Clinical Research

Comparison of Success of Implants versus Endodontically

Treated Teeth
James Porter Hannahan, DMD, and Paul Duncan Eleazer, DDS, MS

Abstract
Implants verses root canal therapy is a current contro-
versy in dentistry. The purpose of this investigation was
to compare the success of each treatment, with mini-
I mplant and endodontic treatments both are highly predictable procedures. Argu-
ments are often made that one treatment is more predictable than the other, but it is
difficult to make an objective comparison. Many of the classic endodontic success
mal subjective grading. Outcome was determined by studies show success as artificially low because of stringent definitions of success, such
clinical chart notes and radiographs. Failure was de- as total radiographic healing or lack of any of adverse signs or symptoms (1–3). It might
fined as removal of the implant or tooth. Uncertain be argued that survival is a better measure of success. Several studies base endodontic
findings for implants were defined as mobility class I or success on survival (4 – 6). Most implant outcome studies use survival as the sole
greater, radiographic signs of bone loss, or an addi- criterion (7). Other authors attempt to use more stringent clinical and radiographic
tional surgical procedure. Mobility, periapical index criteria to evaluate success (8). It remains difficult to compare the success rates be-
score of 3 or greater, or the need for apical surgery was
cause of differing methodologies and definitions of success.
classified as uncertain for endodontically treated teeth.
Numerous factors have been shown to contribute to the predictability of both
Success was recorded if the implant or tooth was in
implants and endodontically treated teeth. Factors that have been linked to implant
place and functional. Implants were placed by peri-
odontists in a group practice, whereas the endodontic
success are location in the mouth and type of restoration. Other patient factors such as
treatments were performed by endodontists in group
systemic disease, smoking, and bone quality have also been implicated as contributing
practice. Charts of 129 implants meeting inclusion cri- to lowered success. In addition, the type of restoration, occlusion, and esthetics play
teria showed follow-up of an average of 36 months roles in the success of the treatment. Other problems arise when evaluating endodontic
(range, 15–57 months), with a success rate of 98.4%. success. Prognosticators implicated most strongly are the presence of a preoperative
One hundred forty-three endodontically treated teeth radiolucency, the periodontal condition of the tooth, the quality of the fill and its length,
were followed for an average of 22 months (range, and the quality of the coronal seal. Host factors such as systemic disease appear to have
18 –59 months), with a success rate of 99.3%. No little correlation to endodontic success (9, 10).
statistically significant differences were found (P ⫽ Another factor that complicates comparison of the 2 treatments is the fact that
.56). When uncertain findings were added to the fail- the 2 treatments have different biologic factors related to their outcome. Endodontic
ures, implant success dropped to 87.6%, and endodon- failure is generally the result of infection (11–13). It is widely accepted that some
tic success declined to 90.2%. This difference was not portion of the root canal system provides a niche for infection to evade the body’s
statistically significant (P ⫽ .61). We found that 12.4% defenses. This niche might be a missed canal, infected dentinal tubules, or a portion of
of implants required interventions, whereas 1.3% of end- the canal that was not totally obturated, allowing a persistent biofilm. Implant failures
odontically treated teeth required interventions, which are usually a result of an inability of the body to tolerate the implant material. Failures
was statistically significant (P ⫽ .0003). The success of of implants occur during the treatment phase, immediately after placement, or later
implant and endodontically treated teeth was essentially during the maintenance phase. Early failures are generally the result of inadequate
identical, but implants required more postoperative treat- osseointegration and are attributed to formation of a fibrous connective tissue interface
ments to maintain them. (J Endod 2008;34:1302–1305) with the implant body. This type of failure is at the implant-bone interface, often caused
by overheating of the bone during placement or poor quality of the bone (14). Areas of
Key Words bone with large cancellous spaces such as the posterior maxilla have been shown to
Endodontics, implant, success have lower success rates as a result of the bone quality. Inflammation at the site of
placement increases the rate of fibrous connective tissue healing around implants.
Failures during the maintenance phase are generally caused by bacterial infection or
From the Department of Endodontics, University of Ala- biomechanical factors that progressively deprive the implant of osseointegration in a
bama at Birmingham, Birmingham, Alabama. process similar to that of periodontal disease around the implant body (15–17). Roos-
Address requests for reprints to Dr Paul D. Eleazer, Uni- Jansaker (18) noted progressive periimplant bone loss in conjunction with a soft tissue
versity of Alabama at Birmingham, Department of Endodon-
tics, 1530 Third Ave S, SDB 417, Birmingham, AL 35294.
inflammatory response as a “common” occurrence in implants 9 –14 years after place-
E-mail address: [email protected]. ment. The etiology of this disease is the accumulation of plaque around the implant and
0099-2399/$0 - see front matter restoration, which progresses to cause bone loss. Roos-Jansaker et al. (19) found a
Copyright © 2008 American Association of Endodontists. higher rate of periimplantitis in smokers and in patients with a history of periodontal
doi:10.1016/j.joen.2008.08.011
disease. Karoussis et al. (20) found a higher rate of periimplantitis among periodontitis
patients (28.6% vs 5.8%) and corresponding overall success rate (90.5% vs 96.5%).
Biomechanical factors also lead to problems during the maintenance phase. Ex-
cessive biomechanical forces on the implant lead to stress and microfractures in the
bone-implant interface, which manifest as loss of osseointegration around the neck of

1302 Hannahan and Eleazer JOE — Volume 34, Number 11, November 2008
 Clinical Research
TABLE 1. Sample of Data Collection Sheet data were collected from a periodontic practice and endodontic data
Implant Data Root Canal Therapy Data from patients presenting for routine recall or treatment of another tooth
at an endodontic practice. Charts were selected in alphabetical se-
Tooth # Tooth #
Patient age at treatment Patient age at treatment quence, with no exclusions made for systemic disorders, time of im-
Gender (M, F) Gender plant loading, or tooth implant position in the mouth, and were re-
Ethnicity Ethnicity viewed on patients with clinical and radiographic follow-ups more than
Smoker (yes, no, no. of y) Smoker (yes, no, no. of y) 1 year after treatment. Table 1 depicts the data collected. The clinical
Diabetes Diabetes
Presurgical procedure Most recent recall data were gathered from the chart notes, and radiographs were evalu-
Most recent recall Radiographs taken at ated and graded by the principal investigator. Implants were loaded by
recall agreement with the periodontist and the restoring dentist, typically
Radiographs taken at recall Root canal therapy tooth shortly after uncovery. All restorative treatments were completed by the
in function
Implant in function Root canal therapy tooth patient’s general dentist. Success was defined as radiographic evidence
present in mouth that the implant or treated tooth was still present in the mouth, and that
Implant present in mouth No. of appointments there was no notation of signs or symptoms requiring intervention dur-
Periimplant radiolucency Obturation length ing the follow-up period in the chart notes. Uncertain findings were
Mobility Post present
Post-treatment intervention Preoperative area defined for implants as charted mobility greater than class I, radio-
Intervention time Post-treatment graphically detectable bone loss, or additional surgical procedure re-
intervention quired. Typical surgical interventions for implants were flap exposures
Endodontic treatment Intervention required
adjacent to implant (yes, no)
for debridement, with or without grafting osseous material. Uncertain
Brand of implant Periapical index findings for endodontic treatments were defined as charted mobility
Length of implant (mm) greater than class I, radiograph judged as periapical index score of 3 or
Width of implant (mm) greater (Table 2), or orthograde endodontic procedure or apical sur-
Bone loss (mm)
Healing after extraction
gery required (22). Preoperative values were not considered.
Time to uncovery/function Failures were defined as removal of the implant or tooth. For a
summary of the definitions used, see Table 3. The data were recorded
and graded by the primary investigator. The Fisher exact test was used to
compare the success of both treatments.
TABLE 2. Summary of Periapical Index Scoring System Used to Grade Endodontic
Treatments (13)
PAI 1 Intact PDL Results
PAI 2 Possible broken PDL
PAI 3 Broken PDL One hundred twenty-nine implants met the inclusion criteria. The
PAI 4 Break in PDL with possible radiolucency average recall was 36 months, with a range of 15–57 months. Seventy-
PAI 5 Broken PDL with definite radiolucency seven implants were in the maxillary arch and 52 in the mandible.
PAI, periapical index; PDL, periodontal ligament. Eighty-nine were anterior implants, and 40 were posterior. One hun-
dred forty-three endodontically treated teeth met the inclusion criteria,
the implant. Rarely forces can be produced that fracture implant com- with an average recall time of 22 months and a range of 18 –59 months.
ponents or even the implants themselves (21). Ninety-nine molars were treated endodontically, as were 26 premolars
Because of the vast differences in the 2 treatments and the methods and 18 anterior teeth. The treatments were scored on the clinical and
used to evaluate them, the clinician is faced with a dilemma when at- radiographic findings as described in Table 1. Of the implants only 2
tempting to determine which treatment is most appropriate. Survival is were lost, for a success rate of 98.4%. Of the endodontic treatments only
a way to determine whether the treatments are providing patients with 1 was lost, for a success rate of 99.3%. The differences were not statis-
functioning members of the dentition. There are many factors that con- tically significant with Fisher exact test (P ⫽ .56). Fourteen implants
tribute to the outcome of each treatment, but there are few studies were scored as uncertain, whereas 13 endodontically treated teeth were
directly comparing the 2 treatments. The purpose of this project was to placed in the uncertain category. No statistically significant difference
directly compare the outcomes of implant treatments and endodontic was found between the uncertain findings with Fisher exact test (P ⫽
treatments. .69). When uncertain findings were added to the failures, implant success
dropped to 87.6%, and endodontic success declined to 90.2% (Fig. 1).
Materials and Methods Again this difference was not statistically significant (P ⫽ .61). However,
This study was approved by the University of Alabama at Birming- 12.4% of implants required interventions, whereas only 1.4% of end-
ham Institutional Review Board as a chart review study. A chart review odontically treated teeth required interventions (Fig. 2). This difference
was carried out in 2 group specialty practices in the same city. Implant was statistically significant (P ⫽ .0003).

TABLE 3. Definitions of Criteria Used to Evaluate the Procedures

Failures Uncertain Findings Success
Implants Removal of implant Mobility class I or greater, radiographic signs of No additional procedures
bone loss, additional surgical procedure
needed
Endodontic Removal of tooth Mobility class I or greater, periapical index score No additional procedures
treatment of 3 or greater (definite presence of
periapical rarefaction), apical surgery needed

JOE — Volume 34, Number 11, November 2008 Success of Implants versus Endodontically Treated Teeth 1303
Clinical Research
100

80

60
Percent Implants n=129
40
Endodontic
20 Treatments
n=143

0
Implants n=127, Endo n=142 Implants n=14, Endo n=12 Implants n=113, Endo n=130
Successes (minus failures) Uncertains Successes (minus failures and
uncertains)

Figure 1. Outcomes. No statistically significant differences were found. Successes minus failures (P ⫽ .56); uncertain group (P ⫽ .69); successes minus failures and
uncertains (P ⫽ .61).

Discussion the mouth or type of treatment. Endodontic treatments were counted

There appears to be little difference in the success of the 2 treat- equally if they were retreatments, or if they were initial treatments.
ments. Both implants and endodontically treated teeth appear to func- Implants included 1-stage and 2-stage treatments. All treatments were
tion with few problems. Although the sample was relatively small, it weighted equally, regardless of any complexities of treatment. Evidence
indicates that both therapies are equally successful when judged by suggests that systemic disease has little effect on endodontic success,
similar standards. Our observation is in agreement with Iqbal and Kim whereas many such conditions might lower implant success. Doyle et al.
(23), who found no difference in long-term prognosis between single- (9) found that no appreciable difference in outcomes existed for dia-
tooth implants and restored root canal–treated teeth. betes mellitus patients versus other implant or endodontic patients.
The only significant difference in the 2 groups was the percentage Periapical pathology was present in the sole tooth lost in the endodontic
that required post-treatment interventions. Implants required addi- group. The quality of the bone at the placement site might affect the
tional procedures more frequently than endodontically treated teeth. ability of the implant to osseoinetgrate. The presence of periodontal
Perhaps the shorter recall times for endodontic treatments were not disease and caries is believed to lower the success of implant treatment,
long enough to observe a problem. Patients continuing treatment in the because oral hygiene is important in the prevention of periimplantitis.
same specialty office could select for patients with problems, or it might All of these factors must be considered before treatment.
select for those satisfied with their outcome, although the periodontists Balevi (24) and Torabinejad et al. (25) performed meta-analyses
having longer recalls were forced or were more willing to recom- and found direct comparisons of endodontic and implants to be quite
mend additional surgical procedures. We were not able to draw any rare. This study used preliminary data from a large study currently
conclusions on systemic disease and treatment outcome. The small underway.
number of patients with systemic disease in our sample made it
impractical to attempt to correlate systemic disease with outcome. Acknowledgments
The data were collected as part of a larger project comparing im- Research was funded in part from a grant from AAE Foundation.
plant and endodontic outcome funded by the American Association
of Endodontists that will have more robust numbers to draw more
powerful conclusions. References
The practice experience of all the operators was relatively similar 1. Friedman S, Abitol S, Lawrence H. Treatment outcome in endodontics: The Toronto
in length of time they had been practicing. Also the restorative work was Study—phase 1: initial treatment. J Endod 2003;29:787–93.
all completed by the referring dentists, giving another measure of sim- 2. Ingle JI, Beveridge EE, Glick DH, et al. Modern endodontic therapy. In: Ingle JI.
Endodontics, 3rd ed. Philadelphia: Lea and Febiger, 1985:26 –50.
ilarity. The difference in group sizes was due to time limitations available 3. Swartz DB, Skidmore AE, Griffin JA. Twenty years of endodontic success and failure.
in the different practices. J Endod 1983;9:198 –202.
The only criterion for inclusion was a recall of more than 12 4. Alley BS, Kitchens GG, Alley LW, et al. A comparison of survival of teeth following
months. No attempt was made to make any distinction on the location in endodontic treatment performed by general dentists or by specialists. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2004;98:115– 8.
5. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient populption
14 in the USA: an epidemilological study. J Endod 2004;30:846 –50.
12 Implants n=16
6. Lazarski MP, Walker WA, Flores CM, et al. Epidemiological evaluation of the out-
10 Endodontic Treatments comes of nonsurgical root canal treatment in a large cohort of insured dental pa-
n=2
tients. J Endod 2001;27:791– 6.
Percent

8
6 7. van Steenberghe D. Outcomes and their measurement in clinical trials of endosseous
4
oral implants. Ann Periodontol 1997;2:291– 8.
8. Misch CE, Perel ML, Wang HL, et al. Implant success, survival, and failure: the
2
International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference.
0 Implant Dent 2008;17:5–15.
Implants n=16 of 129,
Endo n=2 of 143 9. Doyle SL, Hodges JS, Pesun IJ, et al. Factors affecting outcomes for single-tooth
Surgical Intervention implants and endodontic restorations. J Endod 2007;33:399 – 402.
10. Alley BS, Buchanan TH, Eleazer PD. Comparison of the success of root canal
Figure 2. Percentage of treatments requiring intervention after initial treatment. therapy in HIV/AIDS patients and non-infected controls. Gen Dent 2008;56:
Difference is statistically significant (P ⫽ .0003). 155–7.

1304 Hannahan and Eleazer JOE — Volume 34, Number 11, November 2008
 Clinical Research
11. Sundqvist G, Figdor D, Persson S, Sjogven U. Microbiologic analysis of teeth with 19. Roos-Jansaker AM, Renvert H, Lindahl CH, et al. Nine- to fourteen-year follow-up of
failed endodontic treatment and the outcome of conservative re-treatment. Oral Surg implant treatment: part III—factors associated with peri-implant lesions. J Clin Peri-
Oral Med Oral Pathol 1998;85:86 –93. odontol 2006;33:296 –301.
12. Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth can fall. 20. Karoussis IK, Salvi GE, Heitz-Mayfield LJ, et al. Long-term implant prognosis in pa-
Int Endod J 2001;34:1–10. tients with and without a history of chronic periodontitis: a 10-year prospective
13. Chavez de Paz LE. Redefining the persistent infection in root canals: possible role of cohort study of the ITI Dental Implant System. Clin Oral Implants Res
biofilm communities. J Endod 2007;33:652– 62. 2003;14:329 –39.
14. Jaffin RA, Berman CI. The excessive loss of Branemark fixtures in type IV bone: a 5 21. Newman NG, Takei HH, Carranza FA. Carranza’s clinical periodontology. 9th ed.
year analysis. J Periodontol 1991;62:2. Philadelphia: WB Saunders Co, 2002:931– 42.
15. Kozlovsky A, Tal H, Laufer BZ, et al. Impact of implant overloading on the 22. Orstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radio-
peri-implant bone in inflamed and non-inflamed peri-implant mucosa. Clin Oral graphic assessment of apical periodontitis. Endod Dent Traumatol 1986;2:20 –34.
Implants Res 2007;18:601–10. 23. Iqbal MK, Kim S. A review of factors influencing treatment planning decisions of
16. Tabanella G, Nowzari H, Slots J. Clinical microbiological determinants of ailing dental single-tooth implants versus preserving natural teeth with nonsurgical endodontic
implants. [published online ahead of print April 1, 2008]. Clin Implant Dental Relat therapy. J Endod 2008:34:519 –29.
Res.doi:10.1111/j.1708-8208.2008.00088.x. 24. Balevi B. Root canal therapy, fixed partial dentures and implant-supported crowns,
17. Schwartz-Arad D, Laviv A, Levin L. Failure causes, timing, and cluster behavior: an have similar short term survival rates. Evid Based Dent 2008;9:15–7.
8-year study of dental implants. Implant Dent 2008;17:200 –7. 25. Torabinejad M, Anderson P, Bader J, et al. Outcomes of root canal treatment and
18. Roos-Jansaker AM. Long time follow up of implant therapy and treatment of peri- restoration, implant-supported single crowns, fixed partial dentures and extraction
implantitis. Swed Dent J Suppl 2007;188:7– 66. without replacement: a systematic review. J Prosthet Dent 2007; 98(4):285-311.

JOE — Volume 34, Number 11, November 2008 Success of Implants versus Endodontically Treated Teeth 1305