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Implants in endodontics

From: "kendo" To: "ROOTS" Sent: Wednesday, July 01, 2009 8:33 PM Subject: [roots] Endo/Implant Algorithm...........still on the books lads content provided by : Implants in endodontics An interview with Dr. L. Stephen Buchanan, DDS A hot topic of debate has been whether or not implants have a place in today's endodontic practice. Dr. L. Stephen Buchanan, known in endodontics for his pioneering use of micro CT imagery and invention of instruments to provide pre-defined tapered shapes in root canals, has trained in implant placement. He took some time recently to talk with Endo Tribune about the implant specialty's impact on endodontics and why endodontists should be at least knowledgeable about it. Many clinicians, both specialist and general dentists alike, have expressed surprise and questioned the fact that a fair number of endodontists have started training up to place implants as a part of their practices. What is your take on this debate? While at first blush this seems to be out of the realm of endodontic therapy, I'd like to talk about the philosophical and practical reasons that endodontists need to explore this new direction in our field, at least as it is in the United States. First off, one of my concerns and experiences has been seeing endodontists cut out of treatment planning sessions for major and minor reconstructive cases, and it's not just in private practice, it's also happening in some universities. Some of the reasons are our fault and some are the fault of implant surgeons and prosthodontists. Our accountability in this situation has been that endodontists have typically not understood the prosthodontic imperatives of complex restorative cases and I've heard myself ask, "Why are they extracting that tooth and putting an implant in? It has good periodontal health, the tooth has structural integrity, and it's a pretty straightforward root canal." What I missed is what the prosthodontist has to deal with in trying to get an ear-to-ear reconstruction accomplished with a 20- or 30-year success afterwards. My implant education has taught me to have a different understanding of the relative importance of any given tooth. On the other side, there are too many situations where wonderful teeth have been extracted and I'm going to share a story told to me by the president of a leading implant company in America. This executive recently had root canal treatment on an upper first molar by a general dentist. He said the tooth never got comfortable, and after a month of continuing pain, he relayed this problem to an implant surgeon who pulled the tooth and placed an implant. Now granted, he probably didn't have to pay for the implant, but when I asked him what the symptoms were he said the tooth had continued to respond painfully to thermal stimulus-especially heat. This was a classic upper molar case where a 4th canal remained untreated, something that any specialist would have caught had they been in the loop. Tragic, don't you think? How do you answer the question, are we endodontists or endo-implantologists? Let's take a look at what has happened in the field of periodontics. We could easily see that back in the '80s and early '90s when implants first arrived as a credible treatment alternative to trying to save hopeless teeth, there was no part of the periodontal specialty committed to implant surgery, and yet they have been one of the biggest and most constructive players in the field since their entry. In fact, you may remember that the periodontists had to actually threaten Nobel Implant Company with a lawsuit alleging restriction of business practices when they would only let oral surgeons who had been trained by them place their implants. I think we need to start looking at ourselves as the "under-structure specialists." First and foremost, by getting involved in training up on the art and science of implants (whether you choose to place them or not), we can regain the dental profession's respect in the treatment planning process. For those who include implant procedures in their practice, we'll be offering our referring dentists the best treatment options for their patient. We're going to be the least biased specialists to answer the question, "endo or implant?" I think I'm going to be very proud of that in the next five to 10 years. Can endodontists be good at placing implants? Yes, definitely. Any endodontist worth her or his salt has been trained to do apical surgery on anteriors, pre-molars, and molars. Apical surgery on posterior teeth often involves being in the sinus cavity. This is because most of the palatal roots of upper molars are surgically approached from the buccal direction, often through the sinus. Our mandibular molar surgeries and pre-molar surgeries usually involve being near the mental foramen, the where the mental nerve bundle exits near the mandibular canal. We've learned how to take dimensions on our pre-operative radiographs, how to find and dissect the nerve bundle, or how to avoid it altogether. So we are comfortable operating in areas that may give other clinicians nightmares. Second, our abilities to carefully deal with soft and hard tissues are well known, especially since most of us use a microscope. When you start doing all of your incisions and suturing under 6-15x power, using 6-0 suture material is not a problem. Finally, we are extremely precision oriented. Most of us attempt working to within quarter-millimeter increments and we're certainly capable of achieving half-millimeter increments of accuracy. This will serve us well as we place implants, as one of the primary complaints of prosthodontists and restorative dentists is the imprecision of many implants after they are placed and the huge prosthodontic challenges of restoring a poorly positioned implant. What about the training? Without question training is paramount as well as the making and use of drill guides. For endodontists just starting out who already have a thriving endodontic practice and hard-learned professional credibility, they need to be certain to take all the necessary steps to assure a perfect outcome. It took me six months of training, including taking multiple courses, before I really felt like I had enough of a general understanding to be guided by my first mentor, Tom McGarry, a prosthodontist from Oklahoma City, Okla. Tom watched over my shoulder for my first two cases, and the outcomes were pretty nice. With drill guides, these are the levels of success you can have in your very first cases. Ironically, the use of drill guides is not common among all those who have been placing implants for years. Granted, my mentors, like Tom McGarry, Sascha Javonovic at UCLA, and the top implant and oral surgeons in Santa Barbara, have the experience to achieve nice results without it, but for those of us who are new to the game, I believe using model-based or CT-based drill guides is imperative. When I went to the Academy of Osseo Integration meeting in Seattle, I listened to a really brilliant guy, Gene Triplett from Baylor University, talk about the importance of drill guides- and this guy's been around the block in implant surgery. All the treatment planning is done beforehand. The soft tissue structures, the angle and position of the bony plates, and the angles and positions of the adjacent roots, are all taken into account before the patient is anaesthetized. Implant replicas are placed after alignment with a surveyor and the model-based osteotomy is done with a drill press. An implant replica is placed, onto which a drill guide sleeve abutment is attached-holding that sleeve in perfect position-and a light-cured acrylic occlusal stent is fabricated to capture that drill guide sleeve. With this pre-surgical preparation, the actual procedure is very quick and very precise. If you're lucky enough to have adequate attached gingiva, it can often be a flapless procedure and, when we take the final radiograph, we can get the same huge sense of satisfaction we get with an ideally treated endodontic case. With this preparation, we have ensured the accuracy of that placement so that our prosthodontic colleagues are going to have the aesthetic and functional outcome that they're looking for without a huge amount of complex machinations to get that abutment and crown in place. Is there anything else you'd like to say? Procedurally, doing endodontic treatment and re-treatment is way more challenging than doing implant surgery. The best way I can describe the difference between implant surgery and endodontic procedures is that, in root canal therapy, about 10% of the total time is spent in imaging, diagnosis, and treatment planning and about 90% of the time is needed to perform a procedure that is complex because we are seeing with our hands once we get past the orifice. In most implant surgery, the greatest challenge is in the treatment planning stage, where I spend 70% to 90% of my time. With that said, obviously, like endo, there are many hellacious implant cases that require a lot of time and a lot of skill during the procedure. To endodontists who are considering this new direction in their practices, who have taken some courses, and who have learned how to make drill guides, take the advice of one of my co-educators, Dr. Rick Sullivan at Nobel BioCare. He said when starting implant training you'll tend to have overambitious expectations about what you can accomplish in your first 12 months, but will most likely greatly underassess your capabilities beyond that point. Mandibular posterior cases are the place to start, followed by maxillary posterior cases, and last, consider anterior esthetic cases after a lot of training and experience. As a final word, I would never say that all endodontists should place implants and I doubt that more than 20% of us will do so in the next five years. Furthermore, to all of the established implant surgeons who have felt a spike of fear at the thought of endodontists doing implants, take a deep breath and remember we have been and will continue to be one of the greatest referral sources of implant cases. Those implant surgeons who are talented, self-secure, and share knowledge with endodontists will see their practices grow as have ours when we have helped our general practitioner colleagues in their endodontic endeavors. Endo Icon Castellucci Speaks An interview with Dr. Arnaldo Castellucci There's always a lot of controversy over who should do the root canal the general practitioner or a specialist endodontist. What are your thoughts on this? In my opinion, general practitioners should deal with the more generic cases, where they are one hundred percent sure that their knowledge is sufficiently good to furnish the patient with the same results as if an endodontic specialist was executing the work. However, if the case is complex and difficult, it is my belief that it is in the patient's best interest to refer the case to a specialist. In Italy we don't have post-graduate programs and we don't have any kind of specialties except for oral surgery and orthodontics. I limited my practice to endodontics 26 years ago after having my training at Boston University with Professor Herbert Schilder. Now, after so many years of experience, I am considered as a specialist despite my not having the certificate. Therefore, in Italy general dentists are not used to refer patients to specialists, because no such thing exists. As a result of the Italian system, I have a very specialized-and from some perspectives-limited practice. When general practitioners receive difficult cases, they refer to me and my colleagues while they treat the easy cases. I remember that when professor Schilder was president of the AAE, he wrote an editorial in the Journal of Endodontics saying that the future for specialists was represented by "retreatodontics." This he wrote in 1985 and he was absolutely right! Should there be a universial standard of care for endodontic treatment that both general dentists and specialists should follow? Absolutely. Again, general dentists can perform any kind of treatment as long as they guarantee the patient the same result as the specialist. And when the general dentist is not able to do this, he should refer the patient to the specialist. The success of a root canal will always ultimately hinge on how successful the clinician is in cleaning out the canals. What new innovations and technologies do you see that hold the most promise for improving endodontic results? The invention of NiTi instruments was a big, big improvement in the quality of root canal therapy in terms of shaping. Preparing the root canal system today is much easier and faster. Using NiTi rotary instruments and adhering to some basic principles, any general dentist can get wonderful results. In the near future, we will see surface engineering improvements made to NiTi instruments that allow them to be more resistant to breakage and to remain sharp longer. What we need to have in endodontics today is something that will allow us to clean the root canal system faster. Ultrasonics and better irrigating solutions will be the next major improvements. Sometimes, in relatively simple cases, the root canal can be prepared, shaped, and ready to fit the gutta-percha come in one or two minutes, sometimes even less. But two minutes are not enough to clean the root canal system. We need more time. So the root canal is ready to be finished but we still have to wait 30 minutes to an hour for the irrigating solution to work. So I see improvements needed in this field. We need to deliver the irrigating solutions with very narrow needles and to activate them with ultrasonics. This is what I anticipate and hope for in the near future. I trust that research is moving in the right direction to arrive at that point as soon as possible. We in the United States tend to feel that what we are doing in any given specialty is the highest standard. What are your thoughts on the state of endo in the U.S. vs. Europe and the rest of the world? The standard in the U.S. is really high, and this is of course because you have specialists. In the last 10 or 15 years, however, the standard of endo treatment in Italy has also become very high. I've been teaching endo for the past 247 years, and published my textbook 12 years ago and my endodontic journal nine years ago. I have a large group of people who follow not just me but other colleagues who, like me, have a limited endodontic practice and who teach, both privately and at the university. Italy has the largest endodontic society in Europe. We usually have more than 1000 people attending our annual meeting. This is a big achievement if you consider that we don't have specialties. Italy has about 40,000 dentists. I'm not saying that 1,000 people who attended the meeting have a limited practice, but they are very much interested in endo and the quality of the root canal therapy show in the presentations of Italian speakers reveals that the level of endo care here is very, very high. I'm proud of that. If you want to know the state of endo in Europe, I will tell you what Prof. Schilder wrote in the foreword of my textbook 12 years ago: "Italian dentistry is enjoying a renaissance no less spectacular than the intellectual, cultural, and artistic renaissance experienced in Florence in the 13th century. Nowhere in Europe presently is modern endodontics so much appreciated and nowhere does the profession reach out for more information about this vital field." Between your practice, your editing, and your writing and teaching, you keep a very busy schedule. How do you divide your time to manage it all? My mother-in-law used to call me a workaholic. I do work a lot. But I enjoy the work I'm doing and I remember there is an old Chinese saying, "If you are having fun while you are working, one day you can say that you never worked in your life." And I am having fun... I work with patients from 8 in the morning (which is quite early for Italian style) until 3 in the afternoon, every Monday through Thursday. Then in the afternoon I work on my endodontic journal and on my textbook or I prepare my lectures. Friday and Saturday I lecture either in my training center in Florence or around the world. I am divorced, and I consider myself very lucky, because I have a girlfriend who loves me a lot and never complains! Of course I try to spend as much time as possible with her and she always travels with me when I go around the world to lecture. We like to travel, we like to go skiing, scuba diving, and we have many things and interests in common. So far so good. ------------------------------------------------------------------------ Dr. Arnaldo Castellucci is author of the seminal "Endodontics." In addition to his practice limited to endodontics, he is a visiting professor at the University of Florence Dental School and also founder of the Micro-Endodontic Training Center, where he teaches and gives courses. He is the editor of the Italian Endodontic Journal and of the Endodontic Journal and of the Endodontic Informer, and also serves as editor in chief of the Endo Tribune.
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