Treatment Planning the Endodontically- Involved Tooth
Unbiased communication is key to shared decision-making
Brooke Blicher, DMD
Historically, patients have relied on their dentist to unilaterally make treatment decisions on their behalf. In the current age of shared decision-making and patient autonomy,1 however, clinicians must diagnose dental disease and present treatment alternatives to their patients in as unbiased a way as possible. Neither the provider’s own preferences or abilities nor the availability of specialists for referral should influence treatment recommendations.
This maxim holds true in the diagnosis and treatment of endodontic disease. Guiding patients through the choice of whether to save a diseased tooth requiring endodontic treatment or to extract the tooth and pursue replacement options is inherent to the practice of dentistry. Furthermore, proper informed consent hinges on accurate communication of the expectations, risks, and benefits of each option.
In cases requiring endodontic treatment to save the tooth, each patient and each tooth must be considered uniquely. The American Association of Endodontists2 recommends thoughtful consideration of the tooth’s restorability, quality of adjacent bone, esthetic demands, cost-benefit ratio, and systemic factors when determining whether to save or extract a tooth, as well as in considering tooth replacement—either with implants or fixed partial dentures (FPDs) (Figure 1).
Restorative Factors
Most teeth requiring endodontic treatment have some degree of restorative compromise, due to either decay or fracture. These structural losses can negatively impact both the biologic width and ferrule, resulting in early failures of endodontically-treated teeth as a result of periodontal compromise or root fracture. Accordingly, the clinician must assess remaining tooth structure when determining whether to maintain or extract a compromised tooth. Maintenance of an appropriate biologic width between the restorative margin and bone—including the combined gingival sulcus depth, epithelial attachment depth, and connective tissue attachment—is necessary to prevent periodontal inflammation and bone loss.3 Furthermore, an adequate ferrule, defined as the circumferential collar of the crown surrounding the parallel walls of the dentin extending coronally from the shoulder of the preparation,4 provides the necessary retention and resistance to reduce the risk of fracture of endodontically-treated teeth. Because these restorative factors can so significantly affect treatment outcomes, their potential impact must be communicated to patients.
When considering extraction of teeth with replacement by either a dental implant or FPD, the biology of the bone and surrounding periodontium are key factors. Patient-centered issues, such as coexisting oral disease, medical conditions, and medications, can limit options. For example, patients with a history of bisphosphonate use may need to avoid invasive procedures like extractions and implant placement due to the risk of bisphosphonate-related osteonecrosis of the jaw (BRONJ)5 (Figure 2 through Figure 5). Smoking and systemic conditions, such as diabetes, may affect success rates of both endodontically-treated teeth and dental implants.6
Nonbiologic factors play an equally important role when determining whether or not to retain an endodontically-involved tooth. Patients must commit to appropriate restorative care in a timely fashion following endodontic therapy. Permanently restored teeth are significantly less likely to fail than those maintained in temporary restorations.7
Statistical Outcomes
Two factors that differ little between tooth maintenance with endodontic treatment and implant placement are statistical outcomes and patient satisfaction with treatment choices. Endodontic treatment itself offers outcomes similar to implant placement. A systematic review8 found no differences in survival between root canal therapy and implant-retained restorations. Both options offered patients a success rate of 96% in a long-term study. Conversely, a systematic review found success rates for FPDs of 71% at 10 years.9
Just as outcomes differ little between endodontically-treated teeth and implants, patient satisfaction is also similar. High satisfaction is reported for both root canal therapy and implant placement.10 However, certain patients’ past experiences and personal biases may affect treatment choices. Both treating an endodontically-involved tooth and placing dental implants involves a high financial burden, but a variety of factors—including the ability to delay certain portions of implants or insurance reimbursements—can ultimately sway a decision.
Helping Patients Choose
The principle of patient autonomy should guide all aspects of dentistry, particularly when helping patients choose whether to save a tooth with root canal therapy and restoration (Figure 6) or to pursue extraction of the tooth with or without replacement (Figure 7). Furthermore, the alternative treatment choices of doing nothing and leaving the diseased tooth in place or extracting the tooth without a fixed replacement—along with the risks and benefits associated with each option—must always be presented to the patient.
As the American Dental Association Code of Ethics1 specifies, all treatment should be done “according to the patient’s desires, within the bounds of accepted treatment.” Thoughtful consideration of all factors germane to treatment course and outcomes, and thorough communication of these factors to patients, allows the team of patient and practitioner to confidently proceed with appropriate dental care.
About the Author
Brooke Blicher, DMD
Assistant Clinical Professor
Department of Endodontics
Tufts University School of Dental Medicine
Boston, Massachusetts
Clinical Instructor, Department of Restorative Dentistry and Biomaterials Science
Harvard School of Dental Medicine
Boston, Massachusetts
Instructor in Surgery
Dartmouth Medical School
Hanover, New Hampshire
Private Practice
White River Junction, Vermont
References
1. American Dental Association. Principles of Ethics and Code of Professional Conduct. With official advisory opinions revised to April 2012. Chicago, IL: https://www.ada.org/~/media/ADA/About%20the%20ADA/Files/code_of_ethics_2012.ashx. Accessed January 24, 2016.
2. American Association of Endodontists. AAE Position Statement 2007. Implants. Chicago, IL: https://www. aae.org/uploadedfiles/publications_and_research/guidelines_and_position_statements/implantsstatement.pdf. Accessed January 24, 2016.
3. Gargiulo A, Krajewski J, Gargiulo M. Defining biologic width in crown lengthening. CDS Rev. 1995;88 (5):20-23.
4. Juloski J, Radovic I, Goracci C, et al. Ferrule effect: a literature review. J Endod. 2012;38(1):11-19.
5. Katz H. Endodontic implications of bisphosphonate-associated osteonecrosis of the jaws: a report of three cases. J Endod. 2005;31(11):831-834.
6. Doyle SL, Hodges JS, Pesun IJ, et al. Factors affecting outcomes for single-tooth implants and endodontic restorations. J Endod. 2007;33(4):399-402.
7. Chugal NM, Clive JM, Spångberg LS. Endodontic treatment outcome: effect of the permanent restoration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104(4):576-582.
8. Iqbal MK, Kim S. For teeth requiring endodontic treatment, what are the differences in outcomes of restored endodontically treated teeth compared to implant-supported restorations? Int J Oral Maxillofac Implants. 2007;22 suppl:96-116.
9. Pjetursson BE, Tan K, Lang NP, et al. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Clin Oral Implants Res. 2004;15 (6):667-676.
10. Gatten DL, Riedy CA, Hong SK, et al. Quality of life of endodontically treated versus implant treated patients: a University-based qualitative research study. J Endod. 2011;37(7):903-909.
