Colleagues for Excellence

PUBLISHED FOR THE DENTAL PROFESSIONAL COMMUNITY BY THE AMERICAN ASSOCIATION OF ENDODONTISTS Fall/Winter 2003

Its Role in Retaining Our Patients’ Natural Dentition

Welcome to ENDODONTICS: Colleagues for Excellence…the newsletter covering the latest in endodontic treatment,
research and technology. We hope you enjoy our coverage on the full scope of options available for patients through endodontic
treatment and conventional prosthodontics, and that you find this information valuable in your practice. Future issues of
ENDODONTICS will keep you up to date on the state of the art and science in endodontic treatment.

T he dental profession’s most important goal is to maintain the

health and integrity of patients’ dentition through prevention
movement during functions, the ability to withstand the normal
forces of mastication, arch and soft tissue continuity, and overall
and, when necessary, reconstructive treatment. Throughout the esthetics are but a few benefits of retention. These benefits are
last decade, dentistry witnessed a biomechanical revolution in especially true when there are sufficient amounts of sound
endodontics. This revolution provided the public with treatment dentin available for the rehabilitation of teeth through the use of
options never before available to them. sophisticated and technologically proven restorations and
restorative materials. Techniques of crown lengthening and
Endodontic treatment and retreatment, as well as diagnosis and
tooth rebuilding are reliable, predictable and expeditious in the
endodontic surgery, achieve new levels of success and
presence of a sound and stable periodontium.
predictability. The development of nickel-titanium files, coupled
with improvements in devices, such as the apex locator and the One of the major advantages of employing endodontics with
incorporation of microscopy and microsurgical instruments, fixed and removable prosthetics is the rapid return of patients’
created a whole new paradigm in treatment. These advances compromised dentitions to full function and esthetics. This
place endodontic care at the forefront as the primary treatment rapid return is in contrast to a more extended treatment
of choice for tooth retention when the dental pulp is protocol employing implants with the use of provisional
compromised or when the removal of the dental pulp would restorations, while waiting for osseous integration. The
facilitate other reconstructive dental treatment. endodontic-restorative continuum is a treatment modality that
usually minimizes time spent in treatment and presents a cost-
The purpose of this issue of ENDODONTICS: Colleagues for
effective approach to optimal treatment.
Excellence is to provide clinicians with an appreciation of the
full scope of options available for their patients through The advent of dental implants presents treatment options that
endodontic treatment and conventional prosthodontics. When practitioners have not been able to attain in the past. However,
teeth cannot be successfully treated endodontically, research on the long-term efficacy and success of dental
conventional prosthetic restorations, i.e., crowns, bridges and implants is still ongoing. Practitioners should have a
implants, are one of the significant alternative treatment plans comprehensive understanding of the needs of patients and a full
for patients who can no longer retain their natural dentition. appreciation of what endodontic therapy and dental implants
Dental health care providers should accurately educate the bring as modern dental therapies. Patients should be fully
public on the value of retaining natural dentition and allay educated so they understand the benefits and drawbacks of all
concerns when root canal treatment is not a viable option. treatment plans presented, as well as the length of treatment,
projected outcomes and cost considerations.
Patients find tremendous value in retaining their natural
dentition. Continued proprioception and normal physiological
 Treatment Choices and Outcomes Assessment of Teeth for Possible Removal
Modern endodontics provides a greatly increased scope and Artificial Replacement
of treatment modalities available to the dental Tooth retention decisions involving poor prognoses
practitioner. Endodontic treatment options now offer usually include the following considerations:
patients a wide range of choices for tooth retention.
• Need to manage a compromised dental pulp in the
These plans include initial nonsurgical root canal
presence of severe periodontal disease, deep carious
treatment and retreatment; surgical intervention such as
or fractured tooth margins;
periradicular surgery, perforation repairs, root or tooth
resections with the retention of viable and sound root • Ability of a particular tooth or teeth to serve as
structures; root submergence for ridge stability; and abutments for fixed or removable prostheses if
intentional replantation or autotransplantation. treated endodontically;
Practitioners are able to manage the challenges of • Quality of prior endodontic treatment and the ability
various types of root resorption predictably, whether to retreat/perform surgery and retain;
iatrogenic or secondary to trauma, thereby retaining a • Ability to repair or salvage roots/teeth with iatrogenic
sound dentition. Adjunctive services of significant value defects; and/or
that enhance tooth retention include root/tooth
extrusion and crown lengthening. The test of time still • Presence of teeth with suspected cracks or fractures.
advocates that the best “implant” is a natural root. Some of these situations present insurmountable
Studies and research have consistently shown that even obstacles to successful endodontic treatment. In these
outstanding root canal treatment will not be successful situations, practitioners should advise patients about
when covered by a leaking coronal restoration. A extraction. Patients have several good options available
higher level of tooth retention results only when there is for tooth replacement when extraction is the treatment
excellent synergy between the restorative and of choice. Both the endodontist and the referring dentist
endodontic treatments. With a commitment from should explain these options to patients to facilitate
patients to a daily regimen of home care that promotes informed choices. At this point, it may be necessary to
a healthy and sound periodontium, teeth can be refer these patients to other specialists, i.e.,
retained many years in symptom-free function at a 90 periodontists, prosthodontists or orthodontists, to meet
percent or greater level of success. Without a natural the unique needs of the clinical situation presented.
periodontal ligament, this challenge to the patient Treatment Options When a Tooth Cannot be
escalates dramatically. Retained
The literature strongly suggests that persistent The following options should be considered in the
intraradicular or secondary infections, and in some treatment planning process when endodontic,
cases extraradicular infections, are the major causes of periodontal and restorative treatments cannot be used
failure in both poorly and well-treated root canals. to retain a natural tooth:
Some patients may not heal even with meticulous and • Replacement with a tooth-supported, fixed prosthesis
conscientious endodontic treatment, often for unknown (fixed partial denture);
reasons. Practitioners can offer these patients a
• Replacement with a removable prosthesis or
multitude of treatment options, such as nonsurgical
modification of an existing prosthesis (removable
retreatment or surgical intervention, or in more
partial denture);
compromised cases, intentional replantation or
autotransplantation. The literature also supports • Replacement with an implant-supported prosthesis
retreatment of these cases when periradicular (crown/fixed partial denture);
radiolucencies and clinical signs and/or symptoms are • Replacement by transplanting a nonfunctional
present. Subsequent survival rates are over 90 percent. (impacted) third molar tooth;
Tooth retention in conjunction with conventional • Orthodontic movement to reposition teeth; or
prosthetics, as opposed to an extraction in favor of a • No replacement, as in the case of a second or third
conventional/implant-supported prosthetic replacement, molar where there is no opposing dentition.
is still a desirable goal. Teeth that may be perceived as
“endodontic failures” or that lack healing can still be The prognosis for tooth replacement with the listed
saved. Practitioners and their patients can benefit from a options varies significantly within the treatment plan
team approach to determine the cause of refractory and the status of the remaining dentition. For example,
endodontic cases and to provide successful treatment. placement of a fixed prosthesis will require preparation

2 ENDODONTICS: Colleagues for Excellence

 of the adjacent teeth. Conventional prosthetics offer 1990s, the terms “success” and “failure” were in vogue
clinicians many conservative choices to conserve tooth with endodontic treatment. Now choices include
structure, a removable prosthesis, etched retained fixed “healed,” “tendency to heal,” “not healed” and
partial dentures, partial veneer prosthesis, etc. Before “regression,” because patients can relate to the process
initiating treatment, practitioners should evaluate the of disease, treatment and healing. However, mere
pulpal status of each tooth serving as an abutment. changes on a radiograph cannot determine the extent of
the periradicular healing process. The absence of
Alternative treatment choices such as an implant can
clinical signs and symptoms is not an accurate
create challenges for both practitioners and their
barometer for healing. Regrettably, this concept is used
patients. Implants can fail biologically, functionally or
on a global basis for case assessment and determination
iatrogenically, and may require pretreatment sinus lift or
of further treatment or no treatment at all.
ridge augmentation to alter ridges that are too narrow
or have insufficient bulk to support an implant. Another An assessment of past “success-failure” studies in
important cause for concern is the possible loss of endodontics is difficult because of multiple variables.
proprioception. Additional complications to choosing an These studies have erroneously included failures due to

Fig 1: A preoperative radiograph shows presence of a Fig 2: An immediate postoperative radiograph of the tooth Fig 3: A postoperative radiograph six months later demon-
periradicular pathosis in the mandibular left second molar. following root canal therapy. strates periradicular healing following successful root
A dentist initially recommended extraction and replace- canal treatment.
ment of this tooth with an implant. The patient requested a
second opinion from an endodontist who found the tooth
to be treatable.

implant may include pain or sensitivity, mobility or periodontal disease, root fractures, inappropriate
periodontal disease that affects the implant. Implants restorations and the presence of coronal leakage.
and conventionally restored natural teeth share many of These are not endodontic failures. Historically and
the same post-treatment complications, including pain contemporarily, without substantiation, endodontically
or sensitivity, mobility and periodontal disease. Implants treated teeth have been considered “weak links” in the
have a unique complication—the loss of proprioception restorative-periodontal continuum.
leading to occlusal over-load complications.
However, contemporary scientific studies on the structure
If circumstances for a transplant were optimal, a of dentin and the impact of endodontic procedures do not
surgical extraction may be indicated with an support these beliefs. The key is to combine endodontic
accompanying surgical preparation of the recipient site. and prosthodontic treatment to retain the greatest amount
Finally, with some patients, replacement of the tooth is of sound dentin. When the studies are considered “en
not an option for various reasons, and treating dentists masse,” endodontic treatment results in more than a 90
should recognize and respect this option. All treatment percent success rate when microbial challenges are
possibilities, including no treatment, should be eliminated through thorough canal cleaning, shaping and
explained to patients objectively, with the option to seek three-dimensional obturation; coronal leakage is negated
additional opinions from other experts. through proper, sound restorations; and the patient
practices preventive oral self care. Outcomes following
Risk Assessment of Tooth Retention Versus more contemporary treatment modalities and
Removal and Replacement incorporating biologically based parameters of care are
Parameters for assessing the outcomes for the entire
presently being determined to provide further predictable
range of endodontic treatment have been limited
directives for the practitioner.
primarily to clinical and radiographic criteria. Until the

ENDODONTICS: Colleagues for Excellence 3

ENDODONTICS: Colleagues for Excellence

Endodontic treatment and tooth retention, especially when Multiple, lengthy visits are required, along with longer
endodontic treatment and reconstructive dentistry are healing periods and increased costs that are not likely
indicated, should be selected. By not choosing this option, borne by third-party insurers. Most importantly, no
the patient can incur an increased potential for dental consensus exists on what constitutes implant survival
complications, further damage to oral tissues, a significant versus true success, and many studies that extol high
time without full function, a less than satisfactory outcome rates of success can be misleading.
and increased costs. The 10-year survival rate for
Currently, there is a lack of prospective, randomized
conventional prosthodontic treatment and those teeth
clinical trials in all areas of dentistry, including tooth
treated endodontically are the same. Removable
retention incorporating endodontic services versus
prostheses have a significantly poorer prognosis for the
tooth removal and replacement by various means.
abutment teeth adjacent to the edentulous space.
Direct comparison of tooth retention rates versus tooth
While survival rates are comparable to endodontic replacement rates with any type of restorative modality
treatment with the placement of some types of implants, would essentially be comparing “apples to oranges.”
these rates are not true for all designs and all areas of
Patients would benefit from practitioners considering
the mouth. Complications associated with the placement
the entire range of available treatment options. These
of implants rarely exist with quality endodontic services.
options should be based on sound biological principles
However, potential complications could include:
and individually tailored treatment plans that consider
• paresthesia (numbness); patients’ best interests and preferences, and deliver the
• mechanical trauma to bone and bone loss; quality of care that will result in the highest level of
success for the patients.
• perforations of or intrusions into vital anatomical
structures; Because many important and integrated concepts have
• infections; been addressed in this issue of ENDODONTICS:
Colleagues for Excellence, the AAE encourages readers
• implant and superstructure breakage; to review the enclosed reading list to obtain further
• inappropriate placement and inability to restore; information or support for the clinical and evaluative
parameters regarding the importance of tooth reten-
• premature loading followed by lack of
tion, outcomes, rationale for choices and alternative
healing/integration and implant mobility; and/or
considerations in the maintenance of arch integrity
• loss of proprioception. for the patient.

The AAE Public and Professional Affairs Committee, and the Board of Directors developed this issue with special thanks
to James L. Gutmann, D.D.S., coauthor, and Marc Balson, D.D.S., coauthor and source of radiographs.

The information in this newsletter is designed to aid dentists. Practitioners must use
their best professional judgment, taking into account the needs of each individual
patient when making diagnoses/treatment plans. The AAE neither expressly nor
implicitly warrants any positive results, nor expressly nor implicitly warrants
against any negative results, associated with the application of this information. If
you would like more information, call your endodontic colleague or contact the AAE.

Did you enjoy this issue of ENDODONTICS? Did the information have a positive impact on your practice?
Are there topics you would like ENDODONTICS to cover in the future? We want to hear from you!
Send your questions and comments to the AAE at the address below:

ENDODONTICS: Colleagues for Excellence

American Association of Endodontists
211 E. Chicago Ave., Suite 1100
Chicago, IL 60611-2691
www.aae.org
 Reading List
Endodontics: Colleagues for Excellence, Fall/Winter 2003
Contemporary Endodontic Treatment…Its Role in Retaining Our
Patients’ Natural Dentition

Endodontic Treatment Outcomes–Nonsurgical–Retreatment–Surgical

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pathosis. Surgery versus endodontic retreatment. Oral Surg Oral Med Oral Pathol 1996;82:213-7.

Friedman S. Considerations and concepts of case selection in the management of post-treatment endodontic disease
(treatment failure). Endodontic Topics 2002;1:54-78.

Halse A, Molven O. A strategy for the diagnosis of periapical pathosis. J Endod 1986;12:534-8.

Halse A, Molven O. Follow-up after periapical surgery: the value of the one-year control. Endod Dent Traumatol
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Hepworth MJ, Friedman S. Treatment outcome of surgical and non-surgical management of endodontic failures.
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Lazarski MP, Walker WA III, Flores CM, Schindler WG, Hargreaves KM. Epidemiological evaluation of the
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Messer HH. Clinical judgment and decision making in endodontics. Austral Endod J 1999;25:124-32.

Molven O, Halse A, Fristad I. Long-term reliability and observer comparisons in the radiographic diagnosis of
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Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery – radiographic findings 8 to 12
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Molven O, Halse A, Grung B. Surgical management of endodontic failures: indications and treatment results.
Int Dent J 1991;41:33-42.

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Vire DE. Failure of endodontically treated teeth: classification and evaluation. J Endod 1991;17:338-42.

Restorative Options–Outcomes–Tooth Retention–Strength of Endodontically Treated Teeth

Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth.
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Aquilino SA, Shugars DA, Bader JD, White BA. Ten-year survival rates of teeth adjacent to treated and untreated
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Bergman B, Lundquist P, Sjögren U, Sundqvist G. Restorative and endodontic results after treatment with cast post
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Jameson MW, Hood JA, Tidmarsh BG. The effects of dehydration and rehydration on some mechanical properties of
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Papa J, Cain C, Messer HH. Moisture content of vital vs. endodontically treated teeth. Endod Dent Traumatol 1994;
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Implants–Outcomes–Survival–Success

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Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JYK. Clinical complications with implants and implant prostheses.
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Malmqvist JP, Sennerby L. Clinical report on the success of 47 consecutively placed core-vent implants followed from
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Morris HF, Ochi S. Influence of two different approaches to reporting implant survival outcomes for five different
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