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Publication date: July 2009
Review date: March 2011
Expiry date: February 2014
Earn
2 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
Implants or Endodontics:
Alternative Treatments?
A Peer-Reviewed Publication
Written by Richard Nejat, DDS and Fiona Collins, BDS, MBA, MA
2 www.ineedce.com
Educational objectives
Upon completion of this course, the clinician will be able to
do the following:
1. List the common causes of tooth extractions and
potential sequelae.
2. List and describe the success rates for both endodontic
treatment and implant treatment as well as the factors
and conditions that can lead to failure of endodontic and
implant treatment.
3. List and describe the systemic and oral considerations
that are involved in determining whether endodontic
treatment or implant treatment is more appropriate for
a given patient.
4. Describe the implications for decision making together
with the patient, and factors infuencing the patient in his
or her choice of treatment.
Abstract
Refecting improvements in oral health as well as changes in
treatment modalities and patient expectations and preferences,
the majority of current baby boomers in the United States will
retain their natural teeth for life. The impact of an extraction
varies with location, and options may include saving the tooth
through endodontic treatment or extracting the tooth and plac-
ing an implant. Both implant therapy and endodontic therapy
have good success rates. With both endodontic and implant
therapy, success factors and considerations include the patients
systemic and oral health, choice of materials, and technique
used. A patients general health status may dictate which treat-
ment is appropriate, overriding other factors. Considerations
include medication use, infection risk and more generally the
patients ability to withstand the treatment. Oral health consid-
erations include caries experience, periodontal health, alveolar
bone, occlusal load and bruxism, parafunctional habits, health
of the remaining dentition, and the presence of or need for
fxed prostheses. Determination of the appropriate treatment
requires careful consideration of these and potential outcomes,
with the patient participating in the process.
Introduction
Refecting improvements in oral health as well as changes in
treatment modalities and patient expectations and prefer-
ences, the majority of current baby boomers in the U.S. will
retain their natural teeth for life. Nonetheless, caries remains
an endemic health issue affecting more than 90% of adults over
the age of 40
1
and is the primary factor in tooth loss in the U.S.
population. Advanced periodontal disease is responsible for
30%35% of extractions in patients over the age of 40.
2
Other
reasons for extractions other than elective due to crowd-
ing and orthodontic treatment include root fracture, root
resorption and cysts. The aesthetic and functional impact of an
extraction in the (partially) dentate patient varies with location
and whether the result would be a slightly shortened intact
dental arch, severely shortened dental arch or bounded space.
The World Health Organization considers that at least 20 teeth
must be present for the dentition to be functional and aesthetic,
while the dental literature considers an intact arch extending to
the second bicuspids to be functional.
3
Literature research sug-
gests that shortened dental arches may provide good function,
comfort and oral hygiene maintenance.
4,5,6
However, while
potentially compatible with oral health, patients place less
value on a shortened dental arch than on either implants, fxed
or removable prostheses bringing the shortened arch into
question from the patients perspective.
7
Partial edentulism
can result in tilting of adjacent teeth and overeruption of the
opposing dentition, diffculty with oral hygiene measures, the
development of periodontal pockets, exposed furcation areas,
root caries and masticatory problems. Based upon all these
considerations, avoiding extractions or providing the best
possible replacement for teeth is clinically important. In many
cases this will mean either endodontic treatment or implant
placement, followed by a crown and/or fxed prosthesis.
Endodontically treated functional tooth
Image courtesy of Dr. William Watson
Endodontic Treatment
Endodontic therapy may be required as a result of advanced
caries, traumatic injuries, fractures to the teeth, dens invagini-
tus or iatrogenic pulp exposure. The ultimate goal is absence
of infection and complete healing of the periapical tissues, as
well as successful restoration and long-term retention of the
tooth. Endodontic therapy may be a single- or multiple-visit
procedure, nonsurgical or surgical. Procedural objectives in-
clude removal of all pulpal tissue, microbial elimination,
cleansing of the root canal walls and removal of all debris, and
obturation of the root canals. Nonsurgical endodontic therapy
entails coronally accessing the pulp chamber to identify all
root canal openings and providing straight-line access to the
apical foramen or root curvature.
8
The canals are typically
manually and/or mechanically cleaned and shaped with fles
and reamers and intermittently irrigated to remove all debris
and the dentin smear layer and to disinfect the canals. Root
canal irrigants used include sodium hypochlorite, EDTA,
hydrogen peroxide and chlorhexidine gluconate. Lastly, the
root canals are obturated with the objectives of obtaining
www.ineedce.com 3
a sound apical seal, sealing of lateral and accessory canals,
complete flling of all canals, and a good coronal seal for the
root/restoration interface.
Periapical infection, endodontically treated lower incisor
Fractured file and periapical infection
Potential complications
Periapical/recurring microbial infection following treat-
ment is infuenced by the root anatomy, quality of the root fll-
ing and coronal restoration, periodontal health, and marginal
bone loss.
9
50%90% of root-flled teeth have apical evidence
of residual infection, based upon cadaver examinations.
10

Physical issues related to persistent infection include the
varying number of canals that must be identifed and obstruc-
tive or inaccessible areas such as calcifed or accessory canals
and anastomoses.
11
In the case of nonsurgical retreatment, the
ability to completely remove root flling materials plays a role.
Neither Gates-Glidden drills and K fles nor Nd:YAG lasers
were found in one study to completely remove gutta percha
and AH26 (Sealapex).
12
Anatomical obstructions and inac-
cessible areas cause diffculties in microbial sampling used
to determine appropriate antimicrobial therapy and whether
residual infection is present prior to obturating. The type
of microbial infection also plays a role in the persistence of
infection. Both rotary instruments and lasers, together with
EDTA or sodium hypochlorite, were found to be ineffective
in vitro in eliminating E. faecalis from anterior single-rooted
teeth.
13
Fungi have also been found in root canals, more com-
monly in teeth with previous endodontic treatment.
Horizontal and vertical root fractures may occur due to
dentin brittleness, reduced dentin thickness, overinstru-
mentation, restorative technique and/or restoration failure.
Nonvital dentin contains less water than vital dentin, which
could lead to brittleness, reduced shear strength and a
predisposition to fracture.
14,15
Regarding dentin thickness,
dentin less than 1 mm thick remained on the furcation side
in 82% of mandibular molars following post preparation with
Gates-Glidden drills in an in vitro study, indicating the care
required
16
and the risk of perforation or fracture. Materials
used during root canal treatment and post placement infu-
ence the risk. After stainless steel post placement, an in vitro
study indicated, lower load is required for fracture compared
to using glass fber posts that have a modulus of elasticity
closer to that of dentin.
17
Root canal irrigants can affect the
dentins mineral content, surface hardness and roughness,
and bonding capacity. Signifcant decreases in calcium and
phosphorus content in dentin have been found in vitro with
the use of EDTA, chlorhexidine gluconate and hydrogen per-
oxide but not with sodium hypochlorite,
18
and separately only
chlorhexidine gluconate neither affected the dentins surface
hardness nor increased its surface roughness.
19
Another study
showed that sodium hypochlorite immersion can reduce the
force required to fracture dentin.
20
Bonding agents are used
to help prevent fracture at the core buildup/dentin junction.
Use of dentin bonding agents and/or a ferrule preparation
can increase fracture resistance.
21

Coronal fractures in endodontically treated teeth are also
more common than in vital teeth, particularly when the teeth
are not crowned.
Discoloration of endondontically treated teeth is a common
occurrence, ranging from a slightly darkened hue compared to
an adjacent tooth to almost black. This is relatively easily dealt
with, and treatment options range from nonvital bleaching to
veneers to full crown coverage, depending upon the tooth and
the severity of the staining. Nonvital bleaching of teeth has
been shown to often provide acceptable aesthetics.
22

Vertical root fracture
Success Rates
Initial endodontic treatment success rates defned as
complete healing have been reported to be 91%98% in
the absence of pre-existing apical periodontitis.
23,24,25
The
4 www.ineedce.com
presence or absence of apical periodontitis and preparation/
flling technique have been found to be the most important
predictors for success.
26
For teeth with apical periodontitis
at the time of initial treatment, success rates of 74%86%
have been reported.
27,28
Apical surgery has been reported to
have a weighted average success rate of around 70% (range
37%85%).
29
Success rates in previously root-flled teeth are
signifcantly lower, with one report fnding only 62% healed
after retreatment and that this was poorly predicted from
clinical and radiographic signs.
30
The ultimate goal is long-
term tooth retention and functionality, not only endodontic
success (complete healing and no infection). A prospective
study of adults over the age of 50 showed that the relative
risk of tooth loss was approximately four times greater for
endodontically treated teeth.
31
Tooth survival rate following
endodontic therapy is related to resistance to fracture and
the type of restoration. Endodontically treated teeth have
higher survival rates if crowned, and while uncrowned
endondontically treated teeth have been found to be six
times more likely to be lost than crowned teeth,
32
a four-year
review (mean follow-up, 38 months) found a 91.7% survival
rate for cast restorations.
33

Extraction and Implant Treatment
Around two million implants are placed each year. Typi-
cally, a crestal incision is made and the mucosa refected and
calibrated bone drills are used to create a bony socket of
the correct dimensions for the implant. Following implant
placement, the mucosal fap is either repositioned around
the implant (a one-stage procedure) or over the implant until
osseointegration has occurred and a second surgery is carried
out to expose the neck of the submerged implant (a two-stage
procedure). Shortly after exposure, the microbial composi-
tion around the implant is the same as with a one-stage pro-
cedure. An alternative technique is use of a mucosal punch
to create a punchhole through the mucosa to the crestal bone
this is technique-sensitive and by its nature is for one-stage
procedures. Immediate placement of implants following
extraction and delayed placement have been found to have
similar success rates, based upon reviews of the literature.
34

An abutment is later placed into the implant usually after
osseointegration and the superstructure is then fabricated.
Complications
Immediate complications include perforation of the
cortical plate and/or misalignment of the implant within
the bone, a bone receptor site too large or too small for the
implant, damage to the implant surface during placement,
bleeding, microbial and foreign-body contamination of
the implant and implant site, and overheating of the bone.
These complications can cause implant placement to be
aborted or result in short-term failure. With care, these
operator- and environment-related complications can be
minimized and avoided.
Osseointegrated functional implant
Short-term complications include infection as a result of
contamination at the time of or following surgery. Failure to
obtain primary stability at the time of implant placement leads
to failure of the implant to osseointegrate and its removal.
35
Long-term complications are usually a result of lack of
maintenance and poor oral hygiene, starting as reversible
mucositis and progressing if untreated to irreversible peri-
implantitis. Peri-implantitis is the most common cause of im-
plant failure and is preventable with attention to oral hygiene.
Peri-implantitis
Further complications include retrograde peri-implantitis as
a result of periapical infection associated with previous end-
odontic therapy at the site or adjacent to the implant site
36
and
marginal peri-implantitis due to a combination of microbial
infection and occlusal overload.
37
Long-term complications
can also arise from incorrect occlusal and interproximal
contacts of superstructures placed on implant abutments.
Poor functionality and aesthetics can result from compro-
mised positioning of abutments due to the positioning of the
implant at the time of surgery. These complications can be
prevented with careful implant placement. Implant fracture
is a rare event, usually resulting in implant removal. Loosen-
ing of abutments and abutment screw fracture require either
removal of the superstructure, followed by retightening of the
abutment or removal of the abutment and replacement with a
new abutment, followed by assessment of the superstructure
and the occlusion. For implant systems requiring torquing
of the abutment, it is important to ensure that the torque ap-
plied is consistent with the manufacturers recommendations
to avoid over- or undertorquing the abutment. Fracture of
the framework or superstructure can occur this potential
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complication is present with both endodontic and implant
therapies. Factors infuencing long-term complications and
failures include inappropriate prosthesis design, axial and
acentric loading, and parafunctional habits.
38

Success rates
Implant success rates have been reported to be in the
90%96% range. A survival rate of 95.6% over a 1-to-12-year
period was found in 1692 implants placed, with mean time
for removal of failures being 40 months there were more
early failures than late failures, and factors infuencing failure
included bone quality, metabolic diseases, smoking and poor
oral hygiene.
39
A recent study by Wagenberg and Froum
of more than 1900 immediate implants placed between
1988 and 2004 found a success rate of 96%, with machined
implants twice as likely to fail as rough surface implants. A
study of implants placed between 1988 and 1992 found that
7.7% of implants had progressive bone loss at 5- and 10-year
assessments.
40
As with endodontic therapy, success rates
vary with the materials used in this case implant design
and coating. Hollow-screw implants have been found to have
higher success rates than hollow-cylinder implants (95.4%
verus 85.7%),
41
and peri-implantitis was found in one study
over 13 years to be associated more commonly with hydroxy-
apatite-coated implants than with turned-surface titanium
implants.
42
Treatment of advanced peri-implantitis with
surgical and antimicrobial therapy does not guarantee success
and was successful in only 58% of implants treated in one
study.
43
Since the ultimate goal is retention of the implant and
functionality of the superstructure, success rates need to look
beyond retention of the implant and absence of infection. A
study examining implants 5 and 10 years after placement as
abutments for fxed prostheses found implant-abutment con-
nection problems in 7.3% of patients after fve years. Implant
fracture occurred cumulatively in 0.4% of implants.
44

Fractured implant
Treatment Considerations and Selection
Both implant therapy and endodontic therapy have good
success rates. While endodontic therapy retains the tooth (or
root) and provides the basis for a restoration, endodontically
treated teeth are not the equal of healthy intact or vital teeth.
On the other hand, extraction is fnal. With both endodon-
tic and implant therapy, success factors and considerations
include the patients systemic and oral health, choice of ma-
terials, and technique used. Determination of the appropriate
treatment requires careful consideration of these and potential
outcomes, with the patient participating in the process.
Systemic health considerations
A patients general health status may dictate which treatment is
appropriate, overriding other factors. Considerations include
medication use, infection risk and more generally the patients
ability to withstand the treatment. Relevant medications
include anticoagulant therapy and bisphosphonate therapy.
Patients on anticoagulants are at risk for hemorrhage during
surgery and need to have their anticoagulant medication levels
adjusted and managed where this is not possible, non-sur-
gical endodontic therapy would result in less medical risk for
the patient than either extraction and implant placement or
surgical endodontic therapy. Patients on bisphosphonates are
at risk for osteonecrosis of the jaw following dental treatment,
in particular extractions. Under these circumstances, if either
endodontic therapy or extraction (and implant placement) is
required, nonsurgical endodontic therapy is the treatment of
choice.
45
Patients on long-term corticosteroid therapy are also
at increased risk of osteonecrosis.
46
Chemotherapy patients
should not receive implants until blood profles are back to
normal, due to higher implant failure rates,
47
and unless the
timing of treatment is elective and can be delayed, endodontic
treatment would be indicated and implant treatment contra-
indicated in these patients.
Uncontrolled diabetics have higher implant failure rates than
nondiabetics, with failure rates in diabetics occurring in the
frst year.
48
With respect to endodontic therapy, patients with
type 2 diabetes are more susceptible to apical periodontitis
and one study found 81% of diabetics had apical periodonti-
tis, versus 58% of nondiabetics.
49
Implants have been found in
studies to be successful, provided the diabetes was controlled.
Diabetes can impact the results of both endodontic therapy
and implant therapy and may therefore not be a determin-
ing factor. Patients at risk for bacterial endocarditis require
antibiotic prophylaxis prior to dental treatments where oral
bacteria may enter the bloodstream. However, the ongoing
presence of a recalcitrant periapical infection also represents
a potential health risk. Immune-compromised patients are at
risk for infections; however implant therapy and endodontic
therapy can both be successful in these patients.
While smoking is a health risk factor rather than a sys-
temic health consideration in the choice of therapy, smokers
have an increased risk of periodontitis and an increased risk
of disease progression.
50,51
Periodontal disease is however
associated with an increased incidence of apical periodonti-
tis in root-treated teeth,
52
indicating that smokers may also
be at increased risk for endodontic failure. Smokers have
previously been found to have higher implant failure rates
than nonsmokers;
53
however, a recent retrospective study of
more than 1,900 immediate implants placed between 1988
and 2004 found that while smokers had more failures, the
6 www.ineedce.com
difference in failure rates between smokers and nonsmokers
was statistically insignifcant.
54
Based upon the research in
total, it is unclear whether smoking would suggest selection
of implant or endodontic therapy.
Oral health considerations
Oral health considerations include caries experience, peri-
odontal health, alveolar bone, occlusal load and bruxism,
parafunctional habits, health of the remaining dentition, and
the presence of or need for fxed prostheses. Where a tooth is
already an abutment for a bridge, endodontic therapy avoids
having to remove and replace the bridge. Where the tooth or
implant would serve de novo as an abutment for a fxed pros-
thesis or as a single unit, more consideration is warranted to
avoid later removal of the prosthesis due to treatment failure.
Secondary and rampant caries can result in restorative
failure. Secondary caries has been reported as the single
most common reason for replacement of restorations,
55
and
a literature review found that 18% of abutment teeth for
fxed prostheses subsequently suffered caries.
56
A long-term
retrospective study of fxed partial prostheses and cantilevers
found that 8% failed due to secondary decay.
57
In patients
with rampant caries or high caries experience, especially with
exposed roots, extraction and implant placement may provide
a better long-term approach for an individual patient if he or
she is periodontally stable and has not undergone irradia-
tion of the jaw. If the endodontically treated tooth would be
a single restored unit, caries experience would be somewhat
less of a consideration since only the individual tooth/res-
toration would be potentially lost. Surgery exposes patients
who have undergone irradiation of the mandible or maxilla
to the risk of osteoradionecrosis, as well as to an increased
risk of implant failure.
58
In these patients who are per se at
risk for rampant caries due to radiation-induced xerostomia
endodontic therapy would avoid these risks and override
caries concerns.
When periodontal health is poor, success rates for both
endodontic and implant therapy are compromised. Peri-im-
plantitis risk is greater in patients with active periodontal dis-
ease,
59
and periodontal disease is associated with an increased
incidence of apical periodontitis in root-treated teeth.
60

Molars with furcation involvement have been found to have
twice the risk of being lost over an eight-year period follow-
ing periodontal therapy, with 30.2% lost versus 14.7% lost
without furcation involvement.
61
Periodontal treatment of
molar furcations may include root resection (and endodontic
treatment). Molar root resection failure rates have been found
to range from 10% to 47.4% over a 10-year period.
62,63
This
would suggest that consideration should be given to implant
placement where there is (advanced) furcation involvement
with more weight placed on this option where the tooth
would serve as an abutment for a fxed prosthesis.
Root considerations include poor crown-to-root ratio
and very short root length relative contraindications for
endodontic/restorative therapy. Poor root confguration and
anatomical obstructions may result in the need for surgical
endodontic therapy and/or retreatments and suggest consid-
ering implant therapy as an option with the patient. Further
root-related considerations are teeth with external or internal
root resorption. Vertical root fractures indicate extraction and
implant treatment. Horizontal root fractures in the coronal
third of the root may still leave suffcient root for a new resto-
ration however, depending upon the depth of the fracture,
periodontal/restorative factors and remaining root length,
consideration instead should be given to implant treatment.
Bone height, width, volume and density and the adjacent
anatomical structures are further considerations. Poor bone
quality and density is associated with a higher short-term
implant failure rate and poor osseointegration. Bone that
is of inadequate height or width makes implant placement
impossible or diffcult and may necessitate bone grafting
prior to implant placement. If a tooth has a poor prognosis,
preserving the socket and placing an implant may avoid the
necessity for bone grafting prior to treatment. Alternatively,
endodontic therapy would avoid the extraction and the need
for procedures such as bone grafting.
Patient considerations
Decision making involves advising and guiding patients
through choices and treatment selection. If a choice can be
clearly delineated because a therapy is contraindicated, the
Endodontic and Implant Treatment Contraindications
Implant
treatment
Nonsurgical
endodontic
treatment
Contraindications
Bisphosphonate therapy X
Head and neck radiation X
Long-term steroid use X
Chemotherapy X Delay
Anticoagulant therapy X Manage
Relative contraindications
Diabetes X X
Smoking X X
Rampant caries X
Short crown-root ratio X
Poor periodontal health X X
Furcation involvement X
Poor root configuration X
Poor bone density, quality X
Poor bone height and width X
Root fracture (varies with location) X
www.ineedce.com 7
process is straightforward. In other situations, the choice is
not obvious and involves weighing factors that may confict
with each other and the patients preferences. Extraction,
implant therapy and restoration can be complex and costly;
endodontic therapy and restoration can also be complex and
costly. One study found that in patients referred for immedi-
ate implant placement, 46% were removed for endodontic
reasons,
64
indicative of past failure rates but also of patient
acceptance of implants. Some patients may prefer endodontic
therapy to retain the natural tooth or root even if there is a high
relative risk of failure, while others may prefer implant treat-
ment. Patient perceptions regarding the various treatments
and the value of retaining the natural root/tooth play a role.
Individual patients who have experienced different proce-
dures may have a clear preference based upon that experience.
Patients who have not experienced either oral surgery or end-
odontic therapy are typically more anxious about endodontic
therapy.
65
Educating the patient on all treatment options,
the risks and benefts of these options, and the use of anxiety
management techniques will help the patient overcome his or
her anxiety and enable the clinician and the patient to select
the most appropriate treatment together.
Summary
Improvements in oral health and treatment modalities have
resulted in more patients than in the past retaining their
teeth. Within the context of preserving the natural dentition,
endondontic therapy is a proven treatment with good suc-
cess rates. Implant therapy also has good success rates and
is a well-accepted treatment. While the natural tooth or root
is retained with endodontic therapy, it is not necessarily the
better option for individual patients. The decision-making
process and treatment choice can be complex for individual
cases. Considerations in selecting implant therapy or end-
odontic therapy for an individual patient include (relative)
contraindications for either treatment, functionality, patient
and tooth-specifc risks, and patient preferences.
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May;30(5):302309.
27. Friedman S, Mor C. The success of endodontic therapyhealing and functionality. J
Calif Dent Assoc. 2004 Jun;32(6):493503.
28. Sjgren U, Hagglund B, Sundqvist G, Wing K. Factors afecting the long-term results of
endodontic treatment. J Endod. 1990 Oct;16(10):498504.
29. Friedman S, Mor C. The success of endodontic therapyhealing and functionality. J
Calif Dent Assoc. 2004 Jun;32(6):493503.
30. Sjgren U, Hagglund B, Sundqvist G, Wing K. Factors afecting the long-term results of
endodontic treatment. J Endod. 1990 Oct;16(10):498504.
31. Paulander J, Axelsson P, Lindhe J, Wennstrom J. Intra-oral pattern of tooth and
periodontal bone loss between the ages of 50 and 60 years. A longitudinal prospective
study. Acta Odontol Scand. 2004 Aug;62(4):214222.
32. Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of
endodontically treated teeth. J Prosthet Dent. 2002 Mar;87(3):256263.
33. Lynch CD, Burke FM, Ni Riordain R, Hannigan A. The infuence of coronal restoration
type on the survival of endodontically treated teeth. Eur J Prosthodont Restor Dent.
2004 Dec;12(4):171176.
34. Chen ST, Wilson TG Jr, Hammerle CH. Immediate or early placement of implants
following tooth extraction: review of biologic basis, clinical procedures, and outcomes.
Int J Oral Maxillofac Implants. 2004;19 Suppl:1225.
35. Lioubavina-Hack N, Lang NP, Karring T. Signifcance of primary stability for
osseointegration of dental implants. Clin Oral Implants Res. 2006;17(3):244250.
36. Quirynen M, Vogels R, Alsaadi G et al. Predisposing conditions for retrograde peri-
implantitis, and treatment suggestions. Clin Oral Implants Res. 2005;16(5):599608.
37. Uribe R, Penarrocha M, Sanchis JM, Garcia O. Marginal peri-implantitis due to occlusal
8 www.ineedce.com
overload. Med Oral. 2004;9(2):159162.
38. Porter JA, von Fraunhofer JA. Success or failure of dental implants? A literature review
with treatment considerations. Gen Dent. 2005;53(6):423432.
39. Kourtis SG, Sotiriadou S, Voliotis S, Challas A. Private practice results of dental
implants. Part I: survival and evaluation of risk factors. Part II: surgical and prosthetic
complications. Implant Dent. 2004;13(4):373385.
40. Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-
up of implant treatment, Part II: presence of peri-implant lesions, J Clin Preiodontal.
2006;33(4):290295.
41. Karoussis IK, Bragger U, Salvi GE, Burgin W, Lang NP. Efect of implant design on survival
and success rates of titanium oral implants: a 10-year prospective cohort study of the
ITI Dental Implant System. Clin Oral Implants Res. 2004;15(1):817.
42. Rosenberg ES, Cho SC, Elian N, Jalbout ZN, Froum S, Evian CI. A comparison of
characteristics of implant failure and survival in periodontally compromised and
periodontally healthy patients: a clinical report. Int J Oral Maxillofac Implants.
2004;19(6):873879.
43. Leonhardt A, Dahlen G, Renvert S. Five-year clinical, microbiological, and
radiological outcome following treatment of peri-implantitis in man. J Periodontol.
2003;74(10):14151422.
44. Pjetursson BE, Tan K, Lang NP, Bragger U, Egger M, Zwahlen M. A systematic review of
the survival and complication rates of fxed partial dentures (FPDs) after an observation
period of at least 5 years. Evid Based Dent. 2005;6(4):9697.
45. Ruggiero S, Gralow J et al. Practical guidelines for the prevention, diagnosis,
and treatment of osteonecrosis of the jaw in patients with cancer. J Oncol Pract.
2006;2(1):714.
46. Ibid.
47. Wolfaardt J, Granstrom G, Friberg B, Jha N, Tjellstrom A. A retrospective study
on the effects of chemotherapy on osseointegration. J Facial Somato Prosthet.
1996;2:99107.
48. Fiorellini JP, Chen PK, Nevins M, Nevins ML. A retrospective study of dental implants in
diabetic patients. Int J Periodontics Restorative Dent. 2000;20:366373.
49. Segura-Egea JJ, Jimenez-Pinzon A, Rios-Santos JV, Velasco-Ortega E, Cisneros-Cabello
R, Poyato-Ferrera M. High prevalence of apical periodontitis amongst type 2 diabetic
patients. Int Endod J. 2005 Aug;38(8):564569.
50. Norderyd O, Hugoson A, Grusovin G. Risk of severe periodontal disease in a Swedish
adult population. A longitudinal study. J Clin Periodontol. 1999;26:608615.
51. Papapanou PN. Periodontal diseases: epidemiology. Ann Periodontol. 1996;1:136.
52. Stassen IG, Hommez GM et al. The relation between apical periodontitis and root-flled
teeth in patients with periodontal treatment need. Int Endod J. 2006;39(4):299308.
53. Bain CE, Moy PK. The association between the failure of dental implants and cigarette
smoking. Intl J Oral Maxillofac Implants. 1993;8:609615.
54. Wagenberg B, Froum SJ. A retrospective study of 1925 consecutively placed immediate
implants from 1988 to 2004. Intl J Oral Maxillofac Implants. 2006;21(1):7180.
55. Deligeorgi V, Mjor IA,Wilson NH. An overview of reasons for the placement and
replacement of restorations. Prim Dent Care. 2001 Jan;8(1):511.
56. Goodacre CJ, Bernal G et al. Clinical complications in fxed prosthodontics. J Prosthet
Dent. 2003; 90(1):3141.
57. Hammerle CHF et al. Long-term analysis of biological and technical aspects of fxed
partial dentures with cantilevers. Int J Prosthodont. 2000;13:409415.
58. Sugarman PB, Barber MT. Patient selection for endosseous dental implants: oral and
systemic considerations. Int J Oral Maxillofac Implants. 2002;17:191201.
59. Porter JA, von Fraunhofer JA. Success or failure of dental implants? A literature review
with treatment considerations. Gen Dent. 2005;53(6):423432.
60. Stassen IG, Hommez GM et al. The relation between apical periodontitis and root-flled
teeth in patients with periodontal treatment need. Int Endod J. 2006;39(4):299308.
61. Wang HL et al. The infuence of molar furcation involvement and mobility on future
clinical attachment loss. J Periodontol. 1994;65(1):2529.
62. Minsk L, Polson AM. The role of root resection in the age of dental implants. Compend
Contin Educ Dent. 2006;27(7):384388.
63. Langer B, Stein SO, Wagenberg B. An evaluation of root resections. A ten-year study. J
Periodontol. 1981;52(12):719722.
64. Becker W, Becker BE, Hujoel P. Retrospective case series analysis of the factors
determining immediate implant placement. Compend Contin Educ Dent.
2000;21(10):805817.
65. Wong M, Lytle WR. A comparison of anxiety levels associated with root canal therapy
and oral surgery treatment. J Endod. 1991;17(9):416465.
Author Profiles
Richard Nejat, DDS
Dr. Richard Nejat is board
certifed by the American
Board of Periodontology. His
practice is at the forefront of
computer-guided implant
dentistry and minimally
invasive dental surgery. He
is a course instructor in vari-
ous continuing educational
seminars, symposiums to
colleges, and dental societies. Dr. Nejat attended
Drew University and continued his education at New
York University, where he attained his doctorate in
dental surgery. Dr. Nejat was elected to membership in
Omicron Kappa Upsilon, the National Dental Honor
Society recognizing academic and clinical excellence
in dentistry. He earned his certifcate in periodontics
from the State University of New York at Stony Brook.
Dr. Nejat is currently clinical assistant professor in the
Department of Periodontology and Implant Dentistry
at New York University and maintains private practices
in Manhattan and Nutley, New Jersey.
Fiona M. Collins, BDS, MBA, MA
Dr. Fiona M. Collins has
clinical, marketing, education
and training, and professional
relations experience. She has
practiced as a general dentist
for 13 years, written and given
CE courses to dental profes-
sionals and students, and
conducted market research
projects. Dr. Collins is a past
member of the Academy of General Dentistry Foun-
dation Strategy Board and has been a member of the
British Dental Association, the Dutch Dental Associa-
tion and the American Dental Association. Dr. Collins
earned her dental degree from Glasgow University and
holds an MBA and an MA from Boston University.
Disclaimer
The authors of this course have no commercial ties with the
sponsors or the providers of the unrestricted educational
grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.
1. The primary factor in tooth loss in the
U.S. population is ________.
a. caries
b. root fracture
c. orthodontic treatment
d. periodontal disease
2. Advanced periodontal disease is
responsible for ________ of extractions
in patients over 40.
a. 2%5%
b. 5%15%
c. 3035%
d. 50%
3. The dental literature suggests that
an intact dental arch provides good
function if ________.
a. it extends to the canines
b. at least one arch extends to the frst molars
c. it extends to the second bicuspids
d. only if all teeth are present
4. Partial edentulism may result in
________.
a. tilting of teeth
b. overeruption of the opposing dentition
c. masticatory problems
d. all of the above
5. The ultimate goal of endodontic
treatment is ________.
a. extraction
b. absence of infection
c. complete healing of the periapical tissues
d. b and c
6. During nonsurgical endodontic
treatment, ________ is required.
a. straight-line access
b. beveled access
c. angled access
d. none of the above
7. Root canal irrigants used include
________.
a. sodium hypochlorite
b. EDTA
c. hydrogen peroxide
d. all of the above
8. Periapical/recurring microbial
infection following endodontic
treatment is infuenced by ________.
a. root anatomy
b. quality of the root flling and coronal
restoration
c. the amount of mouthrinse the patient uses
d. a and b
9. Nonvital dentin contains less ________
than vital dentin, which could lead to
brittleness.
a. fat
b. water
c. blood
d. none of the above
10. Success rates for initial endodontic
treatment in the absence of preexisting
apical periodontitis have been reported
to be ________.
a. 50%60%
b. 75%
c. 80%90%
d. 91%98%
11. For teeth with apical periodontitis at
the time of initial treatment, reported
success rates have been ________.
a. 33%
b. 45%50%
c. 74%86%
d. 95%
12. Uncrowned endodontically treated teeth
have been found to be ____ times more
likely to be lost than crowned teeth.
a. three
b. fve
c. six
d. eight
13. The number of implants placed
annually is around ________.
a. half a million
b. one million
c. less than half a million
d. two million
14. Immediate complications with
implant placement include ________.
a. misalignment of the implant
b. bleeding
c. microbial contamination of the implant
d. all of the above
15. Failure to obtain primary stability
leads to ________.
a. successful treatment
b. failure of the implant to osseointegrate
c. poor appearance of the implant
d. none of the above
16. Long-term implant complications are
commonly a result of ________.
a. using the wrong mouthrinse
b. poor oral hygiene
c. heart disease
d. oral ulcerations
17. The most common cause of implant
failure is ________.
a. facial injury
b. loss of sensation
c. peri-implantitis
d. all of the above
18. Implant success rates have been
reported to be ________.
a. 40%50%
b. 65%75%
c. 90%97%
d. 100%
19. Factors infuencing implant failure
include ________.
a. bone quality
b. poor oral hygiene
c. whether the dental arch is continuous or not
d. a and b
20. Implant fracture was found in one
study to occur in ________ of implants.
a. none
b. 0.4%
c. 1%
d. more than 5%
21. Determination of the appropriate
treatment requires careful
consideration of ________.
a. the patients systemic and oral health
b. choice of materials
c. echnique used
d. all of the above
22. A patients general health
considerations include ________.
a. medication use
b. diet
c. infection risk
d. a and c
23. Relevant medications to consider in
selecting the appropriate treatment
include ________.
a. bisphosphonates
b. anticoagulants
c. calcium supplements
d. a and b
24. Uncontrolled diabetics have higher
________.
a. implant failure rates
b. susceptibility to apical periodontitis after
endodontic treatment
c. a and b
d. none of the above
25. Oral health considerations in selecting
the appropriate treatment include
________.
a. caries experience
b. periodontal health
c. alveolar bone
d. all of the above
26. The single most common reason for
replacement of restorations has been
reported to be ________.
a. poor aesthetics
b. secondary caries
c. metal fatigue
d. all of the above
27. Root considerations in selecting
treatment include ________.
a. crown-to-root ratio
b. root length
c. color of the root
d. a and b
28. Considerations related to the bone in
selecting treatment include ________.
a. bone height and width
b. whether or not a woman is postmenopausal
c. bone volume and density
d. a and c
29. Decision making on the appropriate
treatment involves ________.
a. advising and guiding the patient through
options
b. deciding what to do and then telling the patient
there is only one option
c. considering the patients preferences
d. a and c
30. ________ plays a role in the choice of
treatment.
a. the patients perceptions
b. the patients past treatment experience
c. neither a nor b
d. a and b
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Questions
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Mail completed answer sheet to
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A Division of PennWell Corp.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
ANSWER SHEET
Implants or Endodontics: Alternative Treatments?
Name: Title: Specialty:
Address: E-mail:
City: State: ZIP:
Telephone: Home ( ) Ofce ( )
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Educational Objectives
1. List the common causes of tooth extractions and potential sequelae.
2. List and describe the success rates for both endodontic treatment and implant treatment as well as the factors and
conditions that can lead to failure of endodontic and implant treatment.
3. List and describe the systemic and oral considerations that are involved in determining whether endodontic treatment or
implant treatment is more appropriate for a given patient.
4. Describe the implications for decision making together with the patient, and factors infuencing the patient in his or her
choice of treatment.
Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No
Objective #2: Yes No Objective #4: Yes No
2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0
4. How would you rate the objectives and educational methods? 5 4 3 2 1 0
5. How do you rate the authors grasp of the topic? 5 4 3 2 1 0
6. Please rate the instructors efectiveness. 5 4 3 2 1 0
7. Was the overall administration of the course efective? 5 4 3 2 1 0
8. Do you feel that the references were adequate? Yes No
9. Would you participate in a similar program on a diferent topic? Yes No
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
____________________________________________________________________
__________________________________________________________________
12. What additional continuing dental education topics would you like to see?
____________________________________________________________________
__________________________________________________________________
AUTHOR DISCLAIMER
The authors of this course have no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the
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INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confrmation of passing by receipt of a verifcation
form. Verifcation forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efcacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily refect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the feld related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70%(answering 21 or more questions correctly) on the
examination will receive a verifcation form verifying 2 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
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Many PennWell self-study courses have been approved by the Dental Assisting National
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RECORD KEEPING
PennWell maintainsrecordsof your successful completion of any exam. Pleasecontact our
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all credits earned to date, will be generated and mailed to you within fve business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100%satisfed with this course can request a full refund by
contacting PennWell in writing.
2008 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
AGD Code 149
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