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Dental Tribune Middle East & Africa Edition | 3/2016 8 mCME Treatment planning: Retention of the natural dentition and the replacement of missing teeth mCMEarticlesinDentaltribunehavebeenapprovedby: HaaDashavingeducationalcontentfor2CMECreditHours DHaawardedthisprogramfor2CPDCreditPoints CAPP designates this activity for 2 CE Credits ÿPage9 Fig. 1a. Pre-op image of tooth #19 with pulp necrosis and sympto- matic apical periodontitis. The pa- tient is interested in rehabilitation of theedentulousspace. (Photos/Provided by American As- sociationofEndodontists) Fig. 2a. Pre-op image of tooth #29. Note lateral radiolucency and com- plexcanalanatomy. Table1_Survivalratesfollowinginitialnonsurgicalroot canal treatment. (Table/ProvidedbyAmericanAssociationofEndodontists) Fig.1b.Three-yearrecallimage. The patient has benefited from both root canal treatment and implant therapy. Courtesy of Dr. Tyler Peterson and the University ofMinnesotaSchoolofDentistry. Fig. 2b. Two-year recall image re- veals both excel- lent endodontic and restorative treatment. Note healing of lat- eral radiolucency. Courtesy of Dr. Joe Petrino. ByScott L.Doyle,DDS Preservationofthenaturaldentition is the primary goal of dentistry. Pub- lished surveys indicate that patients generally value teeth and express a desire to save their natural dentition in favor of extraction whenever pos- sible.1,2 Significant technological and biological improvements have been made in all disciplines of dentistry, making long-term retention of natu- ral teeth more attainable. Patients entrust dental professionals to make appropriate recommendations regarding the maintenance and restoration of their oral health and function. It is essential to employ an evidence-based,interdisciplinaryap- proach that addresses the interests of the patient when determining the bestpossiblecourseoftreatment. In July 2014, the American Associa- tion of Endodontists, in collabora- tion with the American College of Prosthodontists and the American Academy of Periodontology, hosted a two-day Joint Symposium titled “Teeth for a Lifetime: Interdiscipli- nary Evidence for Clinical Success.” Approximately 375 general dentists and specialists assembled in Chicago to focus on preserving the natural dentition. The educational program included evidence-based presentations on advanced regenerative techniques, improvements in technology, mini- mally invasive restorative methods and best practices for interdiscipli- nary treatment planning. Dr. Alan Gluskin, chair of the 2014 Joint Sym- posium Planning Committee, con- cluded that the current evidence di- rectsclinicianstoconsidersavingthe natural dentition as the first option whendevelopingtreatmentplans. Dental implants are one of the most significant advancements in contemporary dentistry. This in- novation has had profound effects on endodontic, periodontic and prosthodontic treatment planning for the rehabilitation of edentu- lous spaces and for teeth with an unfavorable prognosis.3 Implant- supported restorations minimize unnecessary preparation of intact abutment teeth and allow fixed prosthodontic replacement when suitable abutments are absent. With appropriateusageandcaseselection, implant dentistry provides a viable option for the replacement of miss- ingteeth.4,5 There has been an increasing trend towardreplacingdiseasedteethwith dental implants. Often, an inade- quateorinappropriateindicationfor tooth extraction has resulted in the removalofteeththatmayhavebeen salvageable.6 Teeth compromised by pulpal or periodontal disease have value and should not be extracted without thoroughly evaluating re- storability and potential retention therapies.7 A recent systematic review pub- lishedintheJournaloftheAmerican Dental Association highlights a key question: “Is the long-term survival rate of dental implants comparable to that of periodontally compro- mised natural teeth that are ad- equately treated and maintained?”8 Nineteen studies with a follow-up period of at least 15 years were in- cludedintheanalysis. The results show that implant sur- vival rates do not exceed those of compromised but adequately treat- edandmaintainedteeth.Thesefind- ings support other studies compar- ing long-term survival of implants and natural teeth,9,10 providing an important message: Periodontally compromised teeth can be retained with quality treatment and appro- priate maintenance. Therefore, it may be advisable to postpone im- plant consideration for the perio- dontitis-susceptible patient to fully utilizeandextendthecapacityofthe naturaldentition.11 Treatment planningoptions A key focus of the Joint Symposium involved treatment planning deci- sions regarding endodontic treat- ment and implant therapy. Should a tooth with pulpal disease be re- tained with root canal treatment and restoration, or be extracted and replaced with an implant-supported restoration? This assessment in- volves a challenging and complex decision-making process that must be customized to suit the patient’s needs and desires.12-14 The topic has received considerable attention in the literature, the media and at den- talcontinuingeducationcourses. Endodontic treatment and implant therapy should not be viewed as competing alternatives, rather as complementary treatment options for the appropriate patient situation (Figs.1a,b).Rootcanaltreatmentisin- dicated for restorable, periodontally sound teeth with pulpal and/or api- cal pathosis. Endodontic treatment on teeth with nonrestorable crowns orteethwithsevereperiodontalcon- ditions is contraindicated, and other options such as implant placement shouldbeconsidered.15 When making treatment decisions, the clinician should consider fac- tors including outcome assessment, local and systemic case-specific is- sues, costs, the patient’s desires and needs, esthetics, potential adverse outcomesandethicalfactors.16 Outcomeassessment: Successandsurvival Treatment outcomes play a key role in the assessment of different treat- ment options. Patients often ask whether a procedure is going to be successful or not. This question can be challenging for a clinician to an- swer due to the variety of reported outcomes in the literature.17 There are differences in the methodology and criteria used to evaluate the out- comes for root canal treatment and implant prosthetics, which makes comparisons between success rates difficult,ifnotimpossible.18 Endodontic studies have historically used “success” and “failure” as out- comemeasuresandhavefocusedon a strict combination of radiographic and clinical criteria.19 In contrast, the implant literature has primar- ily reported “survival,”20, 21 i.e., the implant is either present or absent. Therefore, implant studies that sole- ly evaluate survival as an outcome measure will likely publish higher success rates than endodontic stud- ies that rely on biologic healing and factors related to the entire restored tooth. To establish more valid and less biased comparisons, the same outcome measures should be used. A more patient-centered measure is to compare the outcome of survival, which is considered to be an asymp- tomatic tooth/implant that is pre- sent and functioning in the patient’s mouth.22,23 Multiple large-scale studies includ- ing millions of teeth have used survival to assess the outcome fol- lowing root canal treatment. An in- vestigation using an insurance da- tabase of more than 1.4 million root canal-treated teeth demonstrated that 97 percent were retained within an eight-year follow-up period.24 Other studies show similarly high survival rates (Table 1).25,26 An epide- miological approach allows for the assessment of tooth retention from a large sample of patients experienc- ing actual care in private practices. Systematic reviews27 and controlled studiesfromacademicsettingscom- plement the previous findings. Two prospective trials each reported 95 percent survival rates at four years28 andfourtosixyears29forteethafter initialrootcanaltreatment. Predictabletoothretention: Nonsurgical root canal treat- ment andrestoration The majority of endodontic treat- ment is performed by general den- tists with a high degree of success.26 For complex cases, referral to an en- dodontist with additional training and expertise may result in more favorableoutcomes30 andpositivepatient experiences.31 Interdisciplinary care is important for the management of endodonti- cally treated teeth. The restorative dentist plays a significant role in the outcome by providing an appropri- ate and timely restoration.32 Root canal treatment is not complete un- til the tooth is coronally sealed and restored to function. Multiple stud- ies have confirmed that a definitive restoration has a significant impact on survival.24,25,27,28,33 Therefore, the likelihoodofafavorableoutcomein- creaseswithbothskillfulendodontic care and prompt restorative treat- ment(Figs.2a,b).34 Advancements in technology aid in attaining high levels of tooth reten- tion. The dental operating micro- scope, nickel-titanium instruments, apex locators, enhanced irrigation protocols and dentin preservation strategies are examples of improve- ments that allow clinicians to pre- dictably manage a greater range of treatment options. Additionally, cone-beam-computed tomography facilitates more accurate diagnosis and improved decision-making for the management of endodontic problems.35,36 Comparative studies: Endo- dontically treated teeth and single-toothimplants Large-scale systematic reviews have addressed the relative survival rates of endodontically treated teeth and single-tooth implants. The Academy ofOsseointegrationconductedame- ta-analysis using 13 studies (approxi- mately 23,000 teeth) on restored endodontically treated teeth and 57 studies (approximately 12,000 implants) on single-tooth implants. The outcome data demonstrated no difference between the two groups during any of the observation pe- riods.37 Another systematic review supported by the American Dental Association compared the outcomes of endodontically treated teeth with those of a single-tooth implant-re- stored crown, fixed partial denture and no treatment after extraction. At 97 percent, the long-term sur- vival rate was essentially the same for implant and endodontic treat- ments. Both options were superior toextractionandreplacementofthe missing tooth with a fixed partial Fig. 3. A matched-case comparison of survival rates after treatment with ei- ther a restored endodontically treated tooth (n=196) or a restored single- tooth implant (n=196) performed at thesameinstitution.JEndod2006;31. Fig. 4a. Pre-op image of tooth #30 with previous endodontic treatment and persistent apical periodontitis. A dentist initially recommended extraction and re- placement of this tooth with an implant. The patient requested a second opinion from an endodon- tist who determined the tooth to be treatable. Fig. 4b. Four-year recall image demonstrates apical healing fol- lowing nonsurgical retreatment. Accurate diagnosis prevented the unnecessary treatment of tooth #31.CourtesyofDr.MartinRogers. Fig. 5a. Pre-op image of tooth #19 with pulp necrosisandchronicapicalabscess. Fig. 5b. Two-year recall image demonstrates excellent endodontic treatment and healing of apical periodontitis. Courtesy of Dr. Deb Knaup.