Treating Our Patients Using Endodontic and Implant Restorations PPAC
Treatment Numbers <ul><li>Endodontic and implant restorations are performed daily by dentists and specialists </li></ul><u...
Treatment Numbers 40% increase annually 1997-2007
Treatment Considerations <ul><li>“ Treatment planning for the future: Endodontics, fixed partial dentures – or implants?” ...
Treatment Considerations <ul><li>“ The  success rate  of non-surgical root canal treatment is  unclear  within the endodon...
Implants vs. Endodontics <ul><li>The Academy of Osseointegration’s 2006 workshop on the state of the science of implant de...
Implants vs. Endodontics <ul><li>Furthermore, in response to an ADA Foundation request for proposals Torabinejad, et al, c...
Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></...
Apples vs. Oranges <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></ul><ul...
Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></...
Success Criteria <ul><li>Endodontic Criteria </li></ul><ul><li>1956, Strindberg proposes stringent radiographic criteria <...
Success Criteria <ul><li>Endodontic Criteria </li></ul><ul><li>1956, Strindberg proposes radiographic criteria </li></ul><...
Success Criteria <ul><li>Endodontic Criteria </li></ul><ul><li>1956, Strindberg proposes radiographic criteria </li></ul><...
Success Criteria <ul><li>Endodontic Criteria </li></ul><ul><li>1956, Strindberg proposes radiographic criteria </li></ul><...
Success Criteria
Success Criteria
Endodontic Success Criteria 3-year recall
Endodontic Success Criteria
Endodontic Success Criteria
Endodontic Success Criteria 12 - month recall
Success Criteria <ul><li>1956, Strindberg proposes radiographic criteria </li></ul><ul><li>Beginning in 1966 and since, ma...
Success Criteria <ul><li>Success or Survival? </li></ul><ul><li>The definition of “success” for dental implant studies is ...
Success Criteria <ul><li>Success or Survival? </li></ul><ul><li>Unlike implants and FPDs, RCTs aim to cure existing diseas...
Success Criteria <ul><li>Success or Survival? </li></ul><ul><li>It has been suggested that implant success criteria are no...
Success Criteria <ul><li>Success or Survival? </li></ul><ul><li>“ In essence, the use of  lenient  success criteria in imp...
Success Criteria <ul><li>In order to establish comparable comparisons, it is critical that the same outcome measure is use...
Success Criteria <ul><li>In order to establish comparable comparisons, it is critical that the same outcome measure is use...
Success Criteria <ul><li>The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistry ...
Success Criteria <ul><li>Success or Survival? </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul>...
Success Criteria - Implants <ul><li>Two 3.75 x 18 implants were placed on #9, 10 sites </li></ul><ul><li>Implants appear o...
Success Criteria - Implants Initial visit pt presented with provisional restorations Esthetics case referred to Dr. Debra ...
Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></...
Restorative Impact <ul><li>Lazarski et al examined over 110,000 endodontic cases, and found teeth that were not restored w...
Restorative Impact <ul><li>Lazarski et al examined over 110,000 endodontic cases, and found teeth that were not restored w...
Restorative Impact <ul><li>The Academy of Osseointegration’s 2006 workshop on the state of the science of implant dentistr...
Restorative Impact
Restorative Impact
Restorative Impact
Restorative Impact 22-month recall
Restorative Impact <ul><li>The restoration of an endodontically treated tooth is considered a major determinant of its sur...
Bone Loss Around Implants <ul><li>With implant placement, 1 mm of bone is loss during the first year of placement, with an...
Bone Loss Around Implants Bone Loss (mm) n=455  Error bars = S.E.M.
Cost to Patient <ul><li>Analysis of 2005 insurance data concluded that restored single-tooth implants cost 75-90% more tha...
Cost to Patient <ul><li>Analysis of 2005 insurance data concluded that restored single-tooth implants cost 75-90% more tha...
Cost to Patient Average Price ($$) 130% Increase
Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></...
Who’s Treating? <ul><li>Historically, implants placed by  specialists , while many endodontic studies were conducted on pa...
Who’s Treating? <ul><li>Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were syste...
Who’s Treating? <ul><li>Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were syste...
Who’s Treating?
Who’s Treating?
Who’s Treating?
Who’s Treating?
Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></...
Publication Bias <ul><li>More likely to exist when a particular brand of implant is studied. While endodontics is mostly g...
Publication Bias <ul><li>More likely to exist when a particular brand of implant is studied. While endodontics is mostly g...
Publication Bias <ul><li>More likely to exist when a particular brand of implant is studied. While endodontics is mostly g...
Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></...
Modern Advances <ul><li>Both Iqbal and Kim’s as well as Torabinejad and colleagues’ systemic reviews were conducted  “usin...
Modern Advances <ul><li>Implants </li></ul><ul><ul><li>New implant shape/design </li></ul></ul><ul><ul><li>New surface mod...
Modern Advances <ul><li>Implants </li></ul><ul><ul><li>New implant shape/design </li></ul></ul><ul><ul><li>New surface mod...
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 <ul><li>The Academy of Osseointegration’s 2006 workshop on the state of the science of implant de...
Implants vs. Endodontics <ul><li>The Academy of Osseointegration’s 2006 workshop on the state of the science of implant de...
Implants vs. Endodontics <ul><li>The Academy of Osseointegration’s 2006 workshop on the state of the science of implant de...
Implants vs. Endodontics <ul><li>“… in periodontally sound teeth having pulpal and/or periradicular pathosis, root canal t...
Implants vs. Endodontics <ul><li>“ No difference in the survival rates between the two treatment modalities.” </li></ul><u...
Implants vs. Endodontics n=4477 Unpublished data from AAE Foundation - Bowles, Eleazer, Drum & Goodis 2008
Implants vs. Endodontics <ul><li>Endodontic therapy should be given priority in treatment planning for periodontally sound...
Implants vs. Endodontics <ul><li>Endodontic therapy should be given priority in treatment planning for periodontally sound...
Implants vs. Endodontics <ul><li>The decision to treat a compromised tooth endodontically or replace it with an implant mu...
Implants vs. Endodontics <ul><li>CASE SELECTION </li></ul><ul><li>CASE SELECTION </li></ul><ul><li>CASE SELECTION </li></ul>
Conclusion <ul><li>Functional survival rates are high for both treatments </li></ul>
Conclusion <ul><li>Functional survival rates are high for both treatments </li></ul><ul><li>Endodontic treatment on a hope...
Conclusion <ul><li>Functional survival rates are high for both treatments </li></ul><ul><li>Endodontic treatment on a hope...
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"Every tooth's a snowflake"

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  • The 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.
  • So given this increase in implant placements, a good question to ask is what is driving the decision making/treatment planning for these patients. I apologize for the image, but this is a scanned image of an actual brochure, which was itself a photocopy. It was advertising a course put on by “the Ohio State University Continuing Dental Education” just a couple years ago (2006).
  • These are a few of the quotes contained in the flyer. Apparently “the Ohio State University Continuing Dental Education” wasn’t compelled to run this by the endodontics department for accuracy prior to mailing. Needless to say we plan on presenting evidence that should “clear” up your ideas of endodontic vs. implant success rates.
  • When comparing these two treatment modalities there are five aspects of the literature that should be taken into account.
  • Of 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.
  • Strindberg proposed a one-year timeframe that required COMPLETE radiographic resolution for it to be considered a success.
  • However, there are definite limitations to such a criteria as these authors have discussed. It doesn’t account for an asymptomatic patient with a functioning tooth not to mention the potential for delayed radiographic healing.
  • As 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.
  • According 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 fact…
  • … this was how the tooth presented prior to retreatment.
  • And 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.
  • HERE’S ANOTHER EXAMPLE –Here’s 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.
  • However, here’s the pre-op of the case…
  • So 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 my glass ionomer temporary
  • All of which begs the question: should we be looking at Success, or is Survival a better benchmark?
  • Meanwhile on the implant side of the equation there is question about the consistency of the results.
  • Thus you are more apt to see leniency in the implant literature, while stringency is the trademark of the endodontic literature.
  • All of which is why the Academy of Osseointegration’s mandate to Drs. Iqbal and Kim dealt specifically with the SURVIVAL of the implants and RCTs.
  • …to 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.
  • Let’s 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…
  • …However, the determination of success isn’t quite as clear cut when we look at the bigger picture.
  • At this point in time it is pretty well understood that a proper restoration following RCT is a must.
  • At this point in time it is pretty well understood that a proper restoration following RCT is a must.
  • Which again, is why the AO specified in their mandate, “restored” teeth.
  • Here’s 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, what’s left of the original temporary has collapsed.
  • This 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 dentist’s 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.
  • Another example of poor follow-up. Here’s an immediate post-op film of RCT #19, complete with cotton under a glass ionomer temp (triage) again, cotton placed per restoring dentist’s request.
  • And 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.
  • PPAC INFO, NEED REFERENCES
  • PPAC INFO, NEED REFERENCES
  • These numbers were generated in an university setting, but still demonstrate a marked difference between the two treatment options.
  • Torabinejad and colleagues showed quite a disparity in operator skill level across the literature.
  • While there are many very skilled general practitioners, a case like this merits an objective assessment of one’s skills prior to proceeding with treatment.
  • …for if one of the canals goes untreated, the patient will have a much poorer prognosis.
  • Furthermore 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.
  • This was our final film.
  • But recently there have been tremendous improvements in both implant dentistry and endodontic techniques and materials.
  • “ In 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 wasn’t 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.
  • DR 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 I’VE 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.
  • This is the retreatment post-op image. Not only did the patient’s swelling and symptoms resolve, she saved her existing crowns, money and most importantly her own teeth.
  • Another example of a poor restorative prognosis, due to decay in the furcation, that even the world’s best RCT won’t help.
  • This next case, diagnosed as a necrotic #20 had a coronal fracture evident, but no significant probings.
  • During treatment, with the use of an operating microscope, the fracture was deemed to be confined to the coronal structure.
  • And 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.
  • 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 ENDODONTIST’S GENEROSITY AND NOT AN ADMITION OF ANY WRONGDOING OR IMPLIED WARRANTY.)
  • And note the bony healing at the time of abutment placement.
  • 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.)
  • This is after treatment on the tooth on the right (due to open apice, opted to obturate entirely with MTA).
  • And this is the follow-up from both cases.
  • So what does it all mean? Well, if we consider what the AO asked of Iqbal and Kim. . .
  • The goal of Torabinejad and colleagues’ review, what do we find?
  • Well, Torabinejad and colleagues found comparable success rates, while…
  • . . .Iqbal and Kim simply found no difference. So where does that leave us?
  • Well, Torabinejad suggested that if the tooth had a sound prognosis otherwise, proceed with the endodontic treatment.
  • And if the tooth was to be extracted then the implant is probably the best choice.
  • While Iqbal and Kim simply suggested to look at factors beyond success rates alone.
  • All 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.
  • "Every tooth's a snowflake"

    1. 1. Treating Our Patients Using Endodontic and Implant Restorations PPAC
    2. 2. Treatment Numbers <ul><li>Endodontic and implant restorations are performed daily by dentists and specialists </li></ul><ul><li>For endodontic treatment, estimates for the year 2000 were 30 million endodontic procedures annually (ADA) </li></ul><ul><li>Estimated number of patients receiving endosseous implants </li></ul><ul><ul><li>1996 - 300,000-428,000 annually, </li></ul></ul><ul><ul><li>2000 - 910,000 annually </li></ul></ul><ul><ul><li>future annual growth rate - 18.6% (Millenium Research Group) </li></ul></ul>
    3. 3. Treatment Numbers 40% increase annually 1997-2007
    4. 4. Treatment Considerations <ul><li>“ Treatment planning for the future: Endodontics, fixed partial dentures – or implants?” </li></ul>
    5. 5. Treatment Considerations <ul><li>“ The success rate of non-surgical root canal treatment is unclear within the endodontic literature.” </li></ul><ul><li>“… (endodontics) in general practice, the success rate can be 64% to 75% .” </li></ul><ul><li>“ Endodontic therapy may extend the life of the tooth but very little is known on the extent of tooth longevity.” </li></ul>
    6. 6. Implants vs. Endodontics <ul><li>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 .” </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul>
    7. 7. Implants vs. Endodontics <ul><li>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. </li></ul><ul><ul><ul><ul><li>Torabinejad, et al, 2007 </li></ul></ul></ul></ul>
    8. 8. Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></ul><ul><li>Publication bias </li></ul><ul><li>Modern advances </li></ul>
    9. 9. Apples vs. Oranges <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></ul><ul><li>Publication bias </li></ul><ul><li>Modern advances </li></ul>
    10. 10. Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></ul><ul><li>Publication bias </li></ul><ul><li>Modern advances </li></ul>
    11. 11. Success Criteria <ul><li>Endodontic Criteria </li></ul><ul><li>1956, Strindberg proposes stringent radiographic criteria </li></ul><ul><ul><ul><ul><ul><li>Strindberg LZ, 1956 </li></ul></ul></ul></ul></ul>
    12. 12. Success Criteria <ul><li>Endodontic Criteria </li></ul><ul><li>1956, Strindberg proposes radiographic criteria </li></ul><ul><li>Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised </li></ul><ul><ul><ul><ul><ul><li>Bender IB, Seltzer S and Soltanoff W, 1966 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Van Nieuwenhuysen JP, et al, 1994 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fristad I, et al, 2004 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Gutmann JL, 1992 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Seltzer S, 1988 </li></ul></ul></ul></ul></ul>
    13. 13. Success Criteria <ul><li>Endodontic Criteria </li></ul><ul><li>1956, Strindberg proposes radiographic criteria </li></ul><ul><li>Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised </li></ul><ul><li>However, some studies still use Strindberg’s dated criteria. </li></ul><ul><ul><ul><ul><ul><li>Allen R, Newton C and Brown C, 1991 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sundqvist G, et al, 1998 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sjogren U, et al, 1990 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Farzaneh M, Abitbol S and Friedman S, 2004 </li></ul></ul></ul></ul></ul>
    14. 14. Success Criteria <ul><li>Endodontic Criteria </li></ul><ul><li>1956, Strindberg proposes radiographic criteria </li></ul><ul><li>Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised </li></ul><ul><li>However, some studies still use Strindberg’s dated criteria. </li></ul><ul><li>Fristad and colleagues showed the potential for late radiographic healing. </li></ul><ul><ul><ul><ul><ul><li>Fristad, Molven and Halse, 2004 </li></ul></ul></ul></ul></ul>
    15. 15. Success Criteria
    16. 16. Success Criteria
    17. 17. Endodontic Success Criteria 3-year recall
    18. 18. Endodontic Success Criteria
    19. 19. Endodontic Success Criteria
    20. 20. Endodontic Success Criteria 12 - month recall
    21. 21. Success Criteria <ul><li>1956, Strindberg proposes radiographic criteria </li></ul><ul><li>Beginning in 1966 and since, many authors suggest radiographic criteria is ill advised </li></ul><ul><li>However, some studies still use Strindberg’s dated criteria. </li></ul><ul><li>Fristad and colleagues showed the potential for late radiographic healing. </li></ul><ul><li>Success or Survival? </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul>
    22. 22. Success Criteria <ul><li>Success or Survival? </li></ul><ul><li>The definition of “success” for dental implant studies is often implant survival </li></ul><ul><li>Unlike implants and FPDs, RCTs aim to cure existing disease </li></ul><ul><ul><ul><ul><ul><li>Weiger, et al, 1998 </li></ul></ul></ul></ul></ul>
    23. 23. Success Criteria <ul><li>Success or Survival? </li></ul><ul><li>Unlike implants and FPDs, RCTs aim to cure existing disease </li></ul><ul><li>Thus, RCT studies measure both the healing of existing disease and the occurrence of new disease. </li></ul><ul><ul><ul><ul><ul><li>Torabinejad, et al, 2007 </li></ul></ul></ul></ul></ul>
    24. 24. Success Criteria <ul><li>Success or Survival? </li></ul><ul><li>It has been suggested that implant success criteria are not routinely applied in much of the implant outcomes literature </li></ul><ul><ul><ul><ul><ul><li>Salinas and Eckert, 2007 </li></ul></ul></ul></ul></ul>
    25. 25. Success Criteria <ul><li>Success or Survival? </li></ul><ul><li>“ 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.” </li></ul><ul><ul><ul><ul><ul><li>Watson, et al, 1999 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Johnson, et al, 2000 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Wennstrom, et al, 2005 </li></ul></ul></ul></ul></ul>
    26. 26. Success Criteria <ul><li>In order to establish comparable comparisons, it is critical that the same outcome measure is used to assess both endodontic and implant procedures. </li></ul>
    27. 27. Success Criteria <ul><li>In order to establish comparable comparisons, it is critical that the same outcome measure is used to assess both endodontic and implant procedures </li></ul><ul><li>Due to these differences in meanings of success, it is probable survival rates “will permit less biased, albeit less informative, comparisons.” </li></ul><ul><ul><ul><ul><ul><li>Doyle, et al, 2006 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Eckert and Wollan, 1998 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Creugers, et al, 2000 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Torabinejad, et al, 2007 </li></ul></ul></ul></ul></ul>
    28. 28. Success Criteria <ul><li>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.” </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul>
    29. 29. Success Criteria <ul><li>Success or Survival? </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul>
    30. 30. Success Criteria - Implants <ul><li>Two 3.75 x 18 implants were placed on #9, 10 sites </li></ul><ul><li>Implants appear osseointegrated </li></ul>
    31. 31. Success Criteria - Implants Initial visit pt presented with provisional restorations Esthetics case referred to Dr. Debra Johnson
    32. 32. Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></ul><ul><li>Publication bias </li></ul><ul><li>Modern advances </li></ul>
    33. 33. Restorative Impact <ul><li>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. </li></ul><ul><ul><ul><ul><ul><li>Lazarski et al 2001 </li></ul></ul></ul></ul></ul>
    34. 34. Restorative Impact <ul><li>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. </li></ul><ul><li>The restoration of an endodontically treated tooth is considered a major determinant of its survival. </li></ul><ul><ul><ul><ul><ul><li>Vire DE, 1991 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Siqueira JF, 2001 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hoen MM, Pink FE, 2002 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Salehrabi R, Rotstein I, 2004 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Aquilino SA, Caplan DJ, 2002 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sorensen JA, Martinoff JT, 1985 </li></ul></ul></ul></ul></ul>
    35. 35. Restorative Impact <ul><li>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.” </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul>
    36. 36. Restorative Impact
    37. 37. Restorative Impact
    38. 38. Restorative Impact
    39. 39. Restorative Impact 22-month recall
    40. 40. Restorative Impact <ul><li>The restoration of an endodontically treated tooth is considered a major determinant of its survival. </li></ul><ul><li>More prosthetic complications with implants. </li></ul><ul><ul><ul><ul><ul><li>Goodacre CJ, et al, 2003 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Doyle et al 2006 </li></ul></ul></ul></ul></ul>
    41. 41. Bone Loss Around Implants <ul><li>With implant placement, 1 mm of bone is loss during the first year of placement, with an additional 0.1mm annually. </li></ul><ul><li>Can vary with implant type/material </li></ul>
    42. 42. Bone Loss Around Implants Bone Loss (mm) n=455 Error bars = S.E.M.
    43. 43. Cost to Patient <ul><li>Analysis of 2005 insurance data concluded that restored single-tooth implants cost 75-90% more than similarly restored endodontic-treated teeth </li></ul>
    44. 44. Cost to Patient <ul><li>Analysis of 2005 insurance data concluded that restored single-tooth implants cost 75-90% more than similarly restored endodontic-treated teeth </li></ul><ul><li>Post-treatment problems can increase this cost difference </li></ul>
    45. 45. Cost to Patient Average Price ($$) 130% Increase
    46. 46. Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></ul><ul><li>Publication bias </li></ul><ul><li>Modern advances </li></ul>
    47. 47. Who’s Treating? <ul><li>Historically, implants placed by specialists , while many endodontic studies were conducted on patients treated by dental students. </li></ul><ul><ul><ul><ul><ul><li>Aquilino SA, Caplan DJ, 2002 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bergman B, et al, 1989 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dammaschke T, et al, 2003 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Lynch CD, et al, 2004 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mentink AG, et al, 1993 </li></ul></ul></ul></ul></ul>
    48. 48. Who’s Treating? <ul><li>Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were systematically reviewed. </li></ul><ul><ul><ul><ul><ul><li>Torabinejad, et al, 2007 </li></ul></ul></ul></ul></ul>
    49. 49. Who’s Treating? <ul><li>Of 13,047 identified studies, 147 articles from the endo, prosth and implant literature were systematically reviewed. </li></ul><ul><ul><ul><ul><ul><li>Torabinejad, et al, 2007 </li></ul></ul></ul></ul></ul><ul><li>GPs or Specialists </li></ul><ul><li>Students </li></ul><ul><li>Implant 0% 87% </li></ul><ul><li>Prostho 29% 35% </li></ul><ul><li>Endo 63% 29% </li></ul>
    50. 50. Who’s Treating?
    51. 51. Who’s Treating?
    52. 52. Who’s Treating?
    53. 53. Who’s Treating?
    54. 54. Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></ul><ul><li>Publication bias </li></ul><ul><li>Modern advances </li></ul>
    55. 55. Publication Bias <ul><li>More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic. </li></ul><ul><ul><ul><ul><ul><li>Schnitman PA, Shulman LB, 1979 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Andersson B, et al, 1998 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Brocard D, et al, 2000 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Deporter DA, et al, 1998 </li></ul></ul></ul></ul></ul>
    56. 56. Publication Bias <ul><li>More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic. </li></ul><ul><li>Furthermore, 13% of the implant studies had an evaluator that was different than the operator, while 88% of the endo papers had independent evaluators. </li></ul><ul><ul><ul><ul><ul><li>Torabinejad, et al, 2007 </li></ul></ul></ul></ul></ul>
    57. 57. Publication Bias <ul><li>More likely to exist when a particular brand of implant is studied. While endodontics is mostly generic. </li></ul><ul><li>Furthermore, 13% of the implant studies had an evaluator that was different than the operator, while 88% of the endo papers had independent evaluators </li></ul><ul><li>“… the authors' results confirm the presence of publication bias in implant dentistry literature…” </li></ul><ul><ul><ul><ul><ul><li>Moradi DR, et al, 2006 </li></ul></ul></ul></ul></ul>
    58. 58. Implants vs. Endodontics <ul><li>Success criteria </li></ul><ul><li>Problem areas </li></ul><ul><li>Who’s treating </li></ul><ul><li>Publication bias </li></ul><ul><li>Modern advances </li></ul>
    59. 59. Modern Advances <ul><li>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.” </li></ul><ul><ul><ul><ul><ul><li>Iqbal and Kim, 2007 </li></ul></ul></ul></ul></ul>
    60. 60. Modern Advances <ul><li>Implants </li></ul><ul><ul><li>New implant shape/design </li></ul></ul><ul><ul><li>New surface modifications </li></ul></ul><ul><ul><li>New implant-abutment interfaces </li></ul></ul><ul><ul><li>Immediate loading </li></ul></ul><ul><ul><li>Mini implants </li></ul></ul><ul><ul><li>Etc… </li></ul></ul>
    61. 61. Modern Advances <ul><li>Implants </li></ul><ul><ul><li>New implant shape/design </li></ul></ul><ul><ul><li>New surface modifications </li></ul></ul><ul><ul><li>New implant-abutment interfaces </li></ul></ul><ul><ul><li>Immediate loading </li></ul></ul><ul><ul><li>Mini implants </li></ul></ul><ul><ul><li>Etc… </li></ul></ul><ul><li>Endodontics </li></ul><ul><ul><li>NiTi instrumentation </li></ul></ul><ul><ul><li>Apex locators </li></ul></ul><ul><ul><li>Surgical operating microscope </li></ul></ul><ul><ul><li>Digital radiography </li></ul></ul><ul><ul><li>Materials: MTA, MTAD, Resilon </li></ul></ul><ul><ul><li>DNA hybridization, PCR, etc… </li></ul></ul><ul><ul><li>Etc… </li></ul></ul>
    62. 62. Case Selection
    63. 63. Case Selection
    64. 64. Case Selection
    65. 65. Case Selection – Fx #20
    66. 66. Case Selection
    67. 67. Case Selection 1-month recall
    68. 68. Case Selection
    69. 69. Case Selection
    70. 70. Case Selection
    71. 71. Case Selection
    72. 72. Case Selection 13-month recall
    73. 73. Implants vs. Endodontics <ul><li>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 .” </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul>
    74. 74. Implants vs. Endodontics <ul><li>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 .” </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul><ul><li>AND </li></ul>
    75. 75. Implants vs. Endodontics <ul><li>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.” </li></ul><ul><li>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. </li></ul><ul><ul><ul><ul><li>Torabinejad, et al, 2007 </li></ul></ul></ul></ul>
    76. 76. Implants vs. Endodontics <ul><li>“… 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.” </li></ul><ul><ul><ul><ul><li>Torabinejad, et al, 2007 </li></ul></ul></ul></ul>
    77. 77. Implants vs. Endodontics <ul><li>“ No difference in the survival rates between the two treatment modalities.” </li></ul><ul><ul><ul><ul><ul><li>Iqbal MK, Kim S, 2007 </li></ul></ul></ul></ul></ul>
    78. 78. Implants vs. Endodontics n=4477 Unpublished data from AAE Foundation - Bowles, Eleazer, Drum & Goodis 2008
    79. 79. Implants vs. Endodontics <ul><li>Endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology. </li></ul>
    80. 80. Implants vs. Endodontics <ul><li>Endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and or periradicular pathology. </li></ul><ul><li>Implants should be given priority in treatment planning for teeth that are planned for extraction </li></ul>
    81. 81. Implants vs. Endodontics <ul><li>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. </li></ul><ul><ul><ul><ul><ul><li>Iqbal and Kim 2008 </li></ul></ul></ul></ul></ul>
    82. 82. Implants vs. Endodontics <ul><li>CASE SELECTION </li></ul><ul><li>CASE SELECTION </li></ul><ul><li>CASE SELECTION </li></ul>
    83. 83. Conclusion <ul><li>Functional survival rates are high for both treatments </li></ul>
    84. 84. Conclusion <ul><li>Functional survival rates are high for both treatments </li></ul><ul><li>Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant </li></ul>
    85. 85. Conclusion <ul><li>Functional survival rates are high for both treatments </li></ul><ul><li>Endodontic treatment on a hopeless tooth is just as unethical as extracting a restorable tooth and replacing it with an implant </li></ul><ul><li>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 </li></ul>
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