Root canal or implant – the big question
Whether endodontic or implant therapy is chosen, it should be in the patient’s best interest, says Mark Allen.
The argument of whether extraction and implant therapy is more viable than endodontic treatment remains a hot topic. Of course, both root canal treatment and tooth extraction are historically the two most common procedures to treat damaged or infected teeth and provide pain relief to the patient.
It is the advent of implant dentistry that has caused controversy among specialists, as there are an increasing amount of dentists that believe implants may offer better results than endodontic treatment (Setzer and Ki, 2014; Parirokh et al, 2015).
Implant therapy in general has become an increasingly popular treatment pathway. Especially over the last decade both with dentists and patients. Long-term success rates show to be very positive. According to www.adi.org.uk, around 130,000 individual implants are currently placed each year in the UK. This provides invaluable functional and aesthetic benefits to partial and fully edentulous patients.
As research has pointed out, however, comparing the success of implants and endodontically treated teeth is a difficult task, as success holds different meanings across the two treatment modalities. Furthermore, research shows that both implants and root canal therapy demonstrate good success rates (Setzer and Ki, 2014).
Likewise, neither pathway can 100% guarantee long-term success for the patient. Failure can occur for a number of reasons with both implants and endodontically treated teeth.
The patient’s best interest
As such, it shouldn’t be a question of one or the other. As long as you choose the procedure ethically, based on clinical guidance, experience and the patient’s best interest, that’s all that matters. When implemented correctly, both treatment modalities can help to restore function, comfort and aesthetics. If one isn’t suitable then the other might be. Dental professionals know, it’s a matter of assessing each individual case. Certainly, where possible it is always best to preserve the natural tooth, as long as the circumstances are right to do so.
Indeed, all teeth with pulpal or periapical pathology are candidates for root canal treatment. There are a number of situations where elective root canal treatment is suitable. For instance, where a vital tooth has insufficient tooth substance to retain a jacket crown, the tooth may be root-treated and restored with a post-retained crown. Teeth with doubtful pulps can be considered too, as can patients with pulpal sclerosis following trauma.
Of course, a full case history, clinical examination and careful treatment planning will help to confirm whether root canal therapy is the appropriate course of action.
In some instances, root canal therapy is simply not possible if you cannot save the tooth and restore it to full use. In that case, extraction may be a suitable alternative. Then, followed by implant therapy if the circumstances are right to do so.
Condemning the natural tooth
Before ruling out endodontic therapy and condemning the natural tooth, the following questions should always be asked:
- Is there adequate access? If there is limited space or the patient has a small mouth it may not be possible to carry out root canal treatment
- What’s the patient’s oral hygiene status? If the patient is unable to maintain an acceptable level of oral hygiene, endodontic treatment may not be appropriate
- What is the patient’s general medical condition like? Where old age and/or poor physical health could compromise the treatment outcome, the pros and cons always need to be weighed up
- Is the tooth supported? There must be sufficient bone and periodontal support in order for treatment to be viable
- Is the tooth functional? Where a tooth is unopposed and non-functional, extraction may be the only option
- Are there any root fractures? While it is widely believed that horizontal root fractures have a more favourable prognosis, vertical fractures will often require extraction.
Case-specific treatment challenges
In addition to these factors, practitioners need to consider any case-specific treatment challenges. As well as the individual’s personal needs and preferences. One patient, for instance, might prefer to have the tooth extracted and replaced by an implant instead of undergoing root canal treatment.
Another may want to avoid extraction at all costs. Interestingly, research suggests that a higher percentage of patients would rather opt for endodontic treatment and preserve their natural teeth than have them extracted and replaced with implants (Re et al, 2017).
There can be no doubt of the importance of endodontic therapy in treating patients’ damaged or infected teeth. As long as dentists continue to use effective techniques and reliable, quality products, patients can hold onto their natural teeth for longer.
Implant therapy, where it is suitable to do so, also has a place in helping to preserve function and aesthetics. Dentists should continue to do all they can to ensure the right treatment is provided.
This article first appeared in Endodontic Practice magazine.
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