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).
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
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.