Establishment of a complex restorative treatment plan involves many considerations. Clinicians daily face the decision of whether to perform complex multi-disciplinary rehabilitation of a tooth, or whether to extract and replace it with an implant. There is general agreement among those who are performing routine implant treatment in Manitoba that this mode of therapy is under-utilized when compared to other areas of the country. The questions remains: When should we consider endodontic/restorative treatment vs. extraction and implant replacement? There are no easy answers but there are factors that need to be examined before this decision can be made.
There is no doubt that financial factors play an important role in the patient’s decision of whether to choose implant therapy. It is naïve to believe that insurance reimbursement has no influence on this decision. For most insured patients, endodontic/prosthetic treatment is a covered expense (at least to some extent) whereas implants are not. Until this changes, patients will tend to opt for the procedure that is covered by their plan. This is the primary reason for lack of generalized acceptance of implant treatment in Manitoba.
When considering restoration of a very carious, fractured or broken down tooth, the multiple requirements of Endodontic treatment, Periodontal crown lengthening and/or osseous recontouring followed by post and core crown restoration can cost almost the same amount as an implant/crown. In some cases, (especially in the case of disassembly or surgical endodontic retreatment) the predictability of retreatment may be less than optimal. It can be very frustrating for patients to undergo multiple treatment modalities only to lose the tooth due to factors beyond the control of the clinician. Good patient communication is essential, especially where retreatment is involved.
How can we ensure that we make the right decision?
(1) Excavate all decay to sound dentin and place caries controls before establishing a treatment plan.
(2) Examine for adequate contact, occlusion and proper biologic width. Is crown lengthening or periodontal treatment required prior to restoration? If so, discuss this with the patient before treatment.
(3) Is the tooth to function as a major supporting abutment of a restorative treatment plan ? If the answer is yes, predictability of endodontic or implant treatment results are paramount.
(4) Anterior teeth require special evaluation because of aesthetic concerns. Is there adequate supporting bone? Where will the crown margin be placed? What is the periodontal condition? Where is the smile line?
(5) Is Endodontic retreatment required prior to restoration ? Is radiographic pathology present ? Is the patient willing to undergo surgical endodontic treatment in the event of unsuccessful conventional retreatment?
(6) Consider the hygiene requirements carefully. Does the patient have a history of inadequate hygiene ? Will heroic attempts to salvage a tooth result in greater or less ease in maintenance of hygiene?
(7) Will extraction of the tooth require preparation of adjacent virgin teeth for bridge abutments? Are proximal teeth tilted or in less than optimal occlusion ? Will heavily restored proximal teeth also require elective endodontic treatment to be used as bridge abutments? ( Cost consideration !)
(8) Always thoroughly explain contingency plans to the patient in case of treatment failure.
Above all, provide treatment that is consistent with the individual patient’s Dental IQ, finances and hygiene.