뽑지말고 살리자! 임프란트, 살릴 수 있는 치아를 뽑지는 말아야...

Endo or Implant : AAE Position statement

 

 

 

치아를 뽑고 임프란트를 할 것이냐 치아를 살릴 것이냐? 그 기준은 무엇인가?

답은 ‘자연치아살리기’가 먼저!

 

근관치료를 할 것인가 발치 후 임프란트를 할것인가에 대한 의사결정은 환자의 생각과 치료의 결과를 중요한 요소로 고려되어야 한다.

어떤 치료 결정이던 가장 최근의 연구를 기반으로 한 근거(evidence)를 바탕에 두어야 한다.

시술자인 치과의사는 윤리적으로 모든 가능한 치료방법을 환자에게 알려주어야 한다.

근관치료는 술자가 정확하게 진단하고, 치료계획을 세운 후, 근관을 깨끗이 세정한 후 밀폐하여 치아를 수복 할 수 있는 가장 예지성 있는 치료방법의 하나이다.

 

즉 발치 후 임프란트는 1)환자의 동의와 의지 2)과학적 근거 3) 치료결과의 정당성에 근거를 두어야 한다.

 

Treatment Planning Based on the Best Evidence Produces Ethical and Effective Results

Although there is a lack of clinical trials that directly compare one treatment approach to another [7, 8], there are generally accepted guidelines for the ethical consideration of treatment planning and informed consent. These ethical guidelines provide a framework for all clinical decisions.

Quality dental care can only be provided when treatment planning decisions are made by both the dentist and the patient, based on the patient’s general health status and specific oral health needs [9, 10]. The recommended treatment should be safe, predictable, cost-effective, respectful of patient preferences, aimed at preserving normal anatomy and function, and based upon the best available scientific evidence [10-12].

Evidenced-based dentistry incorporates into dental practice ”judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences” [12].

There is a growing body of evidence to assess the outcomes of both endodontic and implant therapy. Most studies of endodontic therapy analyzed the success or failure by using criteria that included both clinical and radiographic measures, while most studies of single tooth implant treatment reported the outcome as survival (the implant was still in place), or failure (the implant had been removed.)

A critical analysis of the applicable literature requires categorization of the level of evidence to assess its validity, clinical relevance and clinical importance [13]. Consideration must also be given to study design issues. In comparing studies involving different treatment modalities, the consideration of the dependent measures observed is especially important [14]. In the case of endodontic or implant therapy, no prospective studies, and only one retrospective study, compare the two directly.

Comparing studies that measure survival is a valid means to compare endodontic therapy and implant treatment. A recent major literature review conducted by the Academy of Osseointegration found equal survival rates of single tooth implants and restored endodontically treated teeth [11]. These results are consistent with the only study to date directly comparing single tooth implants and restored endodontically treated teeth [15]. Both therapies had overall survival rates of 94 percent, thus providing predictable outcomes. Therefore, the decision to treat a tooth endodontically or place a single-tooth implant should be based on other criteria including restorability of the tooth, quality of bone, esthetic demands, cost-benefit ratio and systemic factors.

Along with overall survival rates of the therapy provided, treatment planning must also consider risk factors. For implant treatment, risk factors include: smoking, diabetes, decreased estrogen levels in postmenopausal women, bone quantity and quality, and use of IV bisphosphonates [17-24]. Risk factors for nonsurgical endodontic therapy include: diabetes, apical periodontitis and inadequate coronal restoration [25-28].

Conclusions

1.     Clinical treatment decisions regarding endodontic or implant therapy must always be made in the best interest of the patient.

2.     These treatment decisions should always be based on the best, most current evidence.

3.     The decision to treat a tooth endodontically or replace it with an implant must be based on factors other than treatment outcomes.

4.     Practitioners are ethically bound to inform patients of all reasonable treatment options.

5.     The standard of care must be applied equally to all practitioners, generalist and specialist alike. Due consideration should be given to patient referral for the evaluation and advice of specialists in retaining natural teeth.

6.     Endodontic treatment is a most predictable procedure when the clinician accomplishes correct diagnosis, appropriate treatment planning, thorough instrumentation, complete obturation with coronal restoration, and compassionate and effective care.

References

Lazarski MP, Walker WA, 3rd, Flores CM, Schindler WG, Hargreaves, KM: Epidemiological evaluation of the outcomes of nonsurgical root canal treatment in a large cohort of insured dental patients. Journal of Endodontics 27:791-796, 2001

Salehrabi R, Rotstein I: Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. Journal of Endodontics 30:846-850, 2004

Creugers NH, Kreulen CM, Snoek PA, de Kanter RJ: A systematic review of single-tooth restorations supported by implants. Journal of Dentistry 28:209-217, 2000

Bragger U, Karoussis I, Persson R, Pjetursson B, Salvi G, Lang N: Technical and biological complications/failures with single crowns and fixed partial dentures on implants: a 10-year prospective cohort study. Clinical Oral Implants Research 16:326-334, 2005

Levine RA, Clem DS, 3rd, Wilson TG, Jr., Higginbotham, F, and Solnit G: Multicenter retrospective analysis of the ITI implant system used for single-tooth replacements: results of loading for 2 or more years. International Journal of Oral & Maxillofacial Implants 14:516-520, 1999

Fugazzotto PA, Beagle JR, Ganeles J, Jaffin R, Vlassis J, Kumar A: Success and failure rates of 9 mm or shorter implants in the replacement of missing maxillary molars when restored with individual crowns: preliminary results 0 to 84 months in function. A retrospective study. Journal of Periodontology 75:327-332, 2004

Bader HI: Treatment planning for implants versus root canal therapy: a contemporary dilemma. Implant Dentistry 11:217-223, 2002

Cochran D: Implant therapy I. Annals of Periodontology 1:707-791, 1996

ADA: Principles of Ethics and Code of Professional Conduct, 2005

ADA: Current Policies, 2005, p 94

Iqbal M, Kim S: Single-tooth implant versus root canal treatment and restoration for compromised teeth: a meta analysis. International Journal of Oral & Maxillofacial Implants, 21:96-116, 2007

ADA: Position statement on evidenced-based dentistry, 2003

Sutherland SE, Matthews DC: Conducting systematic reviews and creating clinical practice guidelines in dentistry: lessons learned. Journal of the American Dental Association 135:747-753, 2004

Cochrane: Cochrane Collaboration Handbook. 2000

Doyle SL, Hodges JS, Pesun IJ, Law AS, Bowles WR: Retrospective cross sectional comparison of initial nonsurgical endodontic treatment and single-tooth implants. Journal of Endodontics 32:822-827, 2006

Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY: Clinical complications with implants and implant prostheses.[see comment]. Journal of Prosthetic Dentistry 90:121-132, 2003

Vehemente VA, Chuang SK, Daher S, Muftu A, Dodson TB : Risk factors affecting dental implant survival. Journal of Oral Implantology 28:74-81, 2002

McDermott NE, Chuang SK, Woo VV,Dodson TB: Complications of dental implants: identification, frequency, and associated risk factors. International Journal of Oral & Maxillofacial Implants 18:848-855, 2003

Morris HF, Ochi S, Winkler S: Implant survival in patients with type 2 diabetes: placement to 36 months. Annals of Periodontology 5:157-165, 2000

August M, Chung K, Chang Y, Glowacki J: Influence of estrogen status on endosseous implant osseointegration.[erratum appears in J Oral Maxillofac Surg 2002 Jan;60(1):134]. Journal of Oral & Maxillofacial Surgery 59:1285-1289; discussion 1290-1281, 2001

Herrmann I, Lekholm U, Holm S, Kultje C: Evaluation of patient and implant characteristics as potential prognostic factors for oral implant failures. International Journal of Oral & Maxillofacial Implants 20:220-230, 2005

Starck WJ, Epker BN: Failure of osseointegrated dental implants after bisphosphonate therapy for osteoporosis: a case report. International Journal of Oral & Maxillofacial Implants 10:74-78, 1995

Wooltorton E: Patients receiving intravenous bisphosphonates should avoid invasive dental procedures. Canadian Medical Association Journal 172:1684, 2005

 

American Association of Endodontists, 211 E. Chicago Ave., Suite 1100, Chicago, IL 60611