Endo versus implants: the phoney war

20 March, 2014

Although difficult to quantify precisely, the use of dental implants has increased enormously in the last 20 years. Figures from the US suggest that, from
1983 to 2002 alone, their use increased ten-fold. It is estimated that more than 200,000 implants were placed in the UK in 2013. Coupled with that, implant
placement and restoration in a general practice setting has become more common in the last decade.

There is no doubt that dental implants have become a viable treatment modality in the replacement of missing teeth. Quality of life improvements have been
highlighted in both edentulous (Curtis et al. 2009) and partially dentate patients (Pavel et al. 2012). Studies report survival rates of implants in the
region of 82 to 94 per cent over a 10-year period (Holm-Pederson et al. 2007), although factors such as smoking, untreated periodontal disease and diabetes
may adversely affect the outcome.

Unfortunately, this has led to a paradigm shift in relation to the treatment planning of teeth with a questionable prognosis. Traditionally, clinicians
assessed teeth on the basis of a multitude of patient and dentist-related factors (Kalsi and Hemmings 2013). More frequently today, teeth to be considered
‘guarded’ in terms of their periodontal, restorative and/or endodontic prognoses are not being considered for rehabilitative treatment.

As clinicians, we need to be introspective on these issues more than ever before. Kay and Nuttall proposed the idea that, as individuals, we will always
have both perceptual and judgemental differences in relation to treatment planning of particular cases. More worrying were the findings of Kvist and Reit
(2002) in their series of papers on treatment planning in endodontics, which suggested that most people rely on a series of heuristic principles to make
treatment planning decisions.

Therefore, there are a number of key questions we need to answer in this debate as we attempt to compare both implants and endodontic treatment:

  • How can we compare both treatment modalities?
  • In these comparisons, which performs better, endodontically treated teeth or implant-retained restorations?
  • What is the cost and risk benefit to the patient of each treatment?
  • How did the ‘turf war’ develop between the two camps?

Comparison of endodontically treated teeth and implants

Comparisons between both have been difficult due to the fundamental differences between the treatments themselves and have traditionally only been based on
longevity. However, as Elemam and Pretty (2011) pointed out, both treatments differ in “the biological process, diagnostic modalities, failure patterns,
and patients’ preferences”.

Outcomes in dental literature can broadly be classified into four categories: success, survival (with and without intervention) and failure. Traditionally,
endodontic outcome studies have spoken in terms of success and failure, with little or no mention of survival of root filled teeth historically. These
strict criteria have been maintained in many studies on outcome of endodontic treatment (Sjogren et al. 1990, Hoskinson et al. 2002, Ng et al. 2011).

More recently, results in endodontic outcome studies have been dichotomised using both strict (success = complete radiographic healing and absence of
signs/symptoms) and lenient (success = reduction in size of periapical lesion and absence of signs and symptoms) criteria (Friedman et al. 2003, Ng et al.

Studies discussing the survival rate of endodontically treated teeth are also now more commonly appearing in the literature (Salehrabi et al. 2004, Kim and
Setzer 2013). While this may serve to alter the perception between both treatment modalities, it may also lead us further from the biological principles of
endodontics and dentistry in general. Unfortunately, as Noyes (1922) outlined almost one hundred years ago: “We are not trained to think in terms of
biological concepts but we are to act in mechanical procedures.” The shift in terms of our appraisal of the evidence merely acts to support this.
Direct comparisons: who wins?

Despite these differences, direct comparisons between the two modalities have been made by some groups. Doyle (2006), in a 10-year study comparing single
tooth implants and initial non- surgical endodontic treatment, found that both modalities had similar survival rates, while the incidence of post-operative
complications requiring intervention was higher in the implant group.

Levin (2013), in a recent systematic review comparing both, found that implant survival rates did not exceed those of compromised teeth, with implant
failure rates recorded as high as 33 per cent in some studies. The conclusion that the decision to extract and replace a tooth, as opposed to treating it,
should be taken cautiously appears to be supported by the evidence. Setzer and Kim (2013) also compare retention versus extraction and replacement, and
draw very similar conclusions.

A common misconception related to the complications associated with implant therapy is that they are often of a minor nature and easily treated.
Frequently, the prosthodontic complications are minor and may include screw loosening or fracture or damage to the permanent restoration.

However, a recent review paper (Armas et al. 2013) highlighted the fact that implant soft tissue complications are common, with peri-mucositis affecting up
to 80 per cent (Zitzmann and Berglundh 2008) and peri-implantitis affecting up to 56 per cent of subjects (Leonhardt et al. 2003). Evidence suggests that
peri-implant mucositis can be successfully treated non surgically if detected early, whereas non-surgical therapy has not been shown to be effective for
the treatment of peri-implantitis (American Academy of Periodontology paper on Peri-Implant Mucositis and Peri-Implantitis: A Current Understanding of
Their Diagnoses and Clinical Implications, 2013).

When making comparisons with the interventions required following a ‘failed’ endodontic treatment, the necessity for surgical intervention is often
presented as an undesirable follow on from the initial non-surgical treatment. However, as the evidence appears to demonstrate, this may also be indicated
in a large number of implant cases.

Also, outcomes following endodontic microsurgical procedures can be as high as 91.5 per cent (Rubinstein and Kim 2002), with anterior teeth in the maxilla
having a better outcome (Song 2013).

This again highlights the need for caution before a decision is made to extract and replace a root filled maxillary anterior tooth with an implant (with
trends showing that immediate placement and early loading are becoming more common) instead of treating it surgically, bearing in mind the aesthetic
outcomes can often be far less than ideal on follow up (Evans and Chen 2008).
Costs to the patient

Direct comparisons between the two treatment modalities on a financial basis reveal that restored single tooth implants cost 75-90 per cent more than
similarly restored endodontically treated teeth based on data from the US (Christensen 2006).

Comparisons should not, however, solely focus on cost. Improvements in our patients’ quality of life must be factored in and the long-term satisfaction
rate of patients with endodontically treated teeth is comparable to those receiving implant therapy (Dugas et al. 2002, Curtis et al. 2009).

Our treatment decisions should be evidence based, patient centred and taken with longevity/prognosis to the forefront. Adherence to these principles will
give patients value for money and clinicians peace of mind.
Is it a turf war?

In a recent editorial in the Journal of Prosthodontics, the rivalry that has developed
between both camps was discussed. There is no doubt the atmosphere in dentistry worldwide has become less collegial as time has gone on. The current
economic climate and the increased competition has led us this way. This, together with the expansion of implant dentistry in a general practice setting,
has made the competition more intense.

Competition is a good thing. It benefits both dentists and patients alike. It is argued that, as competition increases, prices should come down. However,
what we as clinicians cannot compromise on is our quality and our adherence to the biological principles of dentistry, the fundamental backdrop to carrying
out invasive treatments on patients. Some of our more oratorical colleagues in the US often make reference to the daughter or ‘mama’ test during their
presentations, where they basically encourage us to ask ourselves whether it would be the treatment we would propose for our own families.

There is no doubt that, as clinicians, we are sometimes blinded by what we know. Tunnel vision among the endodontic fraternity often means that teeth with
a questionable (or worse) prognosis are treated, without due regard for longevity.

Equally, it has become apparent many salvageable teeth are being extracted and replaced with implants. This swiftness to condemn a tooth without first
exhausting attempts to maintain it can be a costly one, both biologically and financially, to the patient.

As I have already mentioned, comparisons between the two treatments are difficult, if not impossible and, when made, are often not particularly relevant.
Can we really compare like with like in this case? The language used to describe both treatments should be more standardised and evidence based, allowing
our patients to make informed decisions.

We must also reflect carefully on the risks and cost benefit to the patient. Risk factors for failure of both treatments have been well documented. Rubber
dam use, adequate obturation and placement of a well-fitting coronal restoration are essential to ensure favourable outcomes in endodontic treatment.

Equally, correct surgical technique and experience, biological factors (diabetes and periodontal disease) and correct prosthetic rehabilitation are key to
successful implant therapy.

The vast majority of clinicians know the value of both treatments (Fig 5). In 2012, more than 130,000 endodontic treatments were completed on the NHS in
Scotland, while implant placement has increased exponentially in the last decade.

This trend will continue and it is one we should all embrace. It gives our patients choices.

About the author

Bob Philpott graduated with a BDS from the Cork University Dental School. He subsequently completed a house officer position at the University Hospital of

Wales in Cardiff and undertook his specialist training in endodontology at the Eastman Dental Hospital, London, completing his membership in restorative
dentistry of the Royal College of Surgeons, Edinburgh.

Bob has specialist registration in both England and Australia, having spent two years in Melbourne working in private practice and at La Trobe University
as a clinical supervisor. At the end of 2013, he returned to the UK to take up a position as a locum consultant in endodontics at Glasgow Dental Hospital.

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