A startling piece of E-mail came across my desk the other day. It was a letter from the American Association of Endodontists that asked me to fill out an online survey regarding the topic of implants. Among other things, the AAE was interested to know if:
(1) I thought implants had hurt my Endodontic practice,
(2) I thought endodontists should be the ones doing implants and
(3) whether I would be interested in taking AAE sponsored implant courses to teach me how to do them.
Over a decade ago I vividly remember attending a meeting that featured a Texas Endodontist named Paul Radman. He was one of the first endodontists I ever saw who spoke about the topic of implants and suggested that Endodontists were actually the best-qualified clinicians to place them. He seemed to be saying that Endodontists should be doing this procedure because they are:
(1) familiar with periapical bone
(2) routinely managed surgical situations,
(3) were often asked to decide the viability of a compromised tooth (restorability, cracks, perio etc) based on their overall knowledge of the limits of restorability and Periodontics
(4) were used to working in small spaces under high magnification and
(5) were used to doing recalls and evaluating the restorations placed on top of their endodontics. I left the meeting with a chuckle, saying to myself "Well, he must not be very busy if he is doing implants. Doesn't he have enough endo work to do?" Little did I know how great a threat implants would be PERCEIVED to be, a mere dozen years later. The AAE survey I was asked to fill out is ample evidence of that fact.
The most convincing argument for the "Implants Rather Than Endo" advocates appears to be data that is produced (ironically) by Endodontics itself. Endodontics' dirty little secret is that with all the progress that we have made over the last 40 years, success rates have apparently not increased much - at least according to analysis of published studies that were considered valid by Friedman et al (JOE). Unfortunately, this also comes at the expense (literally) of greatly increased overhead costs/procedure. Endodontics has become very costly for both the patient and clinician. Even more so if you treat to the state of the art - with all the devices, instruments, solutions and special materials that it now demands.
The long-term survival rate for endodontically treated teeth in many published studies cited by implant advocates is also abysmal. (It certainly doesn't help matters when some researchers/academics (whose endodontic techniques are questionable) publish statistics that show that their conventional endodontic treatment has less than stellar results.) Although private practice Endodontists have continued to dispute these findings (citing decades of own experience), it is an un-winnable argument when the evidence based advocates say that these perceptions are meaningless without hard data. "Science" will always triumph over perception, no matter how much experience the clinician claims to have. Such are the demands of the Evidence Based jury. As I have written many times before, until we can find a way to bridge these two groups, this dispute over success rates will continue. And it will also continue to add ammunition to the "Implant vs. Endo" argument - on the side of the Implantologists.
The Dec. 2004 issue of the Journal of Endodontics features an article that appears to indirectly address this debate. In this paper "Endodontic Treatment Outcomes in a Large Patient Population in the USA: An Epidemiological Study. (R. Salehrabi and I. Rotstein JOE 30:13:845-850 Dec 2004) a MILLION and a HALF (1,462,936 teeth of 1,126,288 patients) were assessed over 8 years. Treatment was done by General Practitioners and Endodontists in the USA who participated in the Delta Dental insurance plan. The results showed that 97% of teeth were retained in the oral cavity 8 years after treatment. Statistically, of the 41,973 extracted teeth, 35,697 (85%) had no full coronal coverage. Most interestingly a significant difference was found between teeth with a crown and teeth with no crown for all tooth groups tested. Endodontically treated teeth without full coronal coverage were lost at a rate six times greater than fully covered teeth.
Most of the extracted teeth with full coronal coverage had no post. No significant differences were found between teeth with and without post. This is in agreement with Sorensen and Martinoff who suggested that the role of the core is more critical than the post for the long-term success of endodontically treated teeth. It is therefore recommended that teeth undergoing endodontic treatment be restored as soon as possible to prevent coronal leakage or coronal fracture. If the tooth does not require a post, a core should be placed upon completion of canal obturation or soon thereafter. Final restoration with full cuspal coverage should be done if the tooth has lost three or more surfaces.
The study concludes: "With regard to retention rate of teeth, the trend of endodontic outcomes found in the large patient population used in this study, can be useful to the clinician for a rational evidence-based case selection and endodontic treatment decision-making." No doubt the purists among the evidence based clinicians will howl with disbelief. They will say that merely "retaining" the tooth says nothing about its health, periapical status and "true" biologic success of endodontic treatment. They will say that this epidemiological study is "perception" in pseudoscientific form - junk research.
So has this merely degenerated to a discussion of what is considered real endodontic success? Can a retained asymptomatic endodontically treated tooth with a small periapical area that has not increased in 8 years be considered a success? Perhaps we need to ask the patient and listen less to those who measure success in purely biologic terms. We all have patients with apparently atrocious endo that may have a lesion, is asymptomatic and has been for years. While other patients have what appears to be exceptionally nice treatment that that simply won't settle down. Which patient considers their treatment a success?!! Who is mostly likely to consider an implant for their "root canal that didn't work"?
In Manitoba, the decisions regarding implants seem to be much more financially (and insurance) driven. The current fee for placement of a single implant varies but can range from between $3000-$5000 depending on who places it and who restores the tooth. Since virtually none of the current patient insurance plans cover implants as a benefit, most of the cost of the implant has to be borne directly by the patient. Almost all Dental benefit maximums top out at the $1500 mark so that means an outlay of at least an equivalent amount for the implant, EVEN IF the implant was a benefit. On the other hand, most benefit plans WILL pay 50% of the cost of a fixed bridge - which encourages patients to pick this treatment rather than an implant. The result is (unfortunately) that the dentist can sometimes find himself preparing two perfectly virgin teeth for a bridge rather than placing an implant.
So, will Endodontics be supplanted by Implants? Probably not in the foreseeable future. What we can say is that implants give us greater options for cases where the chances for successful retreatment ( possibly due to disassembly, weakness of dentin, multiple previous endo treatments, perio factors etc) may have led to a poorer long term prognosis for retention of the tooth. The other factor is one of cost. Until implants become affordable for the average patient and are at least covered by insurance plans to some extent, it is unlikely that they will be routinely chosen, except by the wealthy.
Endodontic treatment has shown to be a reliable method of retaining dentition when combined with proper restoration of the treated tooth. Although we continue to search for other methods, Endodontic treatment remains an accessible, affordable way for most patients of average means to retain their teeth.