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Do dental implants toll the end of endodontics?

2002; Elsevier BV; Volume: 93; Issue: 6 Linguagem: Inglês

10.1067/moe.2002.126687

1528-395X

Julian Moiseiwitsch,

Dental Education, Practice, Research

Much has been written recently about the revolutionary effect dental implants have had on treatment planning in restorative dentistry. There can be no question that Brånemark implants have radically changed the practice of dentistry. For the first time it is now possible to attain long-sought “screw-in” teeth. To listen to some speakers, it is a wonder any of us bother to retain our natural teeth! If implants are so easy and predictable to place, restore, and maintain, it would seem reasonable to extract and replace natural teeth as soon as they require any major restorative procedure. Some might say that a class I composite is a major restoration because it will need to replaced soon, eventually requiring a crown and then endodontics. Surely then, placing an implant while the bone is healthy is preferable. If such reasoning prevails, the full set of implants will be as essential in the 21st century as a full set of dentures was in the early part of the 20th century. I hope that this seems like an extreme point of view to all readers of this editorial. However, I would suggest that it is only a little more extreme than the view of many implant dentists, a view reminiscent of the “hundred percenters” from the last century. The argument goes like this: Once endodontics is required in a tooth, retention of that tooth must be suspect. Thus, if any other implants are to be placed, why not replace all endodontically treated teeth with implants at the same time? What this view does not take into account is the attitude of the patients. The retention of the natural dentition is important to most patients. Probably the greatest reason for wanting to retain teeth is emotional. We are all very attached to our natural bodies, and teeth are an integral part of who we are. Convenience is also often stated as a reason for wanting to maintain a natural dentition. The 6- to 18-month wait between loss of a tooth and placement of an implant-retained crown is an excellent reason for choosing to maintain a natural tooth. This is especially true of anterior teeth. I would suggest that practitioners who argue that the wait is “only 6 months” try having their central incisors moving around in their mouths every time they speak and eat and see how long 6 months can seem! The complaint that patients have more often than all others when discussing their experience with implants is how inconvenient the implants are during treatment and how misleading the projected lengths of time are for receiving a replacement tooth. Frequently 6 months is quoted as the length of time required before loading an implant after single-tooth extraction. This may be reasonable in a perfect world, when a postextraction healing time of 6 to 8 weeks is followed by 4 months of healing time after implant placement, then a trip to the prosthodontist, who immediately places a perfect temporary crown. Then again, in a perfect world we would all have beautiful straight teeth with no impacted third molars, no periodontal disease, and no caries. In reality, few patients can schedule their lives around their dentist's schedule. A more realistic time frame for restoration of an implant from time of diagnosis to completed tooth replacement is 9 to 12 months, and, in my experience, 18 months is not unusual. This is a time frame for patients who have routine implants with good bone support. It does not include cases in which implants fail to osseointegrate, in which implants are misplaced, in which too few implants are initially placed, in which implants have long-term discomfort associated with them, or in which any other problems occur that I'm sure you've never encountered in your implant practice! Another problem with an aggressive advocacy for more implants is the relative criteria of success for endodontics and implants. Perhaps we, as endodontists, have colluded in the creation of such advocacy by defining endodontic success too narrowly. Rather, I would argue that the outcome criteria for implants have been too loose. The criteria used to determine endodontic success are complete radiographic healing and lack of symptoms after two years. By contrast, most implant studies discuss survival rates without mention of symptoms or radiographic signs. I would suggest that if I limited my endodontic practice to healthy, vital teeth with uncomplicated root canal anatomy in patients who had no systemic disease processes, I could have 99.9% success in my practice. In fact, if I considered only failures on a patient basis rather than on a single-tooth basis (ie, my endodontics was considered successful so long as the case was successfully restored afterwards), I would achieve more than 100% success. This is obviously absurd, but no more so than claiming 100% implant success when 5 out of 6 implants are finally restorable in a patient, providing a fully functional dentition. In endodontics that would represent a 16.5% failure rate. Finally, I would like to look at a cost-benefit analysis of endodontics versus implants. Generally, when we are confronted with the strict choice between endodontics and implant, it is for replacement of a single tooth. Let us assume that both endodontics and implants have the same 20-year survival rate. Let us ignore the inconvenience associated with implant placement and the discomfort of several surgical procedures associated with implant placement. Similarly, we ignore the risk of postoperative discomfort associated with endodontics. Each of these points could be argued, but they must wait for another occasion. Assuming that the benefit in each case is the same, we need to look at the cost of the two methods of replacement. In a recent pilot study, a colleague and I examined precisely this question.1Moiseiwitsch JRD Caplan D A cost-benefit comparison between single tooth implant and endodontics.J Endodont. 2001; 27: 235Google Scholar It became obvious that when endodontics and crown alone were required, the cost of treatment in various parts of the country ranged from a low of $1100 to a high of $2100. The cost of implant placement had a much smaller range, but at $3500 to $4000 was considerably higher than the cost of endodontics. However, when the requirement for crown extension therapy or additional treatment was added to the treatment plan, the cost range for maintaining the tooth was closer to the cost for implant placement and restoration. In such cases, the cost of endodontics, crown extension therapy, foundation, and crown ranged from $1800 to $2800, whereas extraction, simple bone graft, radiographic work-up, implant placement, retainer placement, and crown placement ranged from $3500 to $4000. We chose to ignore possible adjunctive procedures before implant placement such as sinus lift and extensive bone grafts, which would increase the cost of an implant. In some parts of the country, particularly large cities where endodontics tends to be more expensive and the competition between implantologists is high, the cost of the two treatment plans can be close. With so little difference in cost between the two kinds of treatment, endodontics is obviously the superior choice. When a tooth can be saved, it should be saved. As has been stated repeatedly, the treatment plan should be dictated by the prognosis of each tooth being considered. The impact of implantology on dentistry cannot be overstated. It has quite literally revolutionized treatment planning in dentistry. For those patients who can afford modern dentistry, there are few reasons to place removable partial or complete dentures. However, when a single tooth can be treated successfully with endodontic therapy, there are no sound clinical reasons for replacing it with an implant. As dentists, we must strive to continue to save teeth whenever possible. Although the days of “herodontics” are thankfully over, dentistry should not be so overcome with the exciting possibilities of implants that we forget our first duty to offer the best possible treatment for our patients' teeth.