant probings.Case Selection

During treatment, with the use of an operating microscope, the fracture was deemed to be confined to the coronal structure.Case Selection

1-month recallAnd although the tooth was taken out of occlusion (evident on the film) and the patient was instructed to f/u for restorative treatment ASAP, this was how the tooth presented at the 1-month mark. Complete with deep narrow probings of 9+ mm.Case Selection

Subsequently, after discussing it with the patient, including a phone call to the referring dentist, it was decided to proceed with an implant at the same 1-month recall visit. Thus, in this case, the endodontist placed the implant, but offered a financial adjustment in light of the fact the RCT had only been completed 1-month prior. (NOTING THAT THE TREATMENT RENDERED WAS APPROPRIATE AT THE TIME, WITH THE INFORMATION AVAILABLE, AND THE ADJUSTMENT WAS BASED SOLELY ON THE ENDODONTISTS GENEROSITY AND NOT AN ADMITION OF ANY WRONGDOING OR IMPLIED WARRANTY.)Case Selection

100And note the bony healing at the time of abutment placement.Case Selection

A tale of two teeth. (Would recommend audience participation on this. Discuss how both teeth radiographically present like a cracked tooth, but the one on the right does not probe, with sinus tract, while the one on the left does have a narrow deep probing on the distal aspect.)Case Selection

This is after treatment on the tooth on the right (due to open apice, opted to obturate entirely with MTA).Case Selection

13-month recall

And this is the follow-up from both cases.ComplicationsDoyle et al found the incidence of complications to be 5 times greater for implants than endodontically treated teethImplants vs. EndodonticsThe Academy of Osseointegrations 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

ANDImplants vs. EndodonticsThe Academy of Osseointegrations 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

107The goal of Torabinejad and colleagues review, what do we find?Implants vs. Endodonticsin periodontally sound teeth having pulpal and/or periradicular pathosis, root canal therapy resulted inequal outcomes (97%) to extraction and replacement of the missing tooth with an implant.Torabinejad, et al, 2007108Well, Torabinejad and colleagues found comparable success rates, whileImplants vs. EndodonticsNo difference in the survival rates between the two treatment modalities.Iqbal MK, Kim S, 2007109. . .Iqbal and Kim simply found no difference. So where does that leave us?Implants vs. Endodontics n=4477

Unpublished data from AAE Foundation - Bowles, Eleazer, Drum & Goodis 2008Implants vs. EndodonticsEndodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology.111Well, Torabinejad suggested that if the tooth had a sound prognosis otherwise, proceed with the endodontic treatment.Implants vs. EndodonticsEndodontic 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 extraction112And if the tooth was to be extracted then the implant is probably the best choice.Implants vs. EndodonticsThe decision to extract a tooth that might otherwise be retained through endodontic treatment is becoming more common and is an emotionally charged issueIqbal and Kim 2008113While Iqbal and Kim simply suggested to look at factors beyond success rates alone.It is important to note that the 2 treatment alternatives have different aims;

endodontic treatment is provided to treat or prevent apical periodontitis, whereas

implants are used to replace missing teethImplants vs. Endodontics

CASE SELECTIONCASE SELECTIONCASE SELECTION

115All of which are just different ways to say what we all learned in dental school, and that is ALL of our treatment choices should be based on case selection, case selection, case selection.ConclusionFunctional survival rates are high for both treatmentsConclusionFunctional survival rates are high for both treatmentsEndodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implantConclusionFunctional survival rates are high for both treatmentsEndodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implantSince outcomes are similar with either treatment, decisions should be based on other factors such as restorability, costs, esthetics, potential adverse outcomes and ethical factors