Should Endodontic Residency Programs Be Teaching Implant Placement?

Allen Ali Nasseh, DDS, MMSc | John West, DDS, MSD | Rich Mounce, DDS

Allen Ali Nasseh, DDS, MMSc is a practicing endodontist and the founder of MicroSurgical Endodontics (MSEndo) in Boston, Massachusetts. He is also a clinical instructor in the Department of Restorative Dentistry and Biomaterial Sciences/postdoctoral endodontic division of Harvard School of Dental Medicine.

John West, DDS, MSD is the founder and director of the Center for Endodontics in Tacoma, Washington. He is also an affiliate associate professor at the University of Washington. Dr. West has presented unrivaled endodontic continuing education in North America, South America, Europe, and Asia.

Rich Mounce, DDS owns MounceEndo.com, an endodontic instrument and supply company based in Neskowin, Oregon. He has lectured and written globally about endodontics.

Allen Ali Nasseh, DDS, MMSc: Since its inception, the endodontic field has focused on saving teeth, however, over the past two decades, because of the excesses of implant dentistry in promoting implants at the expense of saving teeth, many endodontists have witnessed perfectly salvageable teeth meet their early demise as a result of inappropriate treatment planning. During this time, treatment planning of a compromised tooth has sometimes bypassed consultation with a qualified endodontic specialist. Endodontists now contend that questionable teeth recommended for extraction and implant placement—instead of root canal therapy—should have a consultation not only by an implant surgeon, but also with an endodontist prior to extraction.

The absence of a balanced assessment of salvageability prior to extraction has caused many teeth to be replaced with implants prematurely. Each patient deserves a full understanding of risks versus benefits of all treatment alternatives. This is why many endodontists believe that the endodontic residency programs should provide adequate implant training to endodontists to be able to provide an informed and balanced consultation for implant placement and root canal therapy. Such unbiased opinion regarding the fate of a compromised tooth can only benefit the patient.

Furthermore, endodontists may choose to place implants in special cases where a fracture discovered mi d-endodontic treatment has rendered a previously savable tooth unsalvageable. However, the main goal of endodontic residencies that choose to train residents for implant placement should be to provide a better understanding of treatment planning and outcome assessment of a potential site for implant therapy versus root canal therapy.

Endodontists are currently trained only for endodontic outcome assessment. This is why they also need firsthand experience with implant placement, and the potential challenges and complications it poses, in order to fully understand the risks versus benefits of this treatment modality. It’s only with a full clinical understanding of treatment alternatives that any specialist is qualified to provide an unbiased and appropriate recommendation about the fate of a compromised tooth that would conform to the long-term interest of the patient facing this difficult decision.

John West, DDS, MSD: My answer is a resounding yes. Why? The key question in any dental treatment planning is to save or not to save a tooth. How do you decide? How does any interdisciplinary dentist decide? Everyone knows the old adage, “when you only have a hammer, you fix everything with a hammer.” If an endodontist only truly knows how to save an endodontically diseased tooth through endodontics, then endodontics is always the solution. Actually, the biggest benefit of an implant trained endodontist to the patient is that he or she is not only an interdisciplinary dental thinker but also an interdisciplinary clinician.

The endodontist must know the advantages and disadvantages of an implant in the esthetic zone to weigh restore versus remove and, if removed, how to best replace—implant or fixed bridge? The only way to truly know is to do. By being trained in dental implantology, the endodontist can make the decision in the esthetic zone and provide the implant skill to proceed without the patient having multiple specialists. In my experience as an endodontist, patients begin to feel torn apart and disillusioned when they have a dentist, a periodontist, and an endodontist. This approach is more efficient and predictable for the patient because there is no biological interruption of care and treatment sequence.

Why not? There are 56 endodontic graduate schools in the United States and Canada. Only two—Loma Linda and NYU—are known to teach implant placement at the time of this writing. But the single biggest problem is we have no qualified teachers to teach predictable implant placement. In many graduate schools, implants are confined to other disciplines such as the periodontics or oral surgery departments. There is a territorial challenge to overcome. Finally, while I believe there is enough time in existing endodontic resident curriculums to teach implant placement, again there are no teachers. Until then, the answer to the lead question is yes but the territorial domains and lack of resources say no.

Whether school trained or trained after residency, the endodontist of the future, in my opinion, will place implants and become an even more important resource to and for the interdisciplinary process.

Rich Mounce, DDS: Absolutely yes is the short answer. Endodontists love finding canals, gaining patency, and seeing lateral canals pop out of final x-rays after world class cleaning and shaping. In essence, by and large, we eat, drink, and sleep endodontics. We are passionate about it. This said, to not be conversant in implants is to put our collective heads in the sand.

We are in a turf war for the philosophical underpinnings of dentistry, specifically if saving teeth through world-class endodontics is preferable to extraction and implants. More specifically, the periodontists and oral surgeons by and large are uninformed as to the full range of possibilities for saving teeth that modern endodontic treatment offers, and are far to quick to pick up a forceps. If it looks like a nail, they have a hammer.

With the greatest respect, from my personal viewpoint, the prevailing reasons for this rush to mass tooth extinction is economic. After 25 years as an endodontist, I can count on one hand how many cases periodontists and oral surgeons have sent me for retreatment and tooth retention.

Besides that, whenever I’ve broached the subject of advances in endodontics with periodontists and oral surgeons, I might as well have been talking to the wall. They know what they know and can’t be persuaded that perhaps we have advanced beyond the K-file and lateral condensation circa 1965.

While training endodontic residents on implant placement is not directly an answer to this situation, if it was my wife, in 2016, I would rather she see an endodontist first in any given clinical situation relative to an oral surgeon who sees a non-vital tooth and lesion and arbitrarily extracts the tooth prior to the implant, or a periodontist, while referencing out of date and cherry picked literature, who sees a predictably retreatable tooth and removes it, all the while telling the patient that their implant is more predictable than the retreatment. Viva la’ Endo!