Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: A systematic review.
STATEMENT OF PROBLEM: Dentists and patients are regularly confronted by a difficult treatment question: should a tooth be saved through root canal treatment and restoration (RCT), be extracted without any tooth replacement, be replaced with a fixed partial denture (FPD) or an implant-supported single crown (ISC)?
PURPOSE: The purpose of this systematic review was to compare the outcomes, benefits, and harms of endodontic care and restoration compared to extraction and placement of ISCs, FPDs, or extraction without tooth replacement.
MATERIAL AND METHODS: Searches performed in MEDLINE, Cochrane, and EMBASE databases were enriched by hand searches, citation mining, and expert recommendation. Evidence tables were developed following quality and inclusion criteria assessment. Pooled and weighted mean success and survival rates, with associated confidence intervals, were calculated for single implant crowns, fixed partial dentures, and initial nonsurgical root canal treatments. Data related to extraction without tooth replacement and psychosocial outcomes were evaluated by a narrative review due to literature limitations.
RESULTS: The 143 selected studies varied considerably in design, success definition, assessment methods, operator type, and sample size. Direct comparison of treatment types was extremely rare. Limited psychosocial data revealed the traumatic effect of loss of visible teeth. Economic data were largely absent. Success rates for ISCs were higher than for RCTs and FPDs, respectively; however, success criteria differed greatly among treatment types, rendering direct comparison of success rates futile. Long-term survival rates for ISCs and RCTs were similar and superior to those for FPDs.
CONCLUSIONS: Lack of comparative studies with similar outcomes criteria with comparable time intervals limited comparison of these treatments. ISC and RCT treatments resulted in superior long-term survival, compared to FPDs. Limited data suggested that extraction without replacement resulted in inferior psychosocial outcomes compared to alternatives. Long-term, prospective clinical trials with large sample sizes and clearly defined outcomes criteria are needed.
When providing patients with recommendations for treatment in a given clinical situation, the concept of standard of care is foremost in our minds when making these recommendations. In recent years, the clinical success and longevity of single-tooth replacement using implants has created a divergence of opinion on the recommendation for nonsurgical endodontic treatment and the consequent restorative treatment or extraction and single-tooth implant replacement. Is the decision to choose one treatment modality over the other so clear cut that as clinicians we can refer to standard of care?
These two systematic review articles comparing nonsurgical root canal treatment and single-tooth implants are unique because they are published in two different specialty journals—prosthodontics and endodontics. The primary focus for each article reflects each specialty when presenting treatment outcome. A systematic review provides the clinician with an evidence-based outcome assessment using high-level evidence from systematic reviews and randomized controlled clinical trials. To guide our decisions for treatment recommendations, we want to understand the parameters of success and failure from outcome assessments. For our patients, the measure of success is whether or not a tooth is still present in the mouth. The results of both systematic reviews indicate that the decision to treat a tooth endodontically or replace it with an implant must be based on factors other than the treatment outcomes of the procedures themselves. Both nonsurgical root canal therapy followed by an appropriate restoration and single-tooth implants are excellent treatment modalities for the treatment of compromised teeth. In the Torabinejad review, single-tooth implants and root canal therapy had similar long-term survival data that were superior when compared to fixed partial dentures. If a tooth is restorable based on restorative and periodontal considerations, endodontic treatment should be the first option. For a tooth with poor restorative or periodontal prognosis, extraction and a single-tooth implant should be considered. The functional and psychologic factors and their impact on the patient must be considered in consideration for treatment alternatives offered. There is no doubt that well-designed long-term studies with large sample sizes are needed.
Commentary by Howard E. Strassler, DMD
Professor, Division of Operative Dentistry
Department of Endodontics, Prosthodontics and Operative Dentistry
University of Maryland Dental School