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2 CE credits
This course was written for dentists, dental hygienists, and assistants.

Implants or Endodontics: Alternative Treatments?


A Peer-Reviewed Publication Written by Richard Nejat, DDS and Fiona Collins, BDS, MBA, MA

PennWell designates this activity for 2 Continuing Educational Credits

Publication date: July 2009 Go Green, Go Online to take Review date: March 2011 Expiry date: February 2014 This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 2 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

your course

Educational objectives
Upon completion of this course, the clinician will be able to do the following: 1. List the common causes of tooth extractions and potential sequelae. 2. List and describe the success rates for both endodontic treatment and implant treatment as well as the factors and conditions that can lead to failure of endodontic and implant treatment. 3. List and describe the systemic and oral considerations that are involved in determining whether endodontic treatment or implant treatment is more appropriate for a given patient. 4. Describe the implications for decision making together with the patient, and factors influencing the patient in his or her choice of treatment.

Abstract
Reflecting improvements in oral health as well as changes in treatment modalities and patient expectations and preferences, the majority of current baby boomers in the United States will retain their natural teeth for life. The impact of an extraction varies with location, and options may include saving the tooth through endodontic treatment or extracting the tooth and placing an implant. Both implant therapy and endodontic therapy have good success rates. With both endodontic and implant therapy, success factors and considerations include the patients systemic and oral health, choice of materials, and technique used. A patients general health status may dictate which treatment is appropriate, overriding other factors. Considerations include medication use, infection risk and more generally the patients ability to withstand the treatment. Oral health considerations include caries experience, periodontal health, alveolar bone, occlusal load and bruxism, parafunctional habits, health of the remaining dentition, and the presence of or need for fixed prostheses. Determination of the appropriate treatment requires careful consideration of these and potential outcomes, with the patient participating in the process.

The World Health Organization considers that at least 20 teeth must be present for the dentition to be functional and aesthetic, while the dental literature considers an intact arch extending to the second bicuspids to be functional.3 Literature research suggests that shortened dental arches may provide good function, comfort and oral hygiene maintenance.4,5,6 However, while potentially compatible with oral health, patients place less value on a shortened dental arch than on either implants, fixed or removable prostheses bringing the shortened arch into question from the patients perspective.7 Partial edentulism can result in tilting of adjacent teeth and overeruption of the opposing dentition, difficulty with oral hygiene measures, the development of periodontal pockets, exposed furcation areas, root caries and masticatory problems. Based upon all these considerations, avoiding extractions or providing the best possible replacement for teeth is clinically important. In many cases this will mean either endodontic treatment or implant placement, followed by a crown and/or fixed prosthesis. Endodontically treated functional tooth

Image courtesy of Dr. William Watson

Endodontic Treatment
Endodontic therapy may be required as a result of advanced caries, traumatic injuries, fractures to the teeth, dens invaginitus or iatrogenic pulp exposure. The ultimate goal is absence of infection and complete healing of the periapical tissues, as well as successful restoration and long-term retention of the tooth. Endodontic therapy may be a single- or multiple-visit procedure, nonsurgical or surgical. Procedural objectives include removal of all pulpal tissue, microbial elimination, cleansing of the root canal walls and removal of all debris, and obturation of the root canals. Nonsurgical endodontic therapy entails coronally accessing the pulp chamber to identify all root canal openings and providing straight-line access to the apical foramen or root curvature.8 The canals are typically manually and/or mechanically cleaned and shaped with files and reamers and intermittently irrigated to remove all debris and the dentin smear layer and to disinfect the canals. Root canal irrigants used include sodium hypochlorite, EDTA, hydrogen peroxide and chlorhexidine gluconate. Lastly, the root canals are obturated with the objectives of obtaining
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Introduction
Reflecting improvements in oral health as well as changes in treatment modalities and patient expectations and preferences, the majority of current baby boomers in the U.S. will retain their natural teeth for life. Nonetheless, caries remains an endemic health issue affecting more than 90% of adults over the age of 401 and is the primary factor in tooth loss in the U.S. population. Advanced periodontal disease is responsible for 30%35% of extractions in patients over the age of 40.2 Other reasons for extractions other than elective due to crowding and orthodontic treatment include root fracture, root resorption and cysts. The aesthetic and functional impact of an extraction in the (partially) dentate patient varies with location and whether the result would be a slightly shortened intact dental arch, severely shortened dental arch or bounded space.
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a sound apical seal, sealing of lateral and accessory canals, complete filling of all canals, and a good coronal seal for the root/restoration interface. Periapical infection, endodontically treated lower incisor

Fractured file and periapical infection

mentation, restorative technique and/or restoration failure. Nonvital dentin contains less water than vital dentin, which could lead to brittleness, reduced shear strength and a predisposition to fracture.14,15 Regarding dentin thickness, dentin less than 1 mm thick remained on the furcation side in 82% of mandibular molars following post preparation with Gates-Glidden drills in an in vitro study, indicating the care required16 and the risk of perforation or fracture. Materials used during root canal treatment and post placement influence the risk. After stainless steel post placement, an in vitro study indicated, lower load is required for fracture compared to using glass fiber posts that have a modulus of elasticity closer to that of dentin.17 Root canal irrigants can affect the dentins mineral content, surface hardness and roughness, and bonding capacity. Significant decreases in calcium and phosphorus content in dentin have been found in vitro with the use of EDTA, chlorhexidine gluconate and hydrogen peroxide but not with sodium hypochlorite,18 and separately only chlorhexidine gluconate neither affected the dentins surface hardness nor increased its surface roughness.19 Another study showed that sodium hypochlorite immersion can reduce the force required to fracture dentin.20 Bonding agents are used to help prevent fracture at the core buildup/dentin junction. Use of dentin bonding agents and/or a ferrule preparation can increase fracture resistance.21 Coronal fractures in endodontically treated teeth are also more common than in vital teeth, particularly when the teeth are not crowned. Discoloration of endondontically treated teeth is a common occurrence, ranging from a slightly darkened hue compared to an adjacent tooth to almost black. This is relatively easily dealt with, and treatment options range from nonvital bleaching to veneers to full crown coverage, depending upon the tooth and the severity of the staining. Nonvital bleaching of teeth has been shown to often provide acceptable aesthetics.22 Vertical root fracture

Potential complications Periapical/recurring microbial infection following treatment is influenced by the root anatomy, quality of the root filling and coronal restoration, periodontal health, and marginal bone loss.9 50%90% of root-filled teeth have apical evidence of residual infection, based upon cadaver examinations.10 Physical issues related to persistent infection include the varying number of canals that must be identified and obstructive or inaccessible areas such as calcified or accessory canals and anastomoses.11 In the case of nonsurgical retreatment, the ability to completely remove root filling materials plays a role. Neither Gates-Glidden drills and K files nor Nd:YAG lasers were found in one study to completely remove gutta percha and AH26 (Sealapex).12 Anatomical obstructions and inaccessible areas cause difficulties in microbial sampling used to determine appropriate antimicrobial therapy and whether residual infection is present prior to obturating. The type of microbial infection also plays a role in the persistence of infection. Both rotary instruments and lasers, together with EDTA or sodium hypochlorite, were found to be ineffective in vitro in eliminating E. faecalis from anterior single-rooted teeth.13 Fungi have also been found in root canals, more commonly in teeth with previous endodontic treatment. Horizontal and vertical root fractures may occur due to dentin brittleness, reduced dentin thickness, overinstruwww.ineedce.com

Success Rates
Initial endodontic treatment success rates defined as complete healing have been reported to be 91%98% in the absence of pre-existing apical periodontitis.23,24,25 The
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presence or absence of apical periodontitis and preparation/ filling technique have been found to be the most important predictors for success.26 For teeth with apical periodontitis at the time of initial treatment, success rates of 74%86% have been reported.27,28 Apical surgery has been reported to have a weighted average success rate of around 70% (range 37%85%).29 Success rates in previously root-filled teeth are significantly lower, with one report finding only 62% healed after retreatment and that this was poorly predicted from clinical and radiographic signs.30 The ultimate goal is longterm tooth retention and functionality, not only endodontic success (complete healing and no infection). A prospective study of adults over the age of 50 showed that the relative risk of tooth loss was approximately four times greater for endodontically treated teeth.31 Tooth survival rate following endodontic therapy is related to resistance to fracture and the type of restoration. Endodontically treated teeth have higher survival rates if crowned, and while uncrowned endondontically treated teeth have been found to be six times more likely to be lost than crowned teeth,32 a four-year review (mean follow-up, 38 months) found a 91.7% survival rate for cast restorations.33

Osseointegrated functional implant

Short-term complications include infection as a result of contamination at the time of or following surgery. Failure to obtain primary stability at the time of implant placement leads to failure of the implant to osseointegrate and its removal.35 Long-term complications are usually a result of lack of maintenance and poor oral hygiene, starting as reversible mucositis and progressing if untreated to irreversible periimplantitis. Peri-implantitis is the most common cause of implant failure and is preventable with attention to oral hygiene. Peri-implantitis

Extraction and Implant Treatment


Around two million implants are placed each year. Typically, a crestal incision is made and the mucosa reflected and calibrated bone drills are used to create a bony socket of the correct dimensions for the implant. Following implant placement, the mucosal flap is either repositioned around the implant (a one-stage procedure) or over the implant until osseointegration has occurred and a second surgery is carried out to expose the neck of the submerged implant (a two-stage procedure). Shortly after exposure, the microbial composition around the implant is the same as with a one-stage procedure. An alternative technique is use of a mucosal punch to create a punchhole through the mucosa to the crestal bone this is technique-sensitive and by its nature is for one-stage procedures. Immediate placement of implants following extraction and delayed placement have been found to have similar success rates, based upon reviews of the literature.34 An abutment is later placed into the implant usually after osseointegration and the superstructure is then fabricated. Complications Immediate complications include perforation of the cortical plate and/or misalignment of the implant within the bone, a bone receptor site too large or too small for the implant, damage to the implant surface during placement, bleeding, microbial and foreign-body contamination of the implant and implant site, and overheating of the bone. These complications can cause implant placement to be aborted or result in short-term failure. With care, these operator- and environment-related complications can be minimized and avoided.
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Further complications include retrograde peri-implantitis as a result of periapical infection associated with previous endodontic therapy at the site or adjacent to the implant site36 and marginal peri-implantitis due to a combination of microbial infection and occlusal overload.37 Long-term complications can also arise from incorrect occlusal and interproximal contacts of superstructures placed on implant abutments. Poor functionality and aesthetics can result from compromised positioning of abutments due to the positioning of the implant at the time of surgery. These complications can be prevented with careful implant placement. Implant fracture is a rare event, usually resulting in implant removal. Loosening of abutments and abutment screw fracture require either removal of the superstructure, followed by retightening of the abutment or removal of the abutment and replacement with a new abutment, followed by assessment of the superstructure and the occlusion. For implant systems requiring torquing of the abutment, it is important to ensure that the torque applied is consistent with the manufacturers recommendations to avoid over- or undertorquing the abutment. Fracture of the framework or superstructure can occur this potential
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complication is present with both endodontic and implant therapies. Factors influencing long-term complications and failures include inappropriate prosthesis design, axial and acentric loading, and parafunctional habits.38

treatment requires careful consideration of these and potential outcomes, with the patient participating in the process. Systemic health considerations A patients general health status may dictate which treatment is appropriate, overriding other factors. Considerations include medication use, infection risk and more generally the patients ability to withstand the treatment. Relevant medications include anticoagulant therapy and bisphosphonate therapy. Patients on anticoagulants are at risk for hemorrhage during surgery and need to have their anticoagulant medication levels adjusted and managed where this is not possible, non-surgical endodontic therapy would result in less medical risk for the patient than either extraction and implant placement or surgical endodontic therapy. Patients on bisphosphonates are at risk for osteonecrosis of the jaw following dental treatment, in particular extractions. Under these circumstances, if either endodontic therapy or extraction (and implant placement) is required, nonsurgical endodontic therapy is the treatment of choice.45 Patients on long-term corticosteroid therapy are also at increased risk of osteonecrosis.46 Chemotherapy patients should not receive implants until blood profiles are back to normal, due to higher implant failure rates,47 and unless the timing of treatment is elective and can be delayed, endodontic treatment would be indicated and implant treatment contraindicated in these patients. Uncontrolled diabetics have higher implant failure rates than nondiabetics, with failure rates in diabetics occurring in the first year.48 With respect to endodontic therapy, patients with type 2 diabetes are more susceptible to apical periodontitis and one study found 81% of diabetics had apical periodontitis, versus 58% of nondiabetics.49 Implants have been found in studies to be successful, provided the diabetes was controlled. Diabetes can impact the results of both endodontic therapy and implant therapy and may therefore not be a determining factor. Patients at risk for bacterial endocarditis require antibiotic prophylaxis prior to dental treatments where oral bacteria may enter the bloodstream. However, the ongoing presence of a recalcitrant periapical infection also represents a potential health risk. Immune-compromised patients are at risk for infections; however implant therapy and endodontic therapy can both be successful in these patients. While smoking is a health risk factor rather than a systemic health consideration in the choice of therapy, smokers have an increased risk of periodontitis and an increased risk of disease progression.50,51 Periodontal disease is however associated with an increased incidence of apical periodontitis in root-treated teeth,52 indicating that smokers may also be at increased risk for endodontic failure. Smokers have previously been found to have higher implant failure rates than nonsmokers;53 however, a recent retrospective study of more than 1,900 immediate implants placed between 1988 and 2004 found that while smokers had more failures, the
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Success rates
Implant success rates have been reported to be in the 90%96% range. A survival rate of 95.6% over a 1-to-12-year period was found in 1692 implants placed, with mean time for removal of failures being 40 months there were more early failures than late failures, and factors influencing failure included bone quality, metabolic diseases, smoking and poor oral hygiene.39 A recent study by Wagenberg and Froum of more than 1900 immediate implants placed between 1988 and 2004 found a success rate of 96%, with machined implants twice as likely to fail as rough surface implants. A study of implants placed between 1988 and 1992 found that 7.7% of implants had progressive bone loss at 5- and 10-year assessments.40 As with endodontic therapy, success rates vary with the materials used in this case implant design and coating. Hollow-screw implants have been found to have higher success rates than hollow-cylinder implants (95.4% verus 85.7%),41 and peri-implantitis was found in one study over 13 years to be associated more commonly with hydroxyapatite-coated implants than with turned-surface titanium implants.42 Treatment of advanced peri-implantitis with surgical and antimicrobial therapy does not guarantee success and was successful in only 58% of implants treated in one study.43 Since the ultimate goal is retention of the implant and functionality of the superstructure, success rates need to look beyond retention of the implant and absence of infection. A study examining implants 5 and 10 years after placement as abutments for fixed prostheses found implant-abutment connection problems in 7.3% of patients after five years. Implant fracture occurred cumulatively in 0.4% of implants.44 Fractured implant

Treatment Considerations and Selection


Both implant therapy and endodontic therapy have good success rates. While endodontic therapy retains the tooth (or root) and provides the basis for a restoration, endodontically treated teeth are not the equal of healthy intact or vital teeth. On the other hand, extraction is final. With both endodontic and implant therapy, success factors and considerations include the patients systemic and oral health, choice of materials, and technique used. Determination of the appropriate
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Endodontic and Implant Treatment Contraindications Implant Nonsurgical treatment endodontic treatment Contraindications Bisphosphonate therapy Head and neck radiation Long-term steroid use Chemotherapy Anticoagulant therapy Relative contraindications Diabetes Smoking Rampant caries Short crown-root ratio Poor periodontal health Furcation involvement Poor root configuration Poor bone density, quality Poor bone height and width Root fracture (varies with location) X X X X X X X X X X X X X X X X X Delay X Manage

difference in failure rates between smokers and nonsmokers was statistically insignificant.54 Based upon the research in total, it is unclear whether smoking would suggest selection of implant or endodontic therapy. Oral health considerations Oral health considerations include caries experience, periodontal health, alveolar bone, occlusal load and bruxism, parafunctional habits, health of the remaining dentition, and the presence of or need for fixed prostheses. Where a tooth is already an abutment for a bridge, endodontic therapy avoids having to remove and replace the bridge. Where the tooth or implant would serve de novo as an abutment for a fixed prosthesis or as a single unit, more consideration is warranted to avoid later removal of the prosthesis due to treatment failure. Secondary and rampant caries can result in restorative failure. Secondary caries has been reported as the single most common reason for replacement of restorations,55 and a literature review found that 18% of abutment teeth for fixed prostheses subsequently suffered caries.56 A long-term retrospective study of fixed partial prostheses and cantilevers found that 8% failed due to secondary decay.57 In patients with rampant caries or high caries experience, especially with exposed roots, extraction and implant placement may provide a better long-term approach for an individual patient if he or she is periodontally stable and has not undergone irradiation of the jaw. If the endodontically treated tooth would be
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a single restored unit, caries experience would be somewhat less of a consideration since only the individual tooth/restoration would be potentially lost. Surgery exposes patients who have undergone irradiation of the mandible or maxilla to the risk of osteoradionecrosis, as well as to an increased risk of implant failure.58 In these patients who are per se at risk for rampant caries due to radiation-induced xerostomia endodontic therapy would avoid these risks and override caries concerns. When periodontal health is poor, success rates for both endodontic and implant therapy are compromised. Peri-implantitis risk is greater in patients with active periodontal disease,59 and periodontal disease is associated with an increased incidence of apical periodontitis in root-treated teeth.60 Molars with furcation involvement have been found to have twice the risk of being lost over an eight-year period following periodontal therapy, with 30.2% lost versus 14.7% lost without furcation involvement.61 Periodontal treatment of molar furcations may include root resection (and endodontic treatment). Molar root resection failure rates have been found to range from 10% to 47.4% over a 10-year period.62,63 This would suggest that consideration should be given to implant placement where there is (advanced) furcation involvement with more weight placed on this option where the tooth would serve as an abutment for a fixed prosthesis. Root considerations include poor crown-to-root ratio and very short root length relative contraindications for endodontic/restorative therapy. Poor root configuration and anatomical obstructions may result in the need for surgical endodontic therapy and/or retreatments and suggest considering implant therapy as an option with the patient. Further root-related considerations are teeth with external or internal root resorption. Vertical root fractures indicate extraction and implant treatment. Horizontal root fractures in the coronal third of the root may still leave sufficient root for a new restoration however, depending upon the depth of the fracture, periodontal/restorative factors and remaining root length, consideration instead should be given to implant treatment. Bone height, width, volume and density and the adjacent anatomical structures are further considerations. Poor bone quality and density is associated with a higher short-term implant failure rate and poor osseointegration. Bone that is of inadequate height or width makes implant placement impossible or difficult and may necessitate bone grafting prior to implant placement. If a tooth has a poor prognosis, preserving the socket and placing an implant may avoid the necessity for bone grafting prior to treatment. Alternatively, endodontic therapy would avoid the extraction and the need for procedures such as bone grafting. Patient considerations Decision making involves advising and guiding patients through choices and treatment selection. If a choice can be clearly delineated because a therapy is contraindicated, the
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process is straightforward. In other situations, the choice is not obvious and involves weighing factors that may conflict with each other and the patients preferences. Extraction, implant therapy and restoration can be complex and costly; endodontic therapy and restoration can also be complex and costly. One study found that in patients referred for immediate implant placement, 46% were removed for endodontic reasons,64 indicative of past failure rates but also of patient acceptance of implants. Some patients may prefer endodontic therapy to retain the natural tooth or root even if there is a high relative risk of failure, while others may prefer implant treatment. Patient perceptions regarding the various treatments and the value of retaining the natural root/tooth play a role. Individual patients who have experienced different procedures may have a clear preference based upon that experience. Patients who have not experienced either oral surgery or endodontic therapy are typically more anxious about endodontic therapy.65 Educating the patient on all treatment options, the risks and benefits of these options, and the use of anxiety management techniques will help the patient overcome his or her anxiety and enable the clinician and the patient to select the most appropriate treatment together. Summary Improvements in oral health and treatment modalities have resulted in more patients than in the past retaining their teeth. Within the context of preserving the natural dentition, endondontic therapy is a proven treatment with good success rates. Implant therapy also has good success rates and is a well-accepted treatment. While the natural tooth or root is retained with endodontic therapy, it is not necessarily the better option for individual patients. The decision-making process and treatment choice can be complex for individual cases. Considerations in selecting implant therapy or endodontic therapy for an individual patient include (relative) contraindications for either treatment, functionality, patient and tooth-specific risks, and patient preferences.
1. Beltran-Aguilar ED, Barker LK, Canto MT, Dye BA, Gooch BF, Griffin SO, Hyman J, Jaramillo F, Kingman A, Nowjack-Raymer R, Selwitz RH, Wu T; Centers for Disease Control and Prevention (CDC). Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosisUnited States, 19881994 and 1999 2002. MMWR Surveill Summ. 2005 Aug 26;54(3):143. 2. Klinge N, Hultin M, Berglundh T. Peri-implantitis. Dent Clin N Am. 2005;49:661676. 3. Armellini D, von Fraunhofer JA. The shortened dental arch: a review of the literature. J Prosthet Dent. 2004 Dec;92(6):531535. 4. Ibid. 5. de Sa e Frias V, Toothaker R, Wright RF. Shortened dental arch: a review of current treatment concepts. J Prosthodont. 2004 Jun;13(2):104110. 6. Omar R. The evidence for prosthodontic treatment planning for older, partially dentate patients. Med Princ Pract. 2003;12 Suppl 1:3342. 7. Nassani MZ, Devlin H, McCord JF, Kay EJ. The shortened dental archan assessment of patients dental health state utility values. Int Dent J. 2005 Oct;55(5):307312. 8. Caicedo R, Clark S, Rozo L, Fullmer J. Guidelines for access cavity preparation in endodontics. ADTS, 2006. 9. Stassen IG, Hommez GM, De Bruyn H, De Moor RJ. The relation between apical periodontitis and root-filled teeth in patients with periodontal treatment need. Int
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References

Endod J. 2006 Apr;39(4):299308. 10. Wu MK, Dummer PM, Wesselink PR. Consequences of and strategies to deal with residual post-treatment root canal infection. Int Endod J. 2006 May;39(5):343356. 11. Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006 Apr;39(4):249281. 12. Anjo T, Ebihara A, Takeda A, Takashina M, Sunakawa M, Suda H. Removal of two types of root canal filling material using pulsed Nd:YAG laser irradiation. Photomed Laser Surg. 2004 Dec;22(6):470476. 13. Jha D, Guerrero A, Ngo T, Helfer A, Hasselgren G. Inability of laser and rotary instrumentation to eliminate root canal infection. J Am Dent Assoc. 2006 Jan;137(1):6770. 14. Helfer R et al. Determination of the moisture content of vital and pulpless teeth. J Oral Surg. 1972;34(4):661669. 15. Carter JM et al. Punch shear testing of extracted vital and endodontically-treated teeth. J Biomech. 1983;16:841848. 16. Kuttler S, McLean A, Dorn S, Fischzang A. The impact of post space preparation with Gates-Glidden drills on residual dentin thickness in distal roots of mandibular molars. J Am Dent Assoc. 2004 Jul;135(7):903909. 17. Barjau-Escribano A, Sancho-Bru JL, Forner-Navarro L, Rodriguez-Cervantes PJ, Perez-Gonzalez A, Sanchez-Marin FT. Influence of prefabricated post material on restored teeth: fracture strength and stress distribution. Oper Dent. 2006 Jan Feb;31(1):4754. 18. Ari H, Erdemir A. Effects of endodontic irrigation solutions on mineral content of root canal dentin using ICP-AES technique. J Endod. 2005 Mar;31(3):187189. 19. Ari H, Erdemir A, Belli S. Evaluation of the effect of endodontic irrigation solutions on the microhardness and the roughness of root canal dentin. J Endod. 2004 Nov;30(11):792795. 20. White JD, Lacefield WR, Chavers LS, Eleazer PD. The effect of three commonly used endodontic materials on the strength and hardness of root dentin. J Endod. 2002 Dec;28(12):828830. 21. Aykent F, Kalkan M, Yucel MT, Ozyesil AG. Effect of dentin bonding and ferrule preparation on the fracture strength of crowned teeth restored with dowels and amalgam cores. J Prosthet Dent. 2006 Apr;95(4):297301. 22. Deliperi S, Bardwell DN. Two-year clinical evaluation of nonvital tooth whitening and resin composite restorations. J Esthet Restor Dent. 2005;17(6):369378 23. Friedman S, Mor C. The success of endodontic therapyhealing and functionality. J Calif Dent Assoc. 2004 Jun;32(6):493503. 24. Sjgren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990 Oct;16(10):498504. 24. Friedman S, Mor C. The success of endodontic therapyhealing and functionality. J Calif Dent Assoc. 2004 Jun;32(6):493503. 26. Farzaneh M, Abitbol S, Lawrence HP, Friedman S; Toronto Study. Treatment outcome in endodonticsthe Toronto Study. Phase II: initial treatment. J Endod. 2004 May;30(5):302309. 27. Friedman S, Mor C. The success of endodontic therapyhealing and functionality. J Calif Dent Assoc. 2004 Jun;32(6):493503. 28. Sjgren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990 Oct;16(10):498504. 29. Friedman S, Mor C. The success of endodontic therapyhealing and functionality. J Calif Dent Assoc. 2004 Jun;32(6):493503. 30. Sjgren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990 Oct;16(10):498504. 31. Paulander J, Axelsson P, Lindhe J, Wennstrom J. Intra-oral pattern of tooth and periodontal bone loss between the ages of 50 and 60 years. A longitudinal prospective study. Acta Odontol Scand. 2004 Aug;62(4):214222. 32. Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent. 2002 Mar;87(3):256263. 33. Lynch CD, Burke FM, Ni Riordain R, Hannigan A. The influence of coronal restoration type on the survival of endodontically treated teeth. Eur J Prosthodont Restor Dent. 2004 Dec;12(4):171176. 34. Chen ST, Wilson TG Jr, Hammerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. 2004;19 Suppl:1225. 35. Lioubavina-Hack N, Lang NP, Karring T. Significance of primary stability for osseointegration of dental implants. Clin Oral Implants Res. 2006;17(3):244250. 36. Quirynen M, Vogels R, Alsaadi G et al. Predisposing conditions for retrograde periimplantitis, and treatment suggestions. Clin Oral Implants Res. 2005;16(5):599608. 37. Uribe R, Penarrocha M, Sanchis JM, Garcia O. Marginal peri-implantitis due to occlusal
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overload. Med Oral. 2004;9(2):159162. 38. Porter JA, von Fraunhofer JA. Success or failure of dental implants? A literature review with treatment considerations. Gen Dent. 2005;53(6):423432. 39. Kourtis SG, Sotiriadou S, Voliotis S, Challas A. Private practice results of dental implants. Part I: survival and evaluation of risk factors. Part II: surgical and prosthetic complications. Implant Dent. 2004;13(4):373385. 40. Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year followup of implant treatment, Part II: presence of peri-implant lesions, J Clin Preiodontal. 2006;33(4):290295. 41. Karoussis IK, Bragger U, Salvi GE, Burgin W, Lang NP. Effect of implant design on survival and success rates of titanium oral implants: a 10-year prospective cohort study of the ITI Dental Implant System. Clin Oral Implants Res. 2004;15(1):817. 42. Rosenberg ES, Cho SC, Elian N, Jalbout ZN, Froum S, Evian CI. A comparison of characteristics of implant failure and survival in periodontally compromised and periodontally healthy patients: a clinical report. Int J Oral Maxillofac Implants. 2004;19(6):873879. 43. Leonhardt A, Dahlen G, Renvert S. Five-year clinical, microbiological, and radiological outcome following treatment of peri-implantitis in man. J Periodontol. 2003;74(10):14151422. 44. Pjetursson BE, Tan K, Lang NP, Bragger U, Egger M, Zwahlen M. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Evid Based Dent. 2005;6(4):9697. 45. Ruggiero S, Gralow J et al. Practical guidelines for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients with cancer. J Oncol Pract. 2006;2(1):714. 46. Ibid. 47. Wolfaardt J, Granstrom G, Friberg B, Jha N, Tjellstrom A. A retrospective study on the effects of chemotherapy on osseointegration. J Facial Somato Prosthet. 1996;2:99107. 48. Fiorellini JP, Chen PK, Nevins M, Nevins ML. A retrospective study of dental implants in diabetic patients. Int J Periodontics Restorative Dent. 2000;20:366373. 49. Segura-Egea JJ, Jimenez-Pinzon A, Rios-Santos JV, Velasco-Ortega E, Cisneros-Cabello R, Poyato-Ferrera M. High prevalence of apical periodontitis amongst type 2 diabetic patients. Int Endod J. 2005 Aug;38(8):564569. 50. Norderyd O, Hugoson A, Grusovin G. Risk of severe periodontal disease in a Swedish adult population. A longitudinal study. J Clin Periodontol. 1999;26:608615. 51. Papapanou PN. Periodontal diseases: epidemiology. Ann Periodontol. 1996;1:136. 52. Stassen IG, Hommez GM et al. The relation between apical periodontitis and root-filled teeth in patients with periodontal treatment need. Int Endod J. 2006;39(4):299308. 53. Bain CE, Moy PK. The association between the failure of dental implants and cigarette smoking. Intl J Oral Maxillofac Implants. 1993;8:609615. 54. Wagenberg B, Froum SJ. A retrospective study of 1925 consecutively placed immediate implants from 1988 to 2004. Intl J Oral Maxillofac Implants. 2006;21(1):7180. 55. Deligeorgi V, Mjor IA,Wilson NH. An overview of reasons for the placement and replacement of restorations. Prim Dent Care. 2001 Jan;8(1):511. 56. Goodacre CJ, Bernal G et al. Clinical complications in fixed prosthodontics. J Prosthet Dent. 2003; 90(1):3141. 57. Hammerle CHF et al. Long-term analysis of biological and technical aspects of fixed partial dentures with cantilevers. Int J Prosthodont. 2000;13:409415. 58. Sugarman PB, Barber MT. Patient selection for endosseous dental implants: oral and systemic considerations. Int J Oral Maxillofac Implants. 2002;17:191201. 59. Porter JA, von Fraunhofer JA. Success or failure of dental implants? A literature review with treatment considerations. Gen Dent. 2005;53(6):423432. 60. Stassen IG, Hommez GM et al. The relation between apical periodontitis and root-filled teeth in patients with periodontal treatment need. Int Endod J. 2006;39(4):299308. 61. Wang HL et al. The influence of molar furcation involvement and mobility on future clinical attachment loss. J Periodontol. 1994;65(1):2529. 62. Minsk L, Polson AM. The role of root resection in the age of dental implants. Compend Contin Educ Dent. 2006;27(7):384388. 63. Langer B, Stein SO, Wagenberg B. An evaluation of root resections. A ten-year study. J Periodontol. 1981;52(12):719722. 64. Becker W, Becker BE, Hujoel P. Retrospective case series analysis of the factors determining immediate implant placement. Compend Contin Educ Dent. 2000;21(10):805817. 65. Wong M, Lytle WR. A comparison of anxiety levels associated with root canal therapy and oral surgery treatment. J Endod. 1991;17(9):416465.

Author Profiles
Richard Nejat, DDS Dr. Richard Nejat is board certified by the American Board of Periodontology. His practice is at the forefront of computer-guided implant dentistry and minimally invasive dental surgery. He is a course instructor in various continuing educational seminars, symposiums to colleges, and dental societies. Dr. Nejat attended Drew University and continued his education at New York University, where he attained his doctorate in dental surgery. Dr. Nejat was elected to membership in Omicron Kappa Upsilon, the National Dental Honor Society recognizing academic and clinical excellence in dentistry. He earned his certificate in periodontics from the State University of New York at Stony Brook. Dr. Nejat is currently clinical assistant professor in the Department of Periodontology and Implant Dentistry at New York University and maintains private practices in Manhattan and Nutley, New Jersey. Fiona M. Collins, BDS, MBA, MA Dr. Fiona M. Collins has clinical, marketing, education and training, and professional relations experience. She has practiced as a general dentist for 13 years, written and given CE courses to dental professionals and students, and conducted market research projects. Dr. Collins is a past member of the Academy of General Dentistry Foundation Strategy Board and has been a member of the British Dental Association, the Dutch Dental Association and the American Dental Association. Dr. Collins earned her dental degree from Glasgow University and holds an MBA and an MA from Boston University.

Disclaimer
The authors of this course have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Reader Feedback
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Questions
1. The primary factor in tooth loss in the U.S. population is ________.
a. b. c. d. caries root fracture orthodontic treatment periodontal disease

11. For teeth with apical periodontitis at the time of initial treatment, reported success rates have been ________.
a. b. c. d. 33% 45%50% 74%86% 95%

22. A patients general health considerations include ________.


a. b. c. d. medication use diet infection risk a and c

2. Advanced periodontal disease is responsible for ________ of extractions in patients over 40.
a. b. c. d. 2%5% 5%15% 3035% 50%

12. Uncrowned endodontically treated teeth have been found to be ____ times more likely to be lost than crowned teeth.
a. b. c. d. three five six eight

23. Relevant medications to consider in selecting the appropriate treatment include ________.
a. b. c. d. bisphosphonates anticoagulants calcium supplements a and b

3. The dental literature suggests that an intact dental arch provides good function if ________.
a. b. c. d.

13. The number of implants placed annually is around ________.


a. b. c. d. half a million one million less than half a million two million

it extends to the canines at least one arch extends to the first molars it extends to the second bicuspids only if all teeth are present

24. Uncontrolled diabetics have higher ________.


a. implant failure rates b. susceptibility to apical periodontitis after endodontic treatment c. a and b d. none of the above

4. Partial edentulism may result in ________.


a. b. c. d.

14. Immediate complications with implant placement include ________.


a. b. c. d. misalignment of the implant bleeding microbial contamination of the implant all of the above

tilting of teeth overeruption of the opposing dentition masticatory problems all of the above

5. The ultimate goal of endodontic treatment is ________.


a. b. c. d.

15. Failure to obtain primary stability leads to ________.


a. b. c. d. successful treatment failure of the implant to osseointegrate poor appearance of the implant none of the above

25. Oral health considerations in selecting the appropriate treatment include ________.
a. b. c. d. caries experience periodontal health alveolar bone all of the above

extraction absence of infection complete healing of the periapical tissues b and c

6. During nonsurgical endodontic treatment, ________ is required.


a. b. c. d. straight-line access beveled access angled access none of the above

16. Long-term implant complications are commonly a result of ________.


a. b. c. d. using the wrong mouthrinse poor oral hygiene heart disease oral ulcerations

26. The single most common reason for replacement of restorations has been reported to be ________.
a. b. c. d. poor aesthetics secondary caries metal fatigue all of the above

7. Root canal irrigants used include ________.


a. b. c. d. sodium hypochlorite EDTA hydrogen peroxide all of the above

17. The most common cause of implant failure is ________.


a. b. c. d. facial injury loss of sensation peri-implantitis all of the above

27. Root considerations in selecting treatment include ________.


a. b. c. d. crown-to-root ratio root length color of the root a and b

8. Periapical/recurring microbial infection following endodontic treatment is influenced by ________.


a. root anatomy b. quality of the root filling and coronal restoration c. the amount of mouthrinse the patient uses d. a and b

18. Implant success rates have been reported to be ________.


a. b. c. d. 40%50% 65%75% 90%97% 100%

28. Considerations related to the bone in selecting treatment include ________.


a. b. c. d. bone height and width whether or not a woman is postmenopausal bone volume and density a and c

19. Factors influencing implant failure include ________.


a. b. c. d.

9. Nonvital dentin contains less ________ than vital dentin, which could lead to brittleness.
a. b. c. d. fat water blood none of the above

bone quality poor oral hygiene whether the dental arch is continuous or not a and b

29. Decision making on the appropriate treatment involves ________.

20. Implant fracture was found in one study to occur in ________ of implants.
a. b. c. d. none 0.4% 1% more than 5%

10. Success rates for initial endodontic treatment in the absence of preexisting apical periodontitis have been reported to be ________.
a. b. c. d. 50%60% 75% 80%90% 91%98%

a. advising and guiding the patient through options b. deciding what to do and then telling the patient there is only one option c. considering the patients preferences d. a and c

21. Determination of the appropriate treatment requires careful consideration of ________.


a. b. c. d. the patients systemic and oral health choice of materials echnique used all of the above

30. ________ plays a role in the choice of treatment.


a. b. c. d. the patients perceptions the patients past treatment experience neither a nor b a and b

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ANSWER SHEET

Implants or Endodontics: Alternative Treatments?


Name: Address: City: Telephone: Home ( ) Title: E-mail: State: ZIP: Specialty:

Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Educational Objectives
1. List the common causes of tooth extractions and potential sequelae. List and describe the success rates for both endodontic treatment and implant treatment as well as the factors and 2. conditions that can lead to failure of endodontic and implant treatment. 3. List and describe the systemic and oral considerations that are involved in determining whether endodontic treatment or implant treatment is more appropriate for a given patient. 4. Describe the implications for decision making together with the patient, and factors influencing the patient in his or her choice of treatment.

Mail completed answer sheet to

Academy of Dental Therapeutics and Stomatology,


A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447


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Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No 2. To what extent were the course objectives accomplished overall? 3. Please rate your personal mastery of the course objectives. 4. How would you rate the objectives and educational methods? 5. How do you rate the authors grasp of the topic? 6. Please rate the instructors effectiveness. 5 5 5 5 5 5 4 4 4 4 4 4 Yes Yes Objective #3: Yes No Objective #4: Yes No 3 3 3 3 3 3 2 2 2 2 2 2 No No 1 1 1 1 1 1 0 0 0 0 0 0

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7. Was the overall administration of the course effective? 8. Do you feel that the references were adequate?

9. Would you participate in a similar program on a different topic?

10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ____________________________________________________________________ __________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ____________________________________________________________________ __________________________________________________________________ PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER The authors of this course have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANBs annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANBs Recertification Department at 1-800-FOR-DANB, ext. 445. RECORD KEEPING PennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 2008 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

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