An Endoimplantologist’s Perspective: Interdisciplinary Acceptance

In the scientific and clinical community, it is common knowledge that endodontics has evolved from the dark ages similar to the way implantology did. Arthur Schopenhauer stated truth always goes in 3 stages: first it is ridiculed, then violently opposed, then finally it is accepted as self-evident. Implants enjoy success rates similar to well-selected endodontically treated teeth, and endodontists evolving to include both disciplines are evidence of that change.1-3

INTRODUCTION
It was once thought that root canal treatment was an arduous procedure with uncertain results. Implant dentistry has undergone comparable scrutiny and it has also emerged. Sometimes, for the disciplines of endodontics and implantology, the success rates are underestimated or overestimated; and/or the procedures are not respected due to poor choices by clinicians, or because of a rivalry toward the opposite discipline. Perhaps some clinicians may choose to treat compromised teeth, or choose to endodontically treat a difficult case, realizing later the disservice to the patient and the harm to their own long-term success.4 In comparison, placing implants, with no regard for advancing one's training prior to doing so, can be similarly deleterious. A conflict of interest may also exist whereby those who never received adequate training in one discipline, or those who have a vested interest in a service that they offer, might be reluctant to offer the diametrically opposed discipline. These examples demonstrate why reputations of a procedure, or discipline, can become tainted.
     On the other hand, some practitioners consider the single tooth implant a reasonable alternative to the preservation of a diseased tooth. However, the practitioner should be better prepared to determine which treatment option is most appropriate for each individual patient.5 Furthermore, the debatable concern of defining what constitutes the standard of care, by offering a tooth-supported fixed partial denture as compared to a single-tooth implant, has created alarm.6
     In the early days, replacement of already missing teeth dominated the practice of dentistry, whereas today, patients present for treatment to replace teeth that first need to be extracted before implants can be placed.7 This has led to another heated issue: removing a structurally sound tooth for substitution by implantation. The debate continues, and slowly the adversarial contention of implant versus endodontics has sensibly given way to implant or endodontics.8-10 In the future, treatment options may evolve to include endodontics, implant therapy, or genetic reproduction.
      Implant dentistry and endodontics have steadily undergone paradigm shifts whereby trust and respect are still being established in the dentist's and the public's eye. Due to some similarities occurring with the evolution of each discipline (as financial gains are realized by both the manufacturers and clinicians), more dentists are driven to perform endodontic treatment or place implants. Some dentists seek proper training while others do not, and implantology may undergo criticism (similar to root canal treatment) as poor outcomes and/or undesirable results mount (Figures 1a to 2c). As more clinicians enter the implant realm without reasonable and proper implant training, one might expect that this may blemish the image which implant dentistry (similar to endodontics) has strived to achieve.

Figures 1a to 1d. Adequate training may prevent compromised prosthetics with poor trajectory as shown, although the supragingival restorative outcome appears acceptable.
Figures 2a to 2c. Compromised trajectory. Poor mesiodistal placement. Those choosing to place implants must understand prosthetics. Note poor positioning, poor emergence, and compromised hygiene. Appropriate training in implant surgery and prosthetics can help minimize clinical problems like this.

     Although research is lacking, a reasonable and seasoned endodontist would not disagree on factors that can diminish success. Some factors could include poor skill set, failing to use microscopy, failing to use orifice barriers such as portland cement (MTA), and failing to defer on treating teeth with poor ferrule or deep axial/pulpal floor/or even suborifice root fractures, which yielded a failed outcome. It is accepted as common knowledge that microleakage, fractured teeth, endo/perio issues, and poor clinical crown volumes have never reflected well on endodontic or restorative success rates. Based on extensive experience, it is this author's opinion that combining nonsurgical treatment with surgical treatment more often (during the same clinical visit), does indeed improve endodontic success; and yet, not implementing this approach for more cases undergoing nonsurgical endodontic therapy occurs. When these aforementioned concerns are not considered, the image of endodontics becomes tainted as failures occur. Similarly, implantology has undergone a comparable evolution in materials and techniques. It was once thought that implants did not work or that the procedure was risky. Comparing endodontics and implant dentistry, the consequence(s) of failure due to improper training or experience is tangible.
     In order to preserve the success rates that can be achieved with implant dentistry, the clinician must understand more about the sales and marketing pressures involved. For example, dentists must recognize the pressure of sales and marketing as seen in the implant representative's tantalizing offer to sell an implant start-up package at an abbreviated continuing education course given without due diligence and a solid learning experience. It is imperative that any clinician incorporating implant dentistry into his or her practice understand the principles of implant care so that all the potential risks are understood.
     Currently, it is apparent after reviewing—what others opine, various scrutinizations, and the purported editorials and claims thereof—that a contest exists between endodontics and implant dentistry.11 Also, based on varying parameters, that one procedure is (perhaps) always better than the other. Along these lines, a form of ostracization exists whereby endodontists might be looked upon by peers with peculiarity, or even be investigated by their respective state dental board if they choose to place implants because of arbitrary opinions or a disregard of differences. Some peers may think that an endodontist should not be part of, or included in, the implant treatment team; or that we are not welcome at continuing education courses or other relevant programs with open arms. This has caused a great stir amongst varying parties from a variety of entities with vested interests. The definition of the scope of practice of endodontics and the accreditation standards clearly indicates that participation of endodontists in implant dentistry is warranted and ethical, contrary to what some may believe.
     In light of these political concerns, and more importantly the clinician's dilemma with a patient's clinical issue, it is not always possible to predictably save teeth with periodontal treatment or endodontic treatment, and other options need to be made available. In fact, periodontic and endodontic/implant algorithms have been proposed to help understand if saving the tooth or replacement with an implant is a better option.5,12-14

Figures 3a to 3c. Unpremeditated treatment plan: root canal/apico converted to extraction/graft. Different cases demonstrating why the endodontist must function as endoimplantologist. (Note: Cases were aborted due to intra-operative complications with subsequent extraction/socket grafting [not shown].) Figure 3a. Endodontic therapy rendered, but then aborted due to surgical findings (complete buccal dehiscence with endo/perioinvolvement). Subsequently, extraction and graft rendered (not shown). Figures 3b and 3c. Radiograph demonstrating apical radiolucency No. 7 with surgical exposure showing absolute root fracture and osseous recession.

     Frequently, the endodontist becomes involved with a hopeless tooth and must be proactive. Recognizing that dilemma, it makes sense for the endodontist to offer an unpremeditated treatment plan. This means that any time a patient is scheduled for therapy and intraoperative findings render a diminished prognosis, then the clinician must be able to change course and offer different care than originally planned (Figures 3a to 4c). In other words, the ultimate decision may have to be made extemporaneously as the case develops.15 As with other disciplines in dentistry, not every endodontist has the same skill set. However, for those who foster and develop a skill set for the components needed to plan implants and administer treatment with a prosthetic vision in mind, the endodontist should be a vital component. As more endodontists are becoming involved with implant dentistry, it is critical that the referring doctor and general community understand why endodontists are entering this realm. Recognizably, each discipline has its strengths and weaknesses, and clearly both procedures can work well if basic issues are analyzed for each case.16 However, not every tooth can be saved. Therefore, the endodontist must be accepted and respected as a competent player in the placement of implants, so long as proper training is sought.
      Endodontists need to realize they must be proponents of implant dentistry, not opponents, and thus should be added to the general dentist's and prosthodontist's repertoire of implant surgeons. Changing times have introduced a sensitive subject matter with obstacles that need to be laid to rest.

OBSTACLES
The following are some examples of obstacles that clinicians from both sides of the equation must overcome politically and psychologically to adapt the role of endodontist as endoimplantologist.

Figures 4a to 4c. Unpremeditated treatment plan. During the fixed partial denture temporization phase, this patient developed pulpitis symptoms and was referred for endodontic therapy prior to final impressions. Case was preliminarily accessed and shaped. (Note the faint distal marginal ridge crack.) (a). Distal orifice shown with intra-operative finding; distoaxial/pulpal floor/suborifice root fracture. Endodontic therapy was aborted with extraction/graft rendered (b). After extraction, it was apparent that the internal suborifice vertical root fracture (as seen with an operating microscope), extended to the periphery and was apical of the cemento-enamel junction (c).

Control Issues
An occasional referring dentist may have issues with "control" whereby he or she wants to control persons, places, and things—everything related to patient care. Rather than trusting others and letting things happen, contention and opposition can be a result, albeit unnecessarily. A referring doctor might become offended if the endodontist does not call when hopeless intra-operative situations present to ask what he or she prefers and/or for permission to perform in the patient's best interest via extraction or extraction/grafting. Although it is important to recognize and respect a referring doctor, it is also important to understand that endodontists are qualified to make judgments and perform scrupulously. It is absurd to feel like one must "walk on thin ice" with their referring doctor in order to preserve a "relationship." An example could include: a working relationship with a dentist who remains adamant about the endodontist calling if the tooth cannot be saved so that the patient can be scheduled. The endodontist should become concerned with that relationship because the referring doctor is probably not considering the integral aspects related to that decision as it affects both the patient and endodontist. It is awkward to ask a patient to leave an endodontist's office and drive back to the referring dentist, or worse, to allow the anesthesia to wear off knowing that the patient will be consulted by the dentist later in the day (or on another day), only to go through an event that none of us likes to endure (delayed treatment with interim pain, more unpleasant local anesthesia, time off of work, aggravation). Sometimes, it may not be possible for the endodontist to conveniently call the referring doctor (for whatever reason), or the patient is either orally or intravenously sedated, making a call impractical. After the patient has been told (informed consent) that the tooth cannot be saved, many patients prefer to have the tooth removed and possibly grafted while remaining profoundly anesthetized by the endodontist.

Not Qualified?
Importantly, any dentist can restore or place an implant immediately after graduating from dental school without appropriate training. However, with proper training and attention to detail, dentists (including endodontists) can become not only competent, but proficient in implant surgery (and prosthetics). Endodontists are qualified to understand restorative-prosthetic dentistry. They deal with this on a daily basis with each analysis of restorability for a tooth they treat. They had to train and pass all requirements to become dentists before training to become endodontists. With further training, an endodontist is capable of implant surgery and involvement with prosthetics. It has been said that an endodontist is not qualified to place implants due to a lack of understanding of trajectory and issues thereof. Learning this clinical implant skill did not prove challenging for the author of this article and can be learned with practice and mentorship.

Implant Dentistry Is Not a Specialty
Implant dentistry belongs to no specialty and is now part of many specialties, including endodontics. The American Association of Endodontists (AAE) established the scope of practice of endodontics along with accreditation standards that communicates that it is acceptable for endodontists to be involved with implant dentistry whether for surgical placement or procedures thereof. While the ADA varies its definition from the AAE for the scope of practice of endodontics, the issue of endodontists being involved with implant dentistry is not a concern. Although one can belong to the ADA, one does not have to be a member of the ADA or AAE to be a dentist, or endodontist. As part of our first amendment rights, it is our right as dentists or specialists to be involved with implant dentistry and to advertise appropriately, even with "limited to" or "specialist of" designations if one is a trained specialist, while offering implant surgery.

Ego—Old School Versus New School Mentality
Understand that sometimes it is not possible to "push a rope" with referring doctors/implantologists who do not like change. Some are perhaps territorial, while others may have their own agendas/issues with an endodontist joining their profession. If issues present when working with a colleague of this nature, all that can be done is for the endoimplantologist to continue to educate oneself in surgery, prosthetics, and various other related matters to become a good implant surgeon. In other words, one must continue to strive for proficiency, not just competence. The trained endoimplantologist can perhaps eventually earn the referring doctor's respect and admiration with the potential of having a solid future relationship.

Figures 5a to 5c. Understanding how to manage intraoperative complications. Deciding on how to manage intraoperative complications must be learned and understood before incorporating implant surgery into practice. Implant placed in apical labial concavity (a), with dehiscence (b), and subsequent grafting (c).

     As the status quo is changing, perhaps the endodontist will be able to stand as a beacon for the dogma that implant dentistry is a prosthetic discipline with a surgical component. If that educational model is followed during the course of the endodontist's training, then there can be no hesitation as to one's level of competency with regard to the understanding of principles and skill sets needed to perform implant surgery (Figures 5a to 5c).

Training
A past president of the AAE made a statement that supported implant planning and placement by endodontists.17 Currently, some endodontic residency programs are more involved than others with respect to implant training. Although, it is not necessary to receive all implant training while in an endodontic residency program. Excellent training can be undertaken when one is ready to make the commitment. Once a satisfactory level of training has occurred, one should not worry about how he or she might be accepted in a community. Surprisingly, some referring doctors might think it is admirable that an endodontist wants to be involved and offer another level of care (due to the shortcomings that endodontics and periodontics offer) for certain clinical presentations. Endodontists must focus on what they believe is a better model of patient care and try not to worry about how they will be perceived by a small percentage of resistant dentists; change is inevitable.

Logic
Evolution follows the basic tenet that nature shall tailor change, and if it works, then genes and behaviors become immortalized. Logical thinking prevails with the current debate starting to settle on all platforms that implants do work. In support of that issue, every procedure scheduled for endodontics should be thought of as an exploratory procedure since intraoperative findings or outcomes do occur, thereby necessitating a changed methodology for patient care. Therefore, it is best for the endodontist to transition and change to endoimplantologist. Continuation of patient rapport, removing a hopeless tooth with socket grafting, and preparing the patient for implant planning along with future referring doctor involvement should be encouraged. Certain patients tend to become "ruffled" if they are referred back to perhaps someone else for extraction, while absorbing an incomplete fee for endodontic services. At other times, when an endodontist aborts treatment, patients discover that they cannot be seen that day by their dentist and are left "in limbo" with pain until further action can be taken. Endodontists are qualified to talk about teeth and implants and to pursue those actions needed to steer that course. Implant dentistry is not rocket science and becomes tangible once the basic fundamentals are understood. A competent endoimplantologist can be beneficial to build a referring doctor's restorative implant practice. Removing the unrestorable tooth starts that cascade.

Avoidance Behaviors: Reciprocating Negativity Between Implantologist and Endodontist
Pockets of dentists may speak negatively about endodontics, perhaps due to their skill level, frustrations, or inability to properly treatment plan cases, leading to difficulties with restorative care. Dr. Stephen Buchanan,18 an endodontist, stated he began training in implant dentistry because he saw the specialty threatened by implant surgeons who were disrespecting endodontic therapy.18 On the other hand, it is equally interesting that some endodontists spoke negatively about implant dentistry. Some statements included, "So, you are going to the dark side," and "I wish that the AAE would dump a bunch of money in stem cells so that endodontists can render that care," not realizing how myopic these statements may sound. Recently, the president of the AAE published a rebuttal in the Endo Tribune11 to counter the position of the American Academy of Implant Dentistry regarding which is the better option, placing an implant or saving the tooth. Regrettably, the rivalry between endodontics versus implants staggers forward.11 Ultimately, the endodontist and all colleagues must arrive at a mutual understanding that we are all in this together to serve patients, represent integrity, earn a living, and offer services to patients that they select after options are presented. Endodontists must not be afraid. Instead, they should focus on what they perceive to be the coming change, growing professionally and pushing forward so that they become a part of the change that they envision.

CLOSING COMMENTS
Should endodontists be practicing more comprehensively, thereby evolving to remove teeth that are not predictable, graft bone or soft tissue, place implants, treatment plan patients who come to them for their problems, and plan/participate in a team-centered approach to prosthetic care? In the author's opinion, without a doubt! In a national study, the majority of responding endodontists believed that dental implant placement is within the scope of endodontic practice.2 Arguably, not doing so would mean that evidenced-based dentistry is being ignored, that a clinician is not continuing to understand and implement change, or self-growth is myopic and not occurring. Your endodontist should already be trained (or be training) to become one of your implant surgeons. Offering acceptance for their courage and commitment would prove helpful. Referral of a tooth to the endodontist for "explore and treat as needed" makes most sense, with subsequent development of a relationship; whereby referral for grafting or implant placement becomes the next step toward acceptance.
All of us need to unclench our fists so that we can extend our hands in order to minimize and eventually nullify the interdisciplinary gap.


References

  1. Iqbal MK, Kim S. A review of factors influencing treatment planning decisions of single-tooth implants versus preserving natural teeth with nonsurgical endodontic therapy. J Endod. 2008;34:519-529.
  2. Potter KS, McQuistan MR, Williamson AE, et al. Should endodontists place implants? A survey of U.S. endodontists. J Endod. 2009;35:966-970.
  3. Hannahan JP, Eleazer PD. Comparison of success of implants versus endodontically treated teeth. J Endod. 2008;34:1302-1305.
  4. Glickman GN. President's message. reviving collaboration in dentistry. J Endod. 2009;35:1449.
  5. Morris MF, Kirkpatrick TC, Rutledge RE, et al. Comparison of nonsurgical root canal treatment and single-tooth implants. J Endod. 2009;35:1325-1330.
  6. Curley AW. Dental implant jurisprudence: avoiding the legal failures. J Calif Dent Assoc. 2001;29:847-853.
  7. Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int J Oral Maxillofac Implants. 2009;24(suppl):186-217.
  8. DiMatteo AM. Making the right move: planning your clinical strategy. Inside Dentistry. 2008;4:122-133.
  9. Mounce R. Implants vs. endo: complimentary treatment strategies or adversarial threats? Endo Tribune. 2009;4:1, 4c-5c.
  10. Kurtzman GM. Will dental implants signal the death of endodontic treatment? (Editorial) Implant Practice US. 2009;2:1.
  11. Glickman GN. AAE: Issue in implant debate comes down to saving teeth. Endo Tribune. 2009;4:2B. (Source: AAE).
  12. Serota KS. A tale of two specialties: the endodontic/implant algorithm. Endo Tribune. 2007;2:1, 16-17.
  13. Greenstein G, Cavallaro J, Tarnow D. When to save or extract a tooth in the esthetic zone: a commentary. Compend Contin Educ Dent. 2008;29:136-145.
  14. Hargreaves KM. Treatment Planning: Comparing the Restored Endodontic Tooth and the Dental Implant. Chicago, IL: American Association of Endodontists; 2007.
  15. Stroumza JH. Endoimplantology: part 2, surgical classifications. Dent Today. 2009;28:112-117.
  16. AAE Position Statement: Implants. Chicago, IL: American Association of Endodontists, AAE Special Committee on Implants; 2007.
  17. Rossman LE. AAE president's message: implant your opinion with confidence. J Endod. 2008;34:1025.
  18. Buchanan LS. The future of endodontics, part 2: observations by an endodontist-implant surgeon. Dent Today. 2008;27:134-138.

Dr. Kiser is a graduate of The Ohio State University, with specialty training in endodontics. Additional training included prosthetic training in implant dentistry at The Ohio State University Implant Restorative Dentistry Internship and a Surgical Implant Externship at Midwest Implant Institute. Since then, he has completed other courses of study and certifications. Currently, he maintains a private practice restricted to endodontics and dental implant surgery with related prosthetics. He can be reached via e-mail at the address This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Kiser reports no disclosures.



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