“Every tooth's a snowflake”

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					Treating Our Patients
Using Endodontic and
Implant Restorations

         PPAC
Treatment Numbers
 Endodontic and implant restorations are
  performed daily by dentists and specialists
 For 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
         Implant placement at University of Minnesota 1997-2007
    900
                               Patients
    800
                               Implants

    700
                40%
    600       increase
    500       annually
             1997-2007
    400

    300

    200

    100

     0
     1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
                                          Year
 Treatment Considerations
 “Treatment planning for
  the future: Endodontics,
  fixed partial dentures –
  or implants?”
Treatment Considerations
 “The success rate of
  non-surgical root canal
  treatment is unclear
  within the endodontic
  literature.”
 “…(endodontics) in
  general practice, the
  success rate can be
  64% to 75%.”
 “Endodontic therapy
  may extend the life of
  the tooth but very little
  is known on the extent
  of tooth longevity.”
Implants vs. Endodontics
 The Academy of Osseointegration’s 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
Implants vs. Endodontics
 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
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Apples vs. Oranges
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Success Criteria
Endodontic Criteria
 1956, Strindberg proposes stringent
  radiographic criteria
            Strindberg LZ, 1956
Success Criteria
Endodontic Criteria
 1956, Strindberg proposes radiographic
  criteria
 Beginning in 1966 and since, many authors
  suggest radiographic criteria is ill advised
              Bender IB, Seltzer S and Soltanoff W, 1966
              Van Nieuwenhuysen JP, et al, 1994
              Fristad I, et al, 2004
              Gutmann JL, 1992
              Seltzer S, 1988
Success Criteria
Endodontic Criteria
 1956, Strindberg proposes radiographic
  criteria
 Beginning in 1966 and since, many authors
  suggest radiographic criteria is ill advised
 However, some studies still use Strindberg’s
  dated criteria.
              Allen R, Newton C and Brown C, 1991
              Sundqvist G, et al, 1998
              Sjogren U, et al, 1990
              Farzaneh M, Abitbol S and Friedman S, 2004
Success Criteria
Endodontic Criteria
 1956, Strindberg proposes radiographic
  criteria
 Beginning in 1966 and since, many authors
  suggest radiographic criteria is ill advised
 However, some studies still use Strindberg’s
  dated criteria.
 Fristad and colleagues showed the potential
  for late radiographic healing.
            Fristad, Molven and Halse, 2004
Success Criteria
Success Criteria
Endodontic Success Criteria




                      3-year recall
Endodontic Success Criteria
Endodontic Success Criteria
Endodontic Success Criteria




                    12-month recall
Success Criteria
 1956, Strindberg proposes radiographic
  criteria
 Beginning in 1966 and since, many authors
  suggest radiographic criteria is ill advised
 However, some studies still use Strindberg’s
  dated criteria.
 Fristad and colleagues showed the potential
  for late radiographic healing.
 Success or Survival?
            Iqbal MK, Kim S, 2007
Success Criteria
 Success or Survival?
 The definition of “success” for dental implant
  studies is often implant survival
 Unlike implants and FPDs, RCTs aim to cure
  existing disease
            Weiger, et al, 1998
Success Criteria
 Success or Survival?
 Unlike implants and FPDs, RCTs aim to cure
  existing disease
 Thus, RCT studies measure both the healing
  of existing disease and the occurrence of new
  disease.
            Torabinejad, et al, 2007
Success Criteria
 Success or Survival?
 It has been suggested that implant success
  criteria are not routinely applied in much of
  the implant outcomes literature
            Salinas and Eckert, 2007
Success Criteria
 Success 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, 1999
            Johnson, et al, 2000
            Wennstrom, et al, 2005
  Success Criteria
 In order to establish comparable comparisons, it
  is critical that the same outcome measure is used
  to assess both endodontic and implant
  procedures.
  Success Criteria
 In order to establish comparable comparisons, it
  is critical that the same outcome measure is used
  to assess both endodontic and implant
  procedures
 Due to these differences in meanings of success,
  it is probable survival rates “will permit less
  biased, albeit less informative, comparisons.”
              Doyle, et al, 2006
              Eckert and Wollan, 1998
              Creugers, et al, 2000
              Torabinejad, et al, 2007
Success Criteria
 The Academy of Osseointegration’s 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
Success Criteria
 Success or Survival?
             Iqbal MK, Kim S, 2007
 Success Criteria - Implants
 Two 3.75 x 18 implants
  were placed on #9, 10 sites
 Implants appear
  osseointegrated
Success Criteria - Implants

                         Initial visit pt
                        presented with
                           provisional
                          restorations




            Esthetics case referred to Dr. Debra Johnson
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
 Restorative Impact
 Lazarski 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 2001
 Restorative Impact
 Lazarski 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, 1991
              Siqueira JF, 2001
              Hoen MM, Pink FE, 2002
              Salehrabi R, Rotstein I, 2004
              Aquilino SA, Caplan DJ, 2002
              Sorensen JA, Martinoff JT, 1985
Restorative Impact
 The Academy of Osseointegration’s 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
Restorative Impact
Restorative Impact
Restorative Impact
Restorative Impact




                     22-month recall
Restorative Impact
 The restoration of an endodontically treated
  tooth is considered a major determinant of its
  survival.
 More prosthetic complications with implants.
            Goodacre CJ, et al, 2003
            Iqbal MK, Kim S, 2007
            Doyle et al 2006
Bone Loss Around Implants
  With 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
                 4



                 3
Bone Loss (mm)




                 2



                 1



                 0
                     0   1   2     3    4   5    >   6
                                 Year           n=455 Error bars = S.E.M.
Cost to Patient
 Analysis of 2005 insurance data concluded
  that restored single-tooth implants cost 75-
  90% more than similarly restored endodontic-
  treated teeth
Cost to Patient
 Analysis of 2005 insurance data concluded
  that restored single-tooth implants cost 75-
  90% more than similarly restored endodontic-
  treated teeth
 Post-treatment problems can increase this
  cost difference
Cost to Patient
                       2000



                       1500
  Average Price ($$)




                                           130%
                                         Increase

                       1000



                        500



                         0
                              Endodontic/Restoration   Implant/Restoration
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Who’s Treating?

 Historically, implants placed by specialists,
  while many endodontic studies were
  conducted on patients treated by dental
  students.
               Aquilino SA, Caplan DJ, 2002
               Bergman B, et al, 1989
               Dammaschke T, et al, 2003
               Lynch CD, et al, 2004
               Mentink AG, et al, 1993
Who’s Treating?

 Of 13,047 identified studies, 147 articles from
  the endo, prosth and implant literature were
  systematically reviewed.
            Torabinejad, et al, 2007
Who’s 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
           Students
Implant       0%                        87%
Prostho       29%                       35%
Endo          63%                       29%
Who’s Treating?
Who’s Treating?
Who’s Treating?
Who’s Treating?
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Publication Bias

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

 More 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, 2007
Publication Bias
 More 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
  literature…”
            Moradi DR, et al, 2006
Implants vs. Endodontics
 Success criteria
 Problem areas
 Who’s treating
 Publication bias
 Modern advances
Modern Advances

 Both Iqbal and Kim’s as well as Torabinejad
  and colleagues’ systemic reviews were
  conducted “using material from previous
  decades and therefore reflect the treatment
  approaches prevalent at that time.”
            Iqbal and Kim, 2007
Modern Advances
 Implants
    New implant shape/design
    New surface modifications
    New implant-abutment
     interfaces
    Immediate loading
    Mini implants
    Etc…
Modern Advances
 Implants                   Endodontics
    New implant                NiTi instrumentation
     shape/design               Apex locators
    New surface                Surgical operating
     modifications               microscope
    New implant-abutment       Digital radiography
     interfaces                 Materials: MTA,
    Immediate loading           MTAD, Resilon
    Mini implants              DNA hybridization,
    Etc…                        PCR, etc…
                                Etc…
Case Selection
Case Selection
Case Selection
Case Selection – Fx #20
Case Selection
Case Selection




                 1-month recall
Case Selection
Case Selection
Case Selection
Case Selection
Case Selection




                 13-month recall
Implants vs. Endodontics
 The Academy of Osseointegration’s 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
Implants vs. Endodontics

 The Academy of Osseointegration’s 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


                          AND
Implants vs. Endodontics
 The Academy of Osseointegration’s 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
Implants vs. Endodontics

 “…in periodontally sound teeth having pulpal
  and/or periradicular pathosis, root canal
  therapy resulted in…equal outcomes (97%)
  to extraction and replacement of the missing
  tooth with an implant.”
         Torabinejad, et al, 2007
Implants vs. Endodontics

 “No difference in the survival rates between
  the two treatment modalities.”
            Iqbal MK, Kim S, 2007
    Implants vs. Endodontics




                                                                n=4477



Unpublished data from AAE Foundation - Bowles, Eleazer, Drum & Goodis 2008
Implants vs. Endodontics
 Endodontic therapy should be given priority in
  treatment planning for periodontally sound
  single teeth with pulpal and or periradicular
  pathology.
Implants vs. Endodontics
 Endodontic 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
  extraction
Implants vs. Endodontics
 The decision to treat a compromised tooth
  endodontically or replace it with an implant
  must be based on factors other than
  treatment outcome – since the outcomes are
  similar.
            Iqbal and Kim 2008
Implants vs. Endodontics



    CASE SELECTION
    CASE SELECTION
    CASE SELECTION
Conclusion

 Functional survival rates are high for both
  treatments
Conclusion

 Functional survival rates are high for both
  treatments
 Endodontic treatment on a hopeless tooth is
  just as unethical as extracting a restorable
  tooth and replacing it with an implant
Conclusion
 Functional survival rates are high for both
  treatments
 Endodontic treatment on a hopeless tooth is
  just as unethical as extracting a restorable
  tooth and replacing it with an implant
 Since outcomes are similar with either
  treatment, decisions should be based on
  other factors such as restorability, costs,
  esthetics, potential adverse outcomes and
  ethical factors

				
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