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Endo Versus Implants: Does Your Treatment Plan Pass the “Mama Test”? by Richard Mounce, DDS and Justin Moody, DDS

View Comments (2) More by Justin Moody, DDS (2)More by Richard Mounce, DDS (2)


The decision-making algorithm of tooth retention with endodontic therapy and restoration, and extraction and implants is relatively straightforward if three things are in place. First, the clinician has taken his personal bias out of the decision (and hence his financial interest). Second, the patient fully understands the procedure, alternatives, risks and long-term ramifications of treatment and has had her questions answered (and wishes to proceed with treatment). And third, the clinical situation has been fully assessed taking into account the myriad clinical details of the particular situation.

As an endodontist, it is my empirical observation that there are relatively few teeth that are "tweeners." Tweeners are teeth that could either have successful RCT and be restored or, alternatively, extracted and have an implant placed with an equal weight given to either treatment. In the vast majority of cases, the tooth is solidly in the restorable camp or the nonrestorable camp, but rarely both. Extracting previously endodontically treated teeth arbitrarily, without discussing retreatment or apical surgery, or extracting non-vital asymptomatic restorable teeth with lesions (which have not had endodontic treatment) is a great disservice to the patient. Alternatively, I have observed clinicians fruitlessly doing multiple endodontic procedures on nonrestorable teeth.

From a practical standpoint, in addition to the legal and ethical implications of performing either a root canal or placing an implant when not indicated, it is simply bad for business. For example, from an endodontic standpoint, doing a root canal on an upper second bicuspid with 50 percent bone loss with Class II mobility and expecting the tooth to be a future bridge abutment is not a positive indicator of future success. Patients are not happy, referring doctors are not happy, and neither will the endodontist be when the tooth is lost six months later due to vertical fracture.

Having the patient as an integral and informed partner in the treatment cannot be overstated in value. Ultimately it is the patient's health and wishes that are primary. If the patient wishes to have the treatment (be it endodontics or implants) after objectively being told the pros and cons of treatment, it is a very strong guide to what should be done. My treatment planning presentation is fairly simple, aside from the objective discussion of the case. I simply tell the patients what I would do if they were my family members. In essence, you must ask, does your treatment recommendation pass the "mama test"? What would you do if the patient was your mom?

Assessing cases clinically requires clinical acumen, a part of which is comprehensively looking at the tooth and overall situation and deciding on treatment options with a long-term comprehensive view. This involves considering whether the tooth is restorable, periodontally sound, at risk for long-term vertical root fracture or of strategic importance. In essence, will the tooth be functional and aesthetic for the patient over the long term if retained?

When considering tooth retention through endodontic therapy, risk assessment and treatment planning are essential. Two literature references underscore this point. Touré concluded "The mandibular first molar without crown was the most frequently extracted tooth. The main reasons for extractions were periodontal disease... and nonrestorable tooth damage caused by fracture or caries."

Song reported "...the most common possible cause of failure was perceived leakage around the canal filling material (30.4 percent), followed by a missing canal (19.7 percent), under filling (14.2 percent), anatomical complexity (8.7 percent), overfilling (3.0 percent), iatrogenic problems (2.8 percent), apical calculus (1.8 percent) and cracks (1.2 percent). The frequency of possible failure causes differed according to the tooth position (P < .001)."

Both of these studies underscore the point that long-term endodontic success, to a large degree, is related to factors that are within the control of the clinician and that if the doctor evaluating the case is not the best person to optimize the endodontic result, the case can be referred. For example, citing the studies mentioned, could the clinician not place a post-endodontic coronal seal to eliminate future leakage? The vast majority of missed canals could be located if the clinician takes the time and has optimal visualization using cone beam technology and a surgical microscope to visualize the tooth during treatment. In essence, do the job right the first time. While we will never approach 100 percent success, we can come a lot closer than we would otherwise.

Failed endodontic cases are a subspecialty within the scope of endodontic specialty practice. In general, with minor exceptions, retreatment is a specialist procedure. The risk of iatrogenic events is significant if an iatrogenic event has already occurred and needs correction. While a comprehensive discussion of the assessment of failed root canals is beyond the scope of this article, one key decision point on the feasibility of retreatment is relevant. The clinician should assess if the previous root canal can be revised without exacerbating an existing problem or creating a new one. The case listed notwithstanding, the predictability of endodontic retreatment is very high, in the right hands, approximating the success of first-time treatment. As mentioned, arbitrary extraction ignores a wealth of evidence that retreatment can preserve teeth that otherwise would have to be extracted. If it was your mother, would you rather an under-prepared and under-filled canal system was retreated or an extraction, possible grafting, placement of the implant and restoration at often two to three times the money, time and surgical stress?

References
  1. Touré, et al (Journal of Endodontics, Volume 37, Issue 11, Pages 1512-1515, November 2011
  2. Song, et al (Journal of Endodontics, Volume 37, Issue 11, Pages 1516-1519, November 2011
Author Bios
Dr. Richard Mounce is in endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, LLC, marketing the rotary nickel-titanium MounceFile in Controlled Memory and Standard NiTi. He can be reached at richardmounce@mounceendo.com, www.mounceendo.com or @MounceEndo.

Dr. Justin Moody is in a private practice limited to dental implants in Rapid City, South Dakota. He has lectured internationally and writes about dental implants and technology. He is the founder of the Rocky Mountain Dental Institute and owns and operates The Dental Implant Centers and Horizon West Dental Group. He can be reached at justin@rockymountaindentalinstitute.com, drjustinmoody.com or @drjustinmoody.
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