RCT VS IMPLANT.pptx

DENTAL

1. ROOT CANAL TREATMENT V/S IMPLANT DR MANJUSHA GOVIND IIIrd YEAR PG

2. INTRODUCTION OBJECTIVES OF ENDODONTIC TREATMENT IMPLANTS-INDICATIONS AND CONTRAINDICATIONS POTENTIAL RISKS OF OPTING FOR A ROOT CANAL OVER EXTRACTION AND IMPLANT POTENTIAL RISKS OF OPTING FOR AN IMPLANT DECISION MAKING: IMPLANT OR ROOT CANAL TREATMENT FACTORS INFLUENCING TREATMENT PLANNING SURVIVAL RATES PATIENT FACTORS DURATION OF TREATMENT ESTHETIC CONCERNS FINANCIAL STATUS CLINICIAN’S PROFICIENCY AND PREFERENCE RISK FACTORS AND/OR COMPLEXITY OF EACH TREATMENT MODALITY CONTENTS

3. DENTAL IMPLANTS VS. ROOT CANAL TREATMENT - SUCCESS RATES. OTHER FACTORS NEED TO BE CONSIDERED CONCLUSION REFERENCES

4. Introduction One of the goals of a successful traditional dental practice has been the preservation and rehabilitation of a patient’s natural dentition Endodontic treatment has played a key role in the retention and restoration of teeth affected by pulp and/or periapical pathosis .  Currently, the extraction of natural teeth has generally been considered undesirable and as a treatment choice of last resort when there are financial considerations and limited restorative options Clinicians frequently face the dilemma of whether to endodontically treat and retain a questionable tooth or to extract and potentially replace it with a dental implant. John et al., 2007 ;  Morris et al., 2009

5. • Relief of pain = symptom free • To render the affected tooth biologically acceptable and functioning without a diagnosable pathosis • Removal of pulp from root(s) of tooth • Disinfections of root and surrounding bone • Root canal treatment is an attempt to retain a tooth which may otherwise require extraction OBJECTIVES OF ENDODONTIC TREATMENT

6. INDICATIONS : For partially edentulous arches For single tooth replacement where fixed partial dentures cannot be placed . Patients who are unable to wear RPD. Patients desire . Patients who have adequate bone for the placement of implants. CONTRAINDICATION Presence of non treated or unsuccessfully treated periodontal disease Poor oral hygiene. Uncontrolled diabetes. Chronic steroid therapy . High dose irradiation. Smoking and alcohol abuse. IMPLANTS

7. THE TREATMENT IS LESS INVASIVE  ROOT CANAL MAY BE LESS EXPENSIVE R ECOVERY PERIOD IS SHORTER MAINTAIN YOUR ORIGINAL TOOTH PROCESS IS NEARLY PAINLESS AESTHETICS ARE STILL GREAT TOOTH WILL FUNCTION WELL IMPLANT WILL USUALLY LAST A LONG TIME Benefits of a Dental Implant Benefits of a RCT Potential risks of opting for a root canal over extraction and implant A root canal might weaken the tooth The tooth may fail Complications Can Lead to Tooth Loss Potential risks of opting for An implant Treatment Process Is More Invasive and Lengthy  Longer Recovery Period Root Canal vs Implant: Which Is Best? by  Fermelia Dental  | Jan 13, 2020

8. The main aim of both implant and endodontic therapies is to allow rehabilitation of the patient’s masticatory system DECISION MAKING: IMPLANT OR ROOT CANAL TREATMENT

9. There are different schools of thought on retention of natural tooth with endodontic treatment and conventional prosthodontic rehabilitation or to extract and replace it with an implant‑retained prosthesis . The argument favoring endodontic treatment relies on advances in the following factors: • Advances in instrumentation and materials • Greater predictability • Cost‑efficient compared to implants • More conservative and less invasive • Success rate is more compared to implants

10. In contrast , arguments favoring the implant placement focus on the following: • The poor outcomes of endodontic treatment when compared to implant “success” rates of over 90% • Concerns over the structural durability of a weakened endodontically treated tooth to support a coronal restoration • An implant fixture is seen as a better foundation for restorative dentistry than an endodontically treated tooth • Implant or root canal treatment: Clinical guidelines and decision making K Pradeep, H Rajesh1 , Prassanna Kumar Rao2 , Shashi Kanth Hedge3 , Harish Kumar Shetty

11. Factors influencing treatment planning Survival rates Patient factors Duration of treatment Esthetic concerns Financial status Clinician’s proficiency and preference Risk factors and/or complexity of each treatment modality An Important Dilemma in Treatment Planning: Implant or Endodontic Therapy? Funda Kont Cobankara and Sema Belli October 21st, 2010Reviewed: March 17th, 2011Published: August 29th, 201

12. SURVIVAL RATES Survival rates of endodontic treatment and implant placement are generally taken into account while choosing whether to extract or retain a compromised tooth. One of the primary reasons for the variability of reported outcomes is the inconsistent definition of success in the evaluation criteria . Success in endodontics is very different from success for implants. The endodontic studies have applied strict definitions of success based on clinical and/or radiographic criteria (i.e., absence of apical radiolucency, looseness, and reduction in size of radiolucency) ( Ng et al., 2007 )  while implant studies have considered an implant to be successful if it is functional and present in the mouth without definite signs of absolute failure , such as peri-implant radiolucency or implant mobility ( Doyle et al., 2006 )

13. Implant studies generally report procedures completed by specialists, while many endodontic studies involve work performed by students or general dentist ( Cheung, 2002 ;  Salehrabi & Rotstein 2004 ;  Alley et al., 2004 ;  White et al., 2006 ;  Cohn, 2005 ;  Trope, 2005 ). The average survival rate of teeth that are endodontically treated by a general dentist is ~89.7% after 5 years ; if the treatment is performed by a specialist , the survival rate increases to 98.1% ( Alley et al., 2004 )

14. PATIENT FACTORS   when designing a dental treatment plan, a patient’s expectations may bear more important than the clinical factors.   If an extraction is indicated for a tooth after the initial clinical examination, but the patient wants to save it, the decision can be made to save the tooth; however, the patient should be informed about the possible consequences and potential risks associated with this decision ( Avila et al., 2009 ). Other factors that should be considered include the dental history, the cultural implications of the tooth loss, and the quality of life that such treatment would produce ( Bader, 2001 ,  2002 ;  Tang & Naylor, 2005 ;  Torabinejad & Goodacre, 2006 ;  White et al., 2006 ;  Cohn, 2005 ;  Christensen, 2006 )

15.   PATIENT’S AGE : In young people, implants are contraindicated until the growth phase is completed because the fixture will ankylose, resulting in infraocclusion   However, endodontic treatment can be applied to patients in every age group the patient’s health condition is also an important factor when deciding between implant and endodontic therapy

16. Diabetes mellitus is often accompanied with systemic adverse sequelae, such as wound healing alterations, which may affect the osseointegration of dental implants or healing of periapical lesions. In one study, patients with diabetes showed a reduced likelihood of endodontic success, especially in cases with preoperative periradicular lesions ( Fouad & Burleson, 2003 )

17. Parafunctional habits of patients (such as bruxism) should also be addressed when choosing the appropriate treatment for patients ( Cohn, 2005 ;  Christensen, 2006 ). Because implants lack a periodontal ligament, they are at risk of damage from extreme mechanical forces developed as a result of parafunctional habits 

18. DURATION OF TREATMENT When the time for completion of treatment was evaluated as the time from the beginning of the treatment until time to function, implant treatment had a longer time-to-function than endodontic therapy ( Doyle et al., 2006 ).

19. ESTHETIC CONCERNS When the potential for esthetic acceptability appears to be questionable with the planned implants and restorative therapy or especially in instances where the esthetic outcome is extremely important for the patient, retention of the affected tooth may be a better choice It has been stated that esthetic failures in implant dentistry are known to outnumber mechanical failures, especially in the anterior dentition  Endodontics or implants? A review of decisive riteria and guidelines for single tooth restorations and full arch reconstructions N. U. Zitzmann, G. Krastl, H. Hecker, C. Walter & R. Weiger 2009

20. FINANCIAL STATUS The financial factor may influence the decision-making process for both clinicians and patients. An implant-supported crown costs about twice that of an endodontically treated tooth restored with a crown. From an economic standpoint, endodontic treatment might be a more favorable treatment option than implant-supported crowns

21. CLINICIAN’S PROFICIENCY AND PREFERENCE The decision to restore a diseased tooth with endodontic treatment or to extract the tooth and replace it with implant restoration might be influenced by the clinician’s proficiency and clinical background If a clinician believes that he/she is unable to save a tooth, tooth extraction and future prosthetic replacement will most likely be recommended 

22. RISK FACTORS AND/OR COMPLEXITY OF EACH TREATMENT MODALITY Treatment of a compromised tooth requires the consideration of   prosthodontic factors  such as the extent of caries, crown-root ratio, and dentinal wall thickness endodontic factors   including root canal anatomy, periapical pathology, cause of primary failure in cases of retreatment, and the presence of root resorption or root fracture periodontal factors  such as mobility and furcation problems

23. If the longevity of a conserved tooth as related to these factors is questionable, the extraction of the tooth may sometimes be a better alternative than leaving the tooth in the mouth. The type of restorations used for endodontically treated teeth and the quality of the coronal seal may have a greater impact on the long-term retention of treated teeth than the endodontic treatment itself

24. It should be considered that endodontically treated teeth are associated with less complications and procedural interventions than implant-supported crowns and that complications associated with implant failure significantly impact a patient more negatively than when endodontically treated teeth fail ( Morris et al., 2009 ). While making a decision as to whether to retain and restore or to replace a tooth, the restorative prognosis of the tooth and the physical loading characteristics that it will be endured must also be kept in mind.

25. Success criteria for root canal treated (RCT) teeth and implants. Endodontics or implants? A review of decisive riteria and guidelines for single tooth restorations and full arch reconstructions N. U. Zitzmann, G. Krastl, H. Hecker, C. Walter & R. Weiger 2009 SUCCESS CRITERIA FOR ROOT CANAL TREATED (RCT) TEETH AND IMPLANTS

26. Dental implants vs. root canal treatment - Success rates. Proving which of these two options is best is somewhat difficult. After all, if one treatment has been performed, it's impossible to know what the outcome of the other would have been. However, when the success rate of each alternative is considered independently, it's easier to come up with an answer. And, in general, dental research has shown that both treatment approaches can make an excellent choice.

27. What does dental research show? Endosseous implants versus non-surgical root canal therapy: A systematic review of the literature." ( Blicher 2018) This paper reviewed published research studies that either ... Evaluated the survival rate of teeth that had received root canal treatment. Or evaluated the success or failure of dental implant placement. Its findings were ... The success rate for root canal treatment ranged between 92 and 97% (over a time frame of four to eight years) The success rate for dental implants ranged between 95 and 99% (over a time frame of two to six years). These results suggest that  the overall success rate of either treatment approach is fairly similar

28. what are the differences in outcomes of restored endodontically treated teeth compared to implant-supported restorations?" (Iqbal 2017) This study, which was also a literature review, took into consideration 55 research papers evaluating dental implants and 13 root canal treatment. It came to the conclusion that  no significant differences in survival rates  existed between the two approaches. It continued by stating that the decision for implant placement or root canal therapy (including the placement of an appropriate dental restoration afterward) needs to be based on factors other than just the statistical analysis of predicted treatment outcome. In combination, the findings of both the Blicher and Iqbal literature reviews suggest that  both treatment options can provide a successful outcome . Iqbal M, Kim S. What are the differences in outcomes of restored endodontically treated teeth compared to implant-supported restorations. Int J Oral Maxillofac Implants. 2017;22(Suppl):96-116.

29. If the success rates are similar, what other factors need to be considered? The fact that either root canal treatment or the placement of a dental implant can be expected to provide an excellent end result suggests that the decision between the two will need to hinge on other factors. These include: Case selection .  (How closely the patient's pre-treatment situation conforms to the ideal Issues associated with specific patient  characteristics, habits or concerns . Overall  treatment cost  or  expected cost-effectiveness . This is an important factor because completing full treatment is a necessary part of insuring a procedure's expected success ( especially root canal ).

30. DIABETES Diabetic patients in both endodontic and implant group had more failure when compared with non diabetic patients SOCIOECONOMIC STATUS Patients from higher socioeconomic group received implant therapy (>2.4 times)than from lower SES group AGE Older patients- higher risk of Implant and RCT failures REGION OF INTEREST Patients who had done implant in maxillary and mandibular posterior tooth had more failures than RCT done in same location. SMOKING Smokers in endodontic group have less failure than implant group .Similarly in endodontic and implant groups smokers had more failure than non smokers .

31. AUTHOR YEAR SAMPLE FACTOR DISCUSSED INFERENCE Reese Ryan et al 2015 n= 4084 RCT-3442 IMPLANT-642 AGE Treatment preferred by patient aged 19-46 years –RCT >47 years - IMPLANT Reese Ryan et al 2015 n= 4084 RCT-3442 IMPLANT-642 SOCIOECONOMIC STATUS Treatment preferred by patient High socioeconomic status-IMPLANT Low socioeconomic status -RCT Doyle scott et al 2006 RCT –196 IMPLANT-196 REGION OF INTEREST Outcome based on region of interest RCT – Not dependent on tooth location IMPLANT placed in posterior tooth had more failure Doyle scott et al 2007 RCT –196 IMPLANT-196 SMOKING Treatment outcome in smokers RCT – Less failure (19.2%) IMPLANT- More failure (27.1%)

32. Are there more complications in implants? (Doyle, et al., 2016), reported that dental implants had a 5 x greater number of complications compared to restored RCT teeth. Do outcome assessments reflect technology in evolution? Evidence that with new technology, advancement in electronic apex locators, operating microscopes & materials such as therma - fill,gutta -percha core and MTA, these all have improved the safety and accuracy of RCT. ( Toskos & DiBernardo , 2013) If apical periodontitis persists or develops after root canal treatment then what treatment procedure should be recommended? Reported radiographic success rates of studies with modern microscopic surgical endodontic procedures often are greater than 90%. ( Stoumza , 2015)

33. Is RCT preferred in patients with poor quality of bone ? Quality of bone is an important consideration when treatment planning for implants ( Mombelli & Cionca , 2016). (Christensen, 2016), advised that if bone density/area is problematic or there are anatomical structures present, then RCT should be considered.

34. Bone healing around modern implants follows established sequence of events and results in predictable osseointegration. In a healing bone wound, fibroblast-like osteogenic progenitor cells differentiate into osteoblasts and start to deposit woven bone that gradually grows towards the implant surface. Wound healing around dental implants Cristina C. Villar , Guy Huynh- Ba , Michael P. Mills , David L. Cochran Wound healing around dental implants During 1–3 months of healing, this woven bone is replaced by lamellar bone with increasing bone to implant contact that allows functional loading of the implant.

35. As a clinical application, implant stability is initially decreased up to three weeks due to bone remodeling and followed by an increase to the baseline at 4–5 weeks and then reaching plateau in 8 weeks. Regardless of this remodeling, studies have shown that implants can be successfully loaded immediately after placement although with somewhat reduced survival rates. Development of new implant surfaces has played a critical role in expanding these clinical loading protocols.

36. Conclusion Patient’s preference is of fundamental importance. Some patients prefer not to have extractions at all costs while others avoid high-risk treatments and prefer low risk options. It is the dentists responsibility to involve them in treatment planning by explaining the prognosis of keeping the tooth, costs of treatment and other treatment options to the patients from a professional point of view

37. Robbins and Cotran . Pathologic Basis of Disease. 7th ed. Philadelphia, Elsevier Saunders; 2007: 61-78.  Harsh Mohan. Essential pathology for dental students. 2nd ed. New Delhi, Jaypee; 2002: 126-134.  Das. Concise textbook of surgery. 3rd ed. Calcutta, Dr.S.Das publishers; 2002: 1-7.  Newman MG,Takei HH, Klokkevold PR, Carranza FA. Clinical Periodontology. 10th ed. Missouri: Saunders; 2009: 912, 914-915, 935-936, 960, 1010-1011.  Journal of Burns andWounds (http:/ / www. ncbi . nlm . nih . gov/ pmc / journals/ 211/ ) Villar CC, Huynh‐Ba G, Mills MP, Cochran DL. Wound healing around dental implants. Endodontic Topics. 2011 Sep;25(1):44-62. Ricucci D, Lin LM, Spångberg LS. Wound healing of apical tissues after root canal therapy: a long-term clinical, radiographic, and histopathologic observation study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009 Oct 1;108(4):609-21. REFERENCES

38. Setzer FC, Kim S. Comparison of long-term survival of implants and endodontically treated teeth. Journal of dental research. 2014 Jan;93(1):19-26. Alrahabi M, Ghabbani H, Alnazzawi AA, Zafar MS, Khurshid Z. Root canal treatment versus single-tooth implant. InDental Implants 2020 Jan 1 (pp. 37-48). Woodhead Publishing. Sarkis-Onofre R, Marchini L, Spazzin AO, Santos MB. Randomized controlled trials in implant dentistry: assessment of the last 20 years of contribution and research network analysis. Journal of Oral Implantology. 2019 Aug;45(4):327-33. Uehara PN, Matsubara VH, Igai F, Sesma N, Mukai MK, Araujo MG. Short dental implants (≤ 7mm) versus longer implants in augmented bone area: a meta-analysis of randomized controlled trials. The open dentistry journal. 2018;12:354.

39. THANK YOU