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Question: Now that both specialties of prosthodontics and endodontics are teaching implant placement in postgraduate programs, what effect will this have on treatment recommendations?
There is a continuing downward trend for endodontic and prosthodontic treatments. As a result—and perhaps a cause— of requirements for implant placement training in their specialty graduate training programs, future prosthodontic and endodontic treatment recommendations will change.
Prosthodontists will recommend endodontic treatment less frequently for teeth difficult to restore or have a poorer prognosis, eg, crown lengthening plus endodontics, difficult-to-negotiate canals, retreatment of failed endodontics, and removable or fixed abutments. These teeth will more likely be recommended for extraction and implant placement.
Crowned abutments for either fixed or removable prosthodontics have about a 1% chance per year of endodontics and/or decay around crown margins. Thus, implant-supported restorations for missing teeth will be suggested whenever possible. In many schools, implants rather than fixed or removable partial prosthodontics is the standard of care.
Both endodontists and prosthodontists will be inclined to suggest immediate placement of implants with grafting to save buccal plates to enhance or optimize esthetics.
Trust in implant placement expertise will be key for generalist referrals. Generalists who trust their endodontist may refer to him/her for extraction and immediate placement as long as they feel their patients will most likely return to their practice for restoration. Yet if prosthodontists market themselves as experts in implant placement for esthetics and occlusion, generalists may feel more inclined to them. Increased competition between all specialties also will drive research on surface nano-textures, techniques, genetic research on stem cell morphogenesis, and implant attachment mechanisms.
Certainly, more competition will result in better communication by all specialties to both patient and generalist, and this can only benefit patients.
The hope in any treatment recommendation is to do what is best for the patient. It is always the role of the doctor to educate the patient. Prognosis, cost, alternatives, invasiveness, and duration of care all must be explained to the patient to help them to choose the best treatment options. If endodontic treatment is indicated with a slim chance of long-term success, the patient should know. Some patients may want to explore all avenues to preserve their natural teeth. Some would not risk the treatment costs for a limited chance of success and would rather move on to the next option. Endodontists are often in an excellent position to help a patient with decisions on the logic of saving a tooth or seeking other options.
The restorative phase of an implant is heavily influenced by the surgical placement of the implant in the bone. The most stressful restorative cases are always those when the patient walks in the door with an implant fully integrated and uncovered, because the restorative options become limited. The most predictable outcomes are usually the result of proper pre-restorative planning to help guide the placement of the implant within the bone. As most prosthodontists would be restoring their own placed implants, this relationship certainly would be logical.
For any general dentist, the relationship with a specialist and the ability to communicate with them is paramount. It does not matter who is placing the implant as long as the standard of care is followed. It is the responsibility of the general practitioner to lead the team and communicate the final restorative outcome. The general practitioner must choose whom to refer based on the ability of those involved to contribute experience, and the ability to positively influence the outcome.
Whether the teaching of implant dentistry in both endodontic and prosthodontic postdoctoral programs has a positive or a negative impact on patient care and treatment recommendations remains to be seen; however, one thing is certain and that is that the addition of an established treatment option to both specialties can only be a positive development for patients with non-salvageable teeth. Clearly, the use and abuse of treatment recommendations by healthcare providers will continue to depend on each operator’s personal ethical standard, and the final recommendation will depend on the operator’s knowledge and experience in his or her field as well as his or her knowledge of the other specialist’s field. Despite this knowledge, however, interdisciplinary consultation is still required for the best case outcome. This may indicate that a prosthodontist who is well trained in implant dentistry but not endodontic therapy should consider adding an endodontic consultation to the mix for determining the endodontic prognosis of a tooth, just as an endodontist planning an implant should have a restorative consultation with the prosthodontist or the patient’s restorative dentist prior to placing the fixture. I believe that as long as each specialist recognizes that the expertise and knowledge of the other is required for the best treatment recommendation in treatment planning implant vs endodontic cases, the patient’s interest is served. I do hope that the addition of this procedure to both specialists’ repertoire will not cause indiscriminate tooth removal and implant placement. The tenet of preserving our own biological tissues has been the profession’s axiom for many years and should not be sacrificed so readily in the absence of consensus. We spent the past century educating patients to save their teeth and should not undo this effort for the sake of expediency of a given procedure or the lure of an improved bottom line.
About the Authors
Robert Chapman, DMD
Dr. Chapman is professor emeritus and former chair of the Department of Prosthodontics and Operative Dentistry at Tufts University School of Dental Medicine.
Leonard A. Hess, DDS
Dr. Hess is an associate faculty member of The Dawson Academy and has a private practice in Monroe, North Carolina.
Allen Ali Nasseh, DDS, MMSc
Dr. Nasseh is a clinical instructor and lecturer at the postdoctoral endodontic program at Harvard School of Dental Medicine and has a private practice in microsurgical endodontics in Boston, Massachusetts.