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I 09 roots 1_2016 C.E. article_ treatment planning I _Systemic factors • The list of potential risk factors for peri- implantitis or implant failure is extensive. It includes systemic disease, genetic traits, chronic drug or alcohol consumption, smoking, perio- dontal disease, radiation therapy, diabetes, oste- oporosis, dental plaque and poor oral hygiene.45 •Therearefewmedicalconditionsthatdirectly affect endodontic treatment outcomes. Risk factors that may be associated with decreased survivalofrootcanal-treatedteethincludesmok- ing,46 diabetes,28,46 systemic steroid therapy28 and hypertension.47 • Patients taking antiangiogenic or antiresorp- tive (i.e., bisphosphonates) medications may have an increased risk for developing medication-related osteonecrosis of the jaw. This may affect treatment planningforbothimplantandendodontictreatment. • It is generally recommended to wait for the completion of dental and skeletal growth prior to implant placement.48 _Local factors • Accurate diagnosis. • Restorability assessment: removal of caries/ restorations; adequate ferrule. • Strategic nature of the tooth as it fits into the comprehensive restorative plan. • Caries risk and oral hygiene. • Periodontal assessment: tissue biotype, ad- equate biologic width. •Presenceofcrack(s),rootfracture(s),resorption. • Occlusion and parafunction. • Teeth with less than two proximal contacts and thoseservingasfixedpartialdentureabutmentsmay have lower survival.27 • Need for adjunctive treatment (crown length- ening, orthodontic extrusion, sinus lift, bone graft, etc.), which may impact financial cost and time to function. • Quantity and quality of bone. • Proximity to anatomical structures (maxillary sinus, inferior alveolar nerve, etc.) • Implant esthetics in the anterior region may be challenging.49 In addition to systemic and local factors, it is criticaltoincludethepatient’sconcernsduringtreat- ment planning. Common patient-centered factors include costs, treatment duration, satisfaction with treatment and the potential for adverse outcomes. Financial considerations can influence a patient’s decision when weighing treatment options. The availability of dental insurance may also impact choices.50 Endodontic treatment and restoration offer considerable economic advantages to the patient.51-53 A benefit of root canal treatment is the shorttimeframerequiredtocompletelyrestoreboth dental function and esthetics. In one study of about 400 patients, the restored single-tooth implant showed a longer average and median time to func- tion than similarly restored endodontically treated teeth. Additionally, the implant group had a higher incidenceofpost-treatmentcomplicationsrequiring subsequenttreatmentinterventions.39 Thisincreased post-operative care can impact patients in terms of additional visits, lost wages and unforeseen costs. Clinicians should consider the patient’s prefer- ences, which are often related to function, comfort and esthetics. Tooth loss is associated with an im- pairedqualityoflife,54 andsurveyedpatientsexpress acleardesiretosavetheirnaturaldentitionwhenever possible.2 Large-scale surveys of post-endodontic patients have demonstrated that endodontic treat- ment not only preserves the natural tooth, but also significantlyimprovespatients’qualityoflife.55 More than 97 percent of patients report being satisfied with their endodontic treatment.31 If an implant is used to restore an edentulous space, a similarly high percentage of patients have a positive experience with implant therapy.56 Furthermore, comparative studies demonstrate that patients report a high degree of satisfaction with the overall experience following both procedures.2,15 Despite high survival rates, both endodonti- cally treated teeth and implants are susceptible to complications. Nonrestorable caries, prosthetic failures, periodontal disease, crown/root fractures and specific endodontic factors are examples of complications following root canal treatment.57 Complications associated with implants and related prostheses include: surgical, implant loss, bone loss, peri-implant soft-tissue, mechanical and esthetic/ phonetic.58 A retrospective study directly compared the rates of additional interventions related to com- plications. Implant cases had a substantially higher need for subsequent intervention and maintenance visitsthanendodonticallytreatedteeth.40 However,a morerecentprospectivestudysuggeststhatpatients from both groups have minimal complications at one-year follow-up.15 Fig. 6a_Pre-op image. Tooth #14 was determined to have a vertical root fracture of the MB root. The patient expressed a strong desire to retain the natural dentition but also to rehabilitate the edentulous space. Fig. 6b_Two-year recall image. Tooth #14 had retreatment and resective surgery on the MB root. Two dental implants have restored the edentulous space. Courtesy of Dr. Brian Barsness and the University of Minnesota School of Dentistry. Fig. 6a Fig. 6b