The big debate

Drs. Michael Norton and Julian Webber discuss — implants or endodontics?

Endodontics or implants? It’s a question that’s been keeping dental philosophers occupied since Professor Brånemark discovered osseointegration – and it’s taken one step closer to being answered.

The treatments went head to head as two of Harley Street’s (London, England)  finest took to the stage to fight their corner. Dr. Michael Norton – pulling aside the veil on dental implants – faced off against Dr. Julian Webber, eloquently arguing in favor of endodontics.

The topic for debate was “Implants versus endodontics: addressing a contemporary conundrum.”

But anyone hoping the evening would descend into a free-for-all was set to be disappointed. Dr. Webber, presenting his lecture first, set the tone by declaring an early ceasefire. “It’s not a battle,” he said. “We’re on the same wavelength.”

…The pair sent out a very clear message: implants and endodontics can work in harmony to the benefit of patients.

Dr. Norton was quick to agree, explaining how closely he has worked with Dr. Webber over the years – and acknowledging how “bizarre” it was that they were very good referrers to one another. He paid tribute to the positive effect that relationship has had on his own practice, adding: “I’ve had the good fortune to work with two great endodontists, and there is no question that doing so has refocused my approach to my own implant dentistry.”

Working in harmony
Ignoring the enmity that has sprung up between adherents of each treatment in recent years, the pair sent out a very clear message: implants and endodontics can work in harmony to the benefit of patients.

The entente cordiale continued as the evening wore on, treating the audience to an eloquent, reasoned – but still passionate – debate on how the two approaches fit together in modern dentistry. And if anything, the two clinicians were united against a common enemy, with traditional measures of success swiftly coming into the firing line.

Dr. Webber said: “The problem with endodontics and implants is that if we’re going to compare the two treatment modalities, then we need to define our success criteria. It’s  interesting, because the success criteria are very different between the two. For dental implant studies, success is measured in terms of survival. For endodontics, it’s measured in terms of ability to cure existing disease – and endodontic success studies measure both that and the occurrence of new disease.

So the success criteria are different. And that’s a problem: you can’t compare apples with oranges.”

Difficult reading
Dr. Norton backed this up: “Historically, there’s been confusion in the implant literature, and a free exchange of the terms ‘survival’ and ‘success’ – and these are not the same thing.” And he agreed with Dr. Webber’s problem with the current literature on the debate, adding: “Currently, no guidelines are really set forth to help us make a decision about when to go one way, and when to go the other. And that’s where we – from both the endodontic and the implant side – find ourselves with something of a problem.”

The quality of the scientific literature came under scrutiny from both speakers, who pointed to the pronounced imbalance between who performs the treatment. Most implant studies concentrate on work carried out by specialists or in hospital settings, they argued, while the majority of endodontic papers look at work by general practitioners or students. When dealing with a more level playing field – and excluding anything not of a higher caliber, as in Iqbal and Kim’s 2007 paper – the long-term results for both treatments are comparable. Quoting from Iqbal, Dr. Norton added: “The decision to treat a tooth endodontically or replace it with an implant must be based on factors other than treatment outcomes.”

Save first, replace last
The ultimate factor, both speakers argued, was that every decision should be made with the best interest of patients in mind – but if a tooth can be saved, they should always be given the option. Dr. Norton said: “If I can save a tooth, even if it’s just in the short term, then I will. Implant treatment cannot be justified for a restorable tooth needing first time root canal treatment.  Where the debate starts is with teeth requiring further treatment. Problems set in when teeth are endodontically mismanaged for too long. Failed endo cases are usually associated with longstanding chronic infection, which damages the bone and causes problems for implant treatment.”

The criteria for establishing the suitability of a case for endodontic treatment do not have to be complicated, Dr. Webber added. He said: “In my view, endodontic therapy should be given priority in treatment planning for periodontally sound single teeth with pulpal and periradicular pathology that are restorable. And to me, that’s very simple. Implants should be given priority in treatment planning for teeth that are planned for extraction.”  Dr. Webber was happy to explain his cut-off for referring patients for implant treatment. “It’s pretty simple,” he explained. ‘”If you can’t restore it, and it’s periodontally unsound – it’s time to go.”

When treatment fails
Both clinicians agreed that trying to root treat a hopeless case was damaging, with the critical decision resting on when to “pull the plug.” “Endodontic treatment on a hopeless tooth is just as unethical as implant treatment on a tooth that could be restored,” said Dr. Webber.  And Dr. Norton corroborated this, adding: “The problem with endodontics is that if it’s done badly, you scar that patient’s attitude towards endodontics forevermore. Perhaps dentists doing bad endodontics make it easier for patients to make the wrong decision about retreatment.”

There is no mystery about why a lot of root canal treatment fails, Dr. Webber explained. “Without doubt,” he said. “One of the biggest causes of failure in endodontics is lack of coronal seal.” And he warned: “If you’re going to embrace endodontics – if you want it to be successful – then you’ve got to embrace the technology as well. Modern endodontics is driven by the technology, but you’ve got to come out of the dark ages to see that.”

Keeping up with technology is also a must when it comes to implant placement, said Dr. Norton. And complications are just as important to bear in mind when considering either treatment. He asked: “What about the potential for procedural complications? We all know that not every implant case is a slam dunk, either.”

“If I see that the risks of extracting a tooth to replace it with an implant are possibly greater than the risks of keeping the tooth, then I will encourage the patient to give endodontics a try. What have we got to lose?”  He concluded: “If it’s not a good implant candidate, it’s going to be a disaster. Implants are an expensive alternative to root canal treatment, so they need to be better in every way.”

Complementary closure
Despite the very different makeup of the speakers’ practices, there was only one message to the evening. Forget the competition, because endodontics and implants  complement each other. That sentiment was even echoed by the sponsors for the evening, with Dentsply Implants and Dentsply jointly supporting the debate.

Drs. Webber and Norton regularly refer patients to one another, and their cast-iron belief that this is the best possible way forward for patients was evident throughout.

Dr. Norton closed his lecture by quoting from the AAE guidelines that both speakers referred to throughout their presentations. He said: “Endodontic and implant treatment are most predictable procedures when undertaken with complete care and attention to diagnosis, planning, and execution of treatment.”

“The natural tooth is the ultimate implant,” Dr. Webber said, quoting endodontist Cliff Ruddle in his own closing remarks. “The question of when to save and when to replace comes down to the considerations for treatment planning. One of the main considerations is ethics. So before you answer it, first ask yourself this: what’s best for the patient?”