"Implant Failures Associated With Asymptomatic Endodontically Treated Teeth" by Drs. David Brisman, Adam Brisman and Mark Moses (February JADA) is a clinical report about four implant failures that the authors claim resulted from their proximity to asymptomatic endodontically treated teeth.
While it is commendable that clinicians share experiences from which useful information may be gained, it is very important that conclusions be drawn from sound, scientifically supported evidence—not just four clinical cases.
The issue of possible effects of endodontically involved teeth on the placement of adjacent implants is important and needs to be investigated. These four cases, however, do not appear to add any significant information and actually pose several problems, such as questionable placement of the implants and lack of preoperative evaluation of the adjacent endodontically treated teeth.
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Case 1.
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The patient was a smoker who "ceased smoking for three months before implants were placed." Did he start smoking again immediately after the implant placement? The implant was placed in very close proximity to the endodontically treated tooth. Did the osseous preparation in fact impinge on the periodontal ligament, or PDL, space? Had the bone completely healed following the extraction? The second implant is several millimeters away from the tooth and the apicoectomy site appears to have healed. Perhaps the tooth healed because no treatment was needed on this tooth initially.
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Case 2.
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The information about this patient is very difficult to evaluate. The lack of pre-and postimplant radiographs of the first implant makes it impossible to verify the authors’ claim that "the asymptomatic endodontically treated mandibular right second premolar was the cause of the implant failure." The second implant was clearly impinging on the PDL space of the endodontically treated tooth. After the removal of the implant, the gutta-percha tracing of the sinus tract leads to an area several millimeters below the apex of the endodontically treated tooth with no apparent lesion associated with its root apex. Is the gutta-percha marker actually in a drainage tract, mental foramen or perhaps in granulomatous tissue in the implant extraction site?
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Case 3.
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Once again, the implant clearly is placed very close to the endodontically treated tooth. After removing the implant, the tracing of the drainage tract goes directly to where the implant appears to have touched the root of the tooth. Clearly, when implants are placed in contact with adjacent teeth, bone cannot be expected to develop between the tooth and the implant.
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Case 4.
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The fourth patient experienced an infection following implant placement. This infection responded to surgical débridement around the implant and administration of antibiotics, yet nothing reportedly was done to the endodontically treated tooth. Remarkable resolution was observed within two weeks! How did the adjacent tooth play a role in this case?
While there is not abundant literature regarding endo-implant interactions, several interesting articles may shed some light. The article by Shaffer and colleagues1 mentioned by the authors concluded that "if endodontic pathosis is identified, root canal treatment or extraction should be initiated before implant placement to prevent microbial contamination of the implant during healing." That is common sense, and other articles such as the report by Novaes and colleagues2 show that careful alveolar curettage performed at the time of extraction results in implant integration, but with less implant-bone contact. Readers cannot determine by reading the JADA article how well the extraction sites had healed prior to implant placement.
In an article by Schwartz-Arad and colleagues,3 bone defects from teeth extracted for periodontic and/or endodontic infections were shown to be managed but required careful attention to provide adequate osseous support for the implants.
Recently, a research project reported by Shabahang and colleagues4 demonstrated that there was no difference in osseointegration in implants placed either adjacent to teeth with healthy periradicular tissues or infected teeth. While no one at this time would recommend placing implants near infected teeth, the results of this research project indicate that infected adjacent teeth may play less of a role in failures than other factors.
Many reasons for biologicial implant failures were discussed in the article by Esposito and colleagues5 that the authors quoted, including the presence of infected implants. It is quite possible that implant infection was the etiologic factor in all four cases presented by the authors, yet this possibility apparently was not considered.
In summary, the American Association of Endodontists’ position is that teeth with untreated endodontic infection should be treated prior to placement of an adjacent implant. The quality of the root canal treatment of an endodontically treated tooth should be carefully evaluated as part of the examination before treatment planning that may involve implant placement rather than after the implant fails.
With the emphasis that we currently place on evidence-based approaches to treatment, it is important that speculation be carefully identified as speculation with little or no scientific support.
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Case 1.
Case 2.
