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Second Opinion: Endo vs. Implants: Evaluating Options, Making Clinical Choices


Endo vs. Implants: Evaluating Options, Making Clinical Choices


Second opinions are common in health care; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dentists to share their opinions on various topics, providing you with a "Second Opinion." Perhaps some of these dentists' observations will change your mind; while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession.

— Thomas Giacobbi, DDS, FAGD
Dentaltown Editorial Director
 by Richard E. Mounce, DDS

Viewing endodontics and implants as competitive treatment modalities is unproductive. The clinical indications for endodontics (and retention of the natural tooth) versus extraction (and placement of an implant) are rarely balanced in a risk/reward equation. This is especially true when the financial benefit of the clinician is taken out of the equation and the clinical benefit to the patient is put first. This column was written to discuss the indications and contraindications for endodontics vs. implants in order to provide the clinician with a predictable treatment rationale upon which to make clinical decisions when retention or extraction of the natural tooth is in question.

As a starting place in the discussion, it makes sense to compare an optimized root canal and an optimized implant procedure. Making blanket statements such as "root canals fracture teeth" or "root canals make teeth brittle" or "retreatment doesn't work" fly in the face of the endodontic literature and the everyday experience of endodontists. This said, to give endodontic treatment the best possible chance to heal, it must be performed to the highest standard. For example, it is not the root canal that fractures the tooth when it happens; it is very often the excessive removal of dentin in preparing too large a coronal taper or using a post improperly where a post might not have even been required.

To optimize endodontic outcomes, non-restorable teeth should be extracted. This can only improve the long-term probabilities of higher success rates for root canal treatment. While this seems simple enough, a significant number of nonrestorable teeth are referred to me for evaluation and treatment, perhaps five to 10 percent of any given month's referrals. In other words, clinicians have a widely varying set of ideas about what is restorable and what is not. For example, if the tooth has a high risk of vertical fracture or there is evidence, albeit inconclusive that the root is already vertically fractured, it makes sense to conclusively determine if the root is indeed vertically fractured first before carrying out the endodontic therapy. In any event, to discuss what endodontic therapy is capable of achieving is to evaluate a treatment that is performed at the highest level, as well as on a tooth that is restorable. When one considers the risk of iatrogenic events and their influence on success and failure, virtually all such mistakes are preventable had the given treatment error been recognized as possible and the clinician taken evasive action prior to the misadventure. In essence, as the clinician plans and carries out endodontic treatment, there is one best way forward at any given juncture. Taking a path forward other than the optimal one at that moment diminishes the probabilities of future healing.

Strategies for optimizing first-time orthograde root canal treatment and avoiding iatrogenic outcomes include: using the surgical operating microscope [SOM] (Global Surgical, St. Louis, Missouri), early coronal seal, use of the rubber dam, bonded obturation (RealSeal, SybronEndo, Orange, California), using warm obturation techniques, enhanced irrigation with regard to heating the irrigants, activating them as well as achievement and maintenance of apical patency throughout the entire process of instrumentation and utilizing rotary nickel titanium files safely and correctly, amongst other strategies. A careful pre-operative assessment of both the restorability of the tooth as well as the patient's wishes with regard to aesthetics and function are essential. Furthermore, the clinician can certainly benefit from the use of advanced scanning technology such as the iCAT at a minimum digital radiography (in my hands, DEXIS, DEXIS digital radiography, Alpharetta, Georgia) in decision-making.

Treatment planning for retreatment is more complex than first-time orthograde therapy. When assessing a tooth for retreatment, the technical deficiencies that led to the failure must be considered. In practical terms, can the canals be made patent, can the perforations be sealed, the separated files removed, etc.? If so, to what predictable degree can these issues be addressed? In essence, the clinician needs to determine if a coronal and apical seal can be obtained. If so, assuming that the tooth is restorable and the technical challenges can be overcome, retreatment is highly predictable. It is noteworthy that the introduction of the SOM has allowed many case of failed root canal therapy that previously would have lead to extraction or apical surgery to be efficiently retreated.
"The role of apical surgery
or endodontic surgical intervention should be mentioned as option
relative to the alternatives, including retreatment
and extraction."		 In addition, the role of apical surgery or endodontic surgical intervention should be mentioned as an option relative to the alternatives, including retreatment and extraction. Apical surgery might provide the best option taking into account the fee, direct and indirect costs of the procedure and future prognosis of the tooth, especially if the tooth has been retreated first and has the periodontal support needed to make it viable after the surgery. Endodontic surgery is almost exclusively in the realm of microsurgically-trained endodontists. At a minimum, a consult as to the future prognosis for the case should be obtained.

The decision for or against retention of the natural tooth is quite simple as patients are likely to have strong preferences when all of the options are presented with complete candor. Realistic case presentations that present retention of the natural tooth with realistic success failure percentages and costs will usually bring out a strong preference on the part of the patient.

The advantages of retention of the natural tooth are myriad. The process is faster, more efficient and less expensive than the alternatives and the success failure rates of implants versus endodontics are very similar. (Hannahan, et. al., Journal of Endodontics, November 2008, Vol. 34, Issue 11, PP 1302- 1305; and Doyle, et. al., Journal of Endodontics, September 2006, Vol. 32, Issue 9, PP 822-827). In short, each clinical case should be determined individually given its subjective, objective and radiographic findings and patient preferences.

The above notwithstanding, there are some clinical situations that make treatment planning for or against retention of the natural tooth challenging. These cases include but are not limited to:
  1. Suspected but unproven vertical fracture.
  2. Cases with previous endodontic surgery and retreatment, especially where the cause of failure is unknown.
  3. Cases where radiographic pathology has resolved somewhat after the previous retreatment or surgery but is still present after a time frame in which it would be expected to heal fully.
  4. Resorption, especially cases of suspected internal and external resorption.
  5. Cases where the feasibility of retreatment is not entirely clear. For example, whether a perforation can be sealed, a separated file removed and the canal properly cleaned below the level of the present blockage, etc.
  6. Teeth in need of some types of periodontal surgery.
  7. Poor levels and bone topography.
  8. Unfavorable root structure, fused roots in particular.
  9. Minimal remaining tooth structure.
  10. Rotated or tipped teeth especially where they might act as bridge abutments.
  11. Teeth that will require posts and might already have excessive occlusal forces or missing tooth structure.
  12. Combinations of the above scenarios.
All of the above clinical scenarios can make clinical decisions for and against tooth retention problematic. Nonetheless, the clinician should make a decision as to the advisability of endodontics versus the implant based on solely clinical factors and as mentioned above, where the financial benefit of the clinician is taken out of the picture entirely. Often, the decision to move toward or away from the implant option will require the services of multiple specialists in a team approach and require consultations to aid in discussion of restorability. When viewed comprehensively, the right answer will emerge if the diagnosis and treatment planning is carried out correctly.

On a personal note, the subject of endodontics vs. implants is a personal one for me given what follows. As a specialist, approximately 75 percent or more of my practice is retreatment or finishing cases that have been started elsewhere. The strategies that have been mentioned above are an essential ingredient for me in disassembly of these previously failing root canals as well as their revision and to correct the technical defects that have caused the failure. The question in many of these cases is not whether they can be retreated, simply much more a matter of their being referred for retreatment to specialists capable of revising the previously failed treatment.

When I was 16, I had my second molars removed on my right side. I was not given the choice of root canals; I was told that these teeth were beyond saving, which is a very difficult prospect for me to believe now being an endodontist. In any event, #18 had root canal treatment in approximately 1992 and after a leaking crown, the tooth was retreated in 1998. The mesial root vertically fractured in 2004 and the tooth was removed. In 2008, I had implants to replace #2, #18, and #31. I am personally thankful for the implant option being present to provide a replacement for my missing teeth. I am a testament to the capabilities of implant therapy to restore function.
Author's Bio

Richard E. Mounce, DDS, lectures globally and is widely published. He is in private practice in endodontics in Vancouver, Wash. He offers intensive customized endodontic single- day training programs in his office for small groups of one to two doctors. For information, contact Dennis at 360-891-9111, or write richardmounce@mounceendo.com.
Hand wringing on the part of the endodontic community about the rise of implants in relation to endodontics is wont take anyone forward. My belief if that the collective endodontic community should stress education at the undergraduate and graduate dental school level to promote adequate case selection in both endodontics and implants and do all that is possible to optimize the success rates of both procedures. While this is much easier said than done, simple steps such as adoption of the SOM by general practitioners could in itself make huge strides forward toward the improvement in technical endodontic results. In any event, it is sensible for endodontists to also learn how to place implants and take the lead in offering their referring colleagues implant service especially when the case is referred for retreatment, the tooth is not restorable and needs to be removed. Again, while this is simple to write here, such additional training, while burdensome by some measures, is necessary and advisable in a crowded marketplace in North America especially in metro areas. This capability will ultimately give the endodontist a full range of options for caring for both the roots of the natural dentition as well as the artificial roots of the implant service when natural tooth retention is simple not possible. I welcome your feedback.
Dentaltown Magazine
September 2025
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