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Implant therapy versus endodontic therapy
 

Implant therapy versus endodontic therapy

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    Implant therapy versus endodontic therapy Implant therapy versus endodontic therapy Document Transcript

    • PERSPECTIVES O B S E R VAT I O N S Downloaded from jada.ada.org on December 8, 2010 Implant therapy versus endodontic therapy ot many years ago, options: extraction and no sent my own observations and N when a tooth had questionable strength characteristics and was not vital, the standard of care was endodontic therapy, usually followed by placement of a post and core and replacement; endodontic therapy and the necessary restorative dentistry; or extraction of the tooth, placement of an implant and the required restorative therapy. I write this column from my conclusions. CHOOSING BETWEEN IMPLANT AND ENDODONTIC THERAPY: WHAT TO CONSIDER Informed consent. With a crown. Extraction of the ques- perspective as an experienced patients considering endodontic tionable tooth was considered the prosthodontist who has accom- therapy or implant placement, last resort, unless the patient did plished many surgical implant the dentist should perform a not have the financial resources placements and conventional complete informed-consent pro- to pay for the endodontic and endodontic therapeutic pro- tocol,1-5 which includes a discus- restorative therapy. When cedures. This column expresses sion of alternatives for care, the extraction was necessary, a fixed my own opinions and observa- advantages and disadvantages prosthesis replacing the missing tions on the question of whether of each, the risks involved in tooth and connecting to the adja- a questionable tooth should be each, the costs of each and what cent teeth was considered the extracted and replaced with an will happen if nothing is done. treatment of choice. implant and implant-supported The factors discussed in the Times certainly have crown, or whether conventional remainder of this column should changed. Now, when a tooth has endodontic and restorative be included in the informed con- questionable strength and is not therapy should be accomplished. sent discussion. The patient’s vital, the dentist and patient I will consider many factors rel- input regarding the decision is must make a choice among three ative to this question, then pre- important, since the cost of the therapy and the potential even- tual outcome of the treatment can vary significantly. Gordon J. Christensen, DDS, MSD, PhD Cost. The cost of each of 1440 JADA, Vol. 137 http://jada.ada.org October 2006 Copyright ©2006 American Dental Association. All rights reserved.
    • PERSPECTIVES OBSERVATIONSthe therapies varies TABLEwidely. The table shows Mean fees charged by U.S. general practitioners* formean fees (as recentlyreported in the American replacement of one tooth using each of the treatmentDental Association 2005 alternatives.† 6Survey of Dental Fees ) TREATMENT ALTERNATIVE PROCEDURE COST TOTALcharged by U.S. general CODE‡ ($) COST ($)dentists for the replace- Implant Therapyment of a single tooth Extraction D7111, D7140, 85-196 D7210, D7250using each of the treat- Implant placement D6010 1,443ment choices, using codes Implant abutment D6056, D6057 493-644from CDT-2005.7 Porcelain-fused-to-metal (PFM) crown D2752 777 TOTAL 2,798-3,060 Using mean U.S. feesas a guide, the implant- Endodontic Therapysupported alternative can Endodontic therapy, depending on D3310, D3320, 507-736 number of canals D3330be nearly twice as expen- Post and core D2950, D2954 184-228 Downloaded from jada.ada.org on December 8, 2010sive as the endodontic Crown PFM D2752 777 TOTAL 1,468-1,741alternative. Althoughaffluent patients may not * Random sample.consider the differences in † Source: American Dental Association.6 ‡ Source: American Dental Association.7fees shown in the table tobe significant, mostpatients with typical incomes a decision. requirements are lower thanlikely would consider the fee for Type of bone supporting those for a tooth planned to sup-the endodontic alternative to be the questionable tooth. Usu- port a fixed prosthesis. Formore favorable than that for the ally, the best chance for implant optimum longevity expectations,implant choice. People with success is in the mandible or the highly questionable nonvitalinadequate financial resources premolar and anterior portions teeth that are planned to pro-likely would choose to have the of the maxilla. The posterior vide support to fixed prosthesestooth extracted. Therefore, the maxilla usually has poor bone probably should be replacedcost of the therapy may influ- density and, therefore, a with implants.ence their treatment choice reduced chance of implant suc- Occlusion. Practitionersinordinately. cess. A tooth in the posterior know well that a significant per- Coronal breakdown of the maxilla with a reasonable centage of the population expe-involved tooth. Evaluation of chance of endodontic success riences bruxism or clenching.9the condition of the tooth in should be retained, since suc- Teeth in these patients arequestion and of the potential for cessful placement and long-term required to resist enormoussuccess requires clinical judg- service of implants are less chewing forces. In such situa-ment. If the chance of success of likely in the posterior maxilla tions, teeth that have a ques-endodontic therapy is question- than in other parts of the tionable prognosis for success ofable, extraction of the tooth mouth. Any area with question- endodontic and restorativemay be a better alternative able or abnormal bone density therapy probably should bethan leaving the tooth in the or the presence of potentially removed. However, in bruxersmouth. If at least one-half of the problematic anatomical struc- and clenchers, tooth replace-coronal tooth structure is tures should persuade practi- ment with implants and crownsremaining and the root canal tioners to retain teeth and also has questionable clinicalanatomy does not present an choose the endodontic success potential, because of theatypical appearance, endodontic alternative. extreme forces placed on thetherapy probably is the best Is the tooth to support a teeth in such patients.choice.8.A candid discussion of single crown or a fixed pros- If it is elected to remove athe possibility for endodontic thesis? If the tooth in question tooth and place an implant in atherapy success should be held is planned to retain a single- bruxer or clencher, the dentistwith the patient before making tooth restoration, strength should consider occlusal equili- JADA, Vol. 137 http://jada.ada.org October 2006 1441 Copyright ©2006 American Dental Association. All rights reserved.
    • PERSPECTIVES OBSERVATIONS bration, followed by placement temic diseases—may contraindi- of their treatment. In such of a postoperative occlusal cate the placement of implants. cases, general dentists should splint for nighttime wear to Similarly, some of these factors advise the patient about the reduce the expected occlusal may influence the potential suc- expected potential for success trauma to the implant and cess of endodontic therapy. for each of the therapies if they restoration. Patients should be advised of were to accomplish the treat- Periodontal condition. One these negative factors in rela- ment themselves without of my pet peeves is being asked tion to their planned therapy. referral to specialists. to treat patients who have Overall health must be con- If the patient feels that received implants and who also sidered in any decision between because of the clinical expertise have periodontally treated teeth implants or endodontic therapy. of the practitioner, one or the with mobility classifications of It has been my observation that other therapy has the greatest 1+ to 2 (on the 0-to-3 scale). In on the basis of overall health chance for success, that therapy such cases, the teeth move sig- characteristics, endodontic is the one to choose in that nificantly under occlusal stress, therapy may be indicated over situation. while the implants move only implant surgery in some cases. Potential esthetic result. Downloaded from jada.ada.org on December 8, 2010 slightly during chewing. Long- Time needed for treat- Sometimes implant/restorative term acceptability of the restora- ment. Although some implant therapy can be accomplished tive/prosthodontic therapy is placement situations allow with the expectation of extremely questionable. immediate loading with the res- adequate or even excellent The negative restorative con- toration, many implant situa- esthetic acceptability, while siderations related to the differ- tions require several months for other clinical situations appear ences between the stability of adequate osseointegration to to be difficult with regard to implants and mobile periodon- esthetic acceptability using tally treated teeth should indi- implants and implant-supported cate retention of questionable crowns. When the potential for Patients’ perception of nonvital teeth, if at all possible. esthetic acceptability appears to Teeth in such patients often do the psychological and be questionable if implants and not have to support extreme physiological trauma restorative therapy are used, forces. Teeth that may not be related to each therapy retention of the affected tooth strong enough to survive in the may be one of the key may be a better choice. mouths of clenchers or bruxers factors in their decision. Overall postoperative may have adequate strength to expectations. When all of the serve in periodontally treated preceding characteristics are patients. considered and weighed Patients’ perception of occur before the restoration can together, experienced practi- treatment. Many patients be placed. tioners can estimate the overall fear both endodontic therapy If the dentist anticipates a potential for success of either and even the mere thought of major difference between the implant/restorative or surgery. The dentist should two types of therapies in terms endodontic/restorative therapy, describe candidly the potential of the time required to complete and they can arrive at an edu- discomfort to be expected with them, patients should be cated prognosis. Consideration each type of therapy to ensure encouraged to express their of any one factor alone may lead that the patient understands opinions related to selection of to an illogical conclusion about what to expect during treatment. one or the other treatment on the best therapy. Patients’ perception of the that basis. All of the factors discussed psychological and physiological The practitioner’s profi- above must be considered to trauma related to each therapy ciency. Practitioners have dif- make a valid conclusion about may be one of the key factors in fering degrees of expertise in whether to extract a tooth, place their decision. the various areas of dentistry. an implant and restore it, or Overall health. Many fac- Unfortunately, many patients accomplish endodontic therapy tors—such as smoking, poor do not want to be referred to and the required restorative systemic health and major sys- other practitioners for a portion therapy. 1442 JADA, Vol. 137 http://jada.ada.org October 2006 Copyright ©2006 American Dental Association. All rights reserved.
    • PERSPECTIVES OBSERVATIONSSUMMARY an implant and an implant- 1985;29(3):557-80. 3. Sippy RE. Informed consent: why you supported restoration. s need more than a signature. Dent AssistThe decision to accomplish 2006;75(2):28, 30-1. Dr. Christensen is the director, Practical 4. Dower JS Jr, Indresano AT, Peltier B.endodontic therapy and restore Clinical Courses, and co-founder and senior More about informed consent (letter). JADAa tooth or to extract it was a rel- consultant, CRA Foundation, 3707 N. Canyon 2006;137(4):438-9. Road, Suite 3D, Provo, Utah 84604. Address 5. Graskemper JP. Informed consent: a step-atively easy decision in the past. reprint requests to Dr. Christensen. ping stone in risk management. CompendHowever, in 2006, a compli- Contin Educ Dent 2005;26(4):286, 288-90. The views expressed are those of the author 6. American Dental Association. 2005 surveycating factor is present: the and do not necessarily reflect the opinions or of dental fees. Chicago: American Dental Asso-observable success of dental official policies of the American Dental ciation; 2006:13-30. Association. 7. American Dental Association. CDT-2005:implant therapy. Many factors Current dental terminology. 5th ed. Chicago:discussed in this article relate to 1. Christensen GJ. Informing patients about American Dental Association; 2004. treatment alternatives. JADA 8. Christensen GJ. Post concepts arewhether a tooth should be 1999;130(5):730-2. changing. JADA 2004;135(9):1308-10.retained, treated endodontically 2. Pollack BR. Risk management in the 9. Christensen GJ. Treating bruxism and dental office. Dent Clin North Am clenching. JADA 2000;131(2):83-5.and restored, or replaced with Downloaded from jada.ada.org on December 8, 2010 JADA, Vol. 137 http://jada.ada.org October 2006 1443 Copyright ©2006 American Dental Association. All rights reserved.