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treatment planning CE article | 07 roots 3 2016 ArecentsystematicreviewpublishedintheJournal of the American Dental Association highlights a key question:“Isthelong-termsurvivalrateofdentalim- plants comparable to that of periodontally compro- mised natural teeth that are adequately treated and maintained?”8 Nineteen studies with a follow-up pe- riod of at least 15 years were included in the analysis. The results show that implant survival rates do not exceedthoseofcompromisedbutadequatelytreated and maintained teeth. These findings support other studies comparing long-term survival of implants andnaturalteeth,9, 10 providinganimportantmessage: Periodontally compromised teeth can be retained withqualitytreatmentandappropriatemaintenance. Therefore, it may be advisable to postpone implant consideration for the periodontitis-susceptible pa- tient to fully utilize and extend the capacity of the natural dentition.11 Treatment planning options AkeyfocusoftheJointSymposiuminvolvedtreat- mentplanningdecisionsregardingendodontictreat- ment and implant therapy. Should a tooth with pul- paldiseaseberetainedwithrootcanaltreatmentand restoration,orbeextractedandreplacedwithanim- plant-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 consid- erable attention in the literature, the media and at dental continuing education courses. Endodontic treatment and implant therapy should not be viewed as competing alternatives, rather as complementarytreatmentoptionsfortheappropriate patientsituation(Figs.1a&b).Rootcanaltreatmentis indicated for restorable, periodontally sound teeth with pulpal and/or apical pathosis. Endodontic treat- ment on teeth with nonrestorable crowns or teeth withsevereperiodontalconditionsiscontraindicated, and other options such as implant placement should be considered.15 When making treatment decisions, the clinician should consider factors including out- comeassessment,localandsystemiccase-specificis- sues,costs,thepatient’sdesiresandneeds,aesthetics, potential adverse outcomes and ethical factors.16 Outcome assessment: Success and survival Treatment outcomes play a key role in the assess- ment of different treatment options. Patients often ask whether a procedure is going to be successful or not.Thisquestioncanbechallengingforaclinicianto answer due to the variety of reported outcomes in the literature.17 There are differences in the method- ology and criteria used to evaluate the outcomes for root canal treatment and implant prosthetics, which makescomparisonsbetweensuccessratesdifficult,if notimpossible.18 Endodonticstudieshavehistorically used “success” and “failure” as outcome measures and have focused on a strict combination of radio- graphicandclinicalcriteria.19 Incontrast,theimplant literaturehasprimarilyreported“survival,”20, 21 i.e.,the implantiseitherpresentorabsent.Therefore,implant studies that solely evaluate survival as an outcome measure will likely publish higher success rates than endodontic studies that rely on biologic healing and factors related to the entire restored tooth. To estab- lish more valid and less biased comparisons, the same outcome measures should be used. A more pa- tient-centered measure is to compare the outcome of survival, which is considered to be an asymptom- atic tooth/implant that is present and functioning in the patient’s mouth.22, 23 Table 1: Survival rates following initial nonsurgical root canal treatment. (Provided byAmericanAssociation of Endodontists) Fig.1a: Pre-op image of tooth #19 with pulp necrosis and symptomatic apical periodontitis.The patient is interested in rehabilitation of the edentulous space.(Images courtesy of AmericanAssociation of Endodontists) Fig.1b:Three-year recall image. The patient has benefited from both root canal treatment and implant therapy.(Courtesy of DrTyler Peterson and the University of Minnesota School of Dentistry) Survival rates following initial nonsurgical root canal treatment Author Number of teeth Follow-up (years) Survival (percent) Salehrabi and Rotstein (24) 1,463,936 8 97 Chen et al.(25) 1,557,547 5 93 Lazarski et al.(26) 44,613 3.5 94.4 Fig.1b 32016 Salehrabi and Rotstein (24) 1,463,936897 Chen et al.(25) 1,557,547593 Lazarski et al.(26) 44,6133.594.4