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Dental Tribune Middle East & Africa Edition | 3/2016 9 mCME ◊Page8 Scott L. Doyle, DDS, MS. He cur- rently practices with Metropolitan Endodontics in Minneapolis and servesasanassoci- ate clinical profes- sor for the Division of Endodontics at the University of Minnesota. Doyle is a diplomate of the American Board of En- dodontics. He is a past president of the Minnesota Association of Endodontists, chair of the AAE Continuing Education Committee and serves as a reviewer for the Journal of Endodontics. Doyle has written multiple articles in scientific journals, as well as a chapter on the “En- dodontic Applications of CBCT” in an up- coming textbook. denture.38 Retrospective studies also have compared the outcomes for the two treatment options. A study conduct- ed at the University of Minnesota compared the outcomes of 196 re- stored endodontically treated teeth with 196 matched single-tooth im- plants.39 Both groups had 94 percent survival rates. The survival curves for these two groups are provided in Figure3. Anotherinvestigationfrom the University of Alabama provided similarresults.40 Based upon similar survival rates, the decision to treat a compromised tooth endodontically or replace it with an implant must be based on factors other than treatment out- come.37,41 Several factors influence the decision-making process.42-44 The following lists provide an overview ofcase-specificfactorsthatshouldbe consideredinmakingthistreatment decision. Systemicfactors • The list of potential risk factors for peri-implantitis or implant failure is extensive. It includes systemic dis- ease, genetic traits, chronic drug or alcoholconsumption,smoking,peri- odontal disease, radiation therapy, diabetes,osteoporosis,dentalplaque andpoororalhygiene.45 • There are few medical conditions that directly affect endodontic treat- ment outcomes. Risk factors that may be associated with decreased survival of root canal-treated teeth include smoking,46 diabetes,28,46 sys- temic steroid therapy28 and hyper- tension.47 • Patients taking antiangiogenic or antiresorptive(i.e.,bisphosphonates) medications may have an increased riskfordevelopingmedication-relat- edosteonecrosisofthejaw.Thismay affect treatment planning for both implantandendodontictreatment. • It is generally recommended to wait for the completion of dental and skeletal growth prior to implant placement.48 Localfactors •Accuratediagnosis. • Restorability assessment: removal of caries/restorations; adequate fer- rule. • Strategic nature of the tooth as it fits into the comprehensive restora- tiveplan. •Cariesriskandoralhygiene. • Periodontal assessment: tissue bio- type,adequatebiologicwidth. •Presenceofcrack(s),rootfracture(s), resorption. •Occlusionandparafunction. • Teeth with less than two proximal contacts and those serving as fixed partialdentureabutmentsmayhave lowersurvival.27 • Need for adjunctive treatment (crown lengthening, orthodontic extrusion, sinus lift, bone graft, etc.), whichmayimpactfinancialcostand timetofunction. •Quantityandqualityofbone. •Proximitytoanatomicalstructures (maxillary sinus, inferior alveolar nerve,etc.) •Implantestheticsintheanteriorre- gionmaybechallenging.49 In addition to systemic and local factors, it is critical to include the patient’s concerns during treat- ment planning. Common patient- centered factors include costs, treat- ment duration, satisfaction with treatment and the potential for ad- verseoutcomes. Financial considerations can in- fluence a patient’s decision when weighing treatment options. The availability of dental insurance may also impact choices.50 Endodontic treatment and restoration offer con- siderable economic advantages to the patient.51-53 A benefit of root ca- naltreatmentistheshorttimeframe required to completely restore both dental function and esthetics. In one study of about 400 patients, the re- stored single-tooth implant showed a longer average and median time to function than similarly restored en- dodontically treated teeth. Addition- ally, the implant group had a higher incidence of post-treatment compli- cations requiring subsequent treat- ment interventions.39 This increased post-operative care can impact pa- tients in terms of additional visits, lostwagesandunforeseencosts. Clinicians should consider the pa- tient’s preferences, which are often related to function, comfort and es- thetics. Tooth loss is associated with an impaired quality of life,54 and surveyed patients express a clear desire to save their natural denti- tion whenever possible.2 Large-scale surveys of post-endodontic patients have demonstrated that endodon- tic treatment not only preserves the natural tooth, but also signifi- cantly improves patients’ quality of life.55 More than 97 percent of pa- tients report being satisfied with their endodontic treatment.31 If an implant is used to restore an eden- tulous space, a similarly high per- centage 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 endodontically treated teeth and implants are susceptible to compli- cations. Nonrestorable caries, pros- thetic failures, periodontal disease, crown/root fractures and specific endodontic factors are examples of complications following root canal treatment.57 Complications associ- ated with implants and related pros- thesesinclude:surgical,implantloss, bone loss, peri-implant soft-tissue, mechanical and esthetic/phonet- ic.58 A retrospective study directly compared the rates of additional interventions related to complica- tions. Implant cases had a substan- tially higher need for subsequent intervention and maintenance visits than endodontically treated teeth.40 However, a more recent prospective study suggests that patients from both groups have minimal compli- cationsatone-yearfollow-up.15 Endodontic retreatment op- tions The consequences of failure and subsequent treatment differ be- tween endodontics and implants. Endodontic failure can usually be addressed successfully by retreat- ment, microsurgery or by extraction and potential implant placement. Intervention after implant failure may vary from minimal restorative repairstomultiplecorrectivesurger- iesand/ortheuseofadifferentpros- thesis.59 Nonsurgicalretreatment,orrevision, is often the first choice to address post-treatment apical periodonti- tis,60,61 provided that the tooth is suitable for further restoration and that the restoration will have a good long-term prognosis (Figs 4a, b).62 Current best evidence indicates that the survival of nonsurgical retreat- ment is similar to that of primary treatment, and that the two treat- ments share similar prognostic fac- tors.63 Two studies specifically evalu- ated survival following retreatment. An epidemiological study using an insurancedatabaseof4,744retreated teethreportedan89percentsurvival rateatfiveyears64andaprospective trial of 858 retreated teeth reported a95percentsurvivalatfouryears.28 Modern techniques and rationale contribute to excellent potential outcomes for retreatment. An im- portant factor when considering retreatment is the ability to iden- tify and address the etiology of post- treatment disease.63 Primary sources of nonhealing are persistent intra- canal microorganisms or ingress of microorganisms following treat- ment. If the etiology of the problem is deemed correctable via an ortho- gradeapproach, retreatment isoften the first choice. If not, a surgical ap- proach may be the more predictable option.65 Contemporary endodontic micro- surgery has undergone significant technological and procedural ad- vancements.66,67 Recently performed studies suggest that microsurgical techniques using biocompatible root-end filling materials provide significant improvements over tra- ditional methods. A meta-analysis showed contemporary microsurgi- caltechniquestohaveasignificantly improved outcome (94 percent) compared to older techniques and instruments (59 percent).68 A recent systematic review investigating cur- rent microsurgery found survival rates of 94 percent at two to four years and 88 percent at four to six years, indicating that teeth treated with endodontic microsurgery tended to be lost at low rates over the time studied.69 Microsurgery, with appropriate case selection, is a predictable procedure for teeth that may have been considered for ex- tractioninthepast. Ethics and interdisciplinary consultation Clinicians are ethically bound to inform patients of all reasonable treatment options, explain the risks and benefits involved with the avail- able treatment options, and obtain informed consent before initiating treatment. This information should be conveyed in an impartial man- ner.1 Patients value participation in the decision-making process and should be encouraged to exercise autonomy by communicating their preferences.70 Clinical treatment de- cisions regarding either endodontic treatment or tooth extraction with implant therapy must always be made in the best interest of the pa- tient using the best, most current evidence. Should it be necessary, experts from the dental team may need to be called upon to assist the clinician in rendering the highest quality of care (Figs. 5a, b). The standard of care must be applied equally to all clinicians, generalists and specialists alike.TheAAE’sEndodonticCaseDif- ficulty Assessment Form and Guide- lines provides valuable information to aid the clinician in case selection and determining whether to treat or refer. Patients are deserving of the best possible outcome for each case. Interdisciplinary communication and collaboration during treatment planningmaximizethislikelihood. Specialists and restorative dentists should be viewed as partners in the treatment planning team. Endodon- tists are uniquely positioned to eval- uate the restorability and prognostic longevity of teeth and recommend whether to attempt natural tooth preservation or consider extraction and replacement with an implant.71 Likewise, the endodontist should be well-versed in implant treatment planning to assist patients and re- ferring colleagues in making an in- formed choice regarding all replace- mentoptions.72,73 If a tooth has a questionable prog- nosis, the endodontic specialist be- comes an indispensable part of the treatment planning team. The endo- dontist has experience with various treatment options that have poten- tialtopreservethenaturaldentition. Consultation regarding a questiona- bletoothisofteninthepatient’sbest interest prior to considering extrac- tion. If the prognosis of a restorable tooth is categorized as questionable or unfavorable in multiple areas of evaluation, extraction should be considered after appropriate consul- tation with all relevant specialists. Only then is the decision to extract an informed choice. Extraction is an irreversible treatment, but if neces- sary, dental implants provide an excellent option to replace missing teeth(Figs.6a,b). Casereport A case report (Figs. 7-10) demon- strates an alternative treatment op- tion for a patient to save a natural tooth. A 70-year-old female present- ed to an endodontist’s office with a complaint of persistent pain to bit- ing. Tooth #31 had a history of root canal treatment and coronal resto- ration. A thorough examination, including CBCT, led to the diagnosis of previously treated tooth #31 with symptomaticapicalperiodontitis. A detailed explanation of the risks andbenefitsassociatedwithalltreat- ment options was presented. The patient expressed a strong desire to save her tooth and consented to intentional replantation. Tooth #31 was atraumatically extracted and continuously hydrated with Hanks’ Balanced Salt Solution. No cracks or fractures were visible. Apical micro- surgery was performed extraorally. The root end was resected, ultrasoni- cally prepared and filled with min- eral trioxide aggregate. The tooth was replanted. The patient remains asymptomatic and very satisfied withhertreatment. A recent systematic review and me- ta-analysis revealed a mean survival rate of 88 percent for intentional re- plantation.* With careful case selec- tion, intentional replantation may allow for a reasonable, cost-effective treatment option for teeth that do not heal following endodontic treatment. Clinicians are advised to explore all options before recom- mending extraction. Referral to an endodontist can aid in the retention ofacompromisedtooth. Conclusion Patients are living longer; therefore, preservationofthenaturaldentition is more important than ever. Help- ing patients maintain their “Teeth for a Lifetime” is the fundamental goal of dentistry and often aligns withthedesiresofthepatient.Awide range of endodontic procedures re- sult in a high level of tooth retention and patient satisfaction. Large-scale studies provide strong support that the restored endodontically treated tooth offers a highly predictable, long-term approach to preserving “nature’simplant”—atoothwithan intactperiodontalligament. Thus, excellent endodontic treat- ment followed by an immediate res- toration of equal quality promises to give patients service and function while maintaining their esthetics for years. The results of multiple studies indicate that the high survival rates for the natural tooth are similar to those reported for the restored sin- gle-toothimplant. Therefore, clinicians must consider additional factors when making treatment planning decisions, all of which must be in the best interest of the patient. Endodontic treatment and implant therapy should not be viewed as competing alternatives, rather as complementary treatment options for the appropriate patient situation. This article originally appeared in ENDODONTICS: Colleagues for Ex- cellence, Spring 2015. Reprinted with permissionfromtheAmericanAsso- ciation of Endodontists, ©2015. The AAE clinical newsletter is available at www.aae.org/colleagues. A complete list of references is avail- able from the publisher, and also at www.aae.org/colleagues. Case report contributed by Dr. Rob- ertS.Roda. 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.7.Pre-opimage. Fig.9.Post-opimage. Fig. 6b. Two-year recall image. Tooth #14 had retreatment and resective surgery on the MB root. Twodentalimplantshaverestored the edentulous space. Courtesy of Dr. Brian Barsness and the Univer- sity of Minnesota School of Den- tistry. Fig.8.Root-endfillingwithMTA. Fig.10.Seven-monthrecallimage. Dental Tribune Middle East & Africa Edition | 3/20169