8. Prognosis, Endodontics and Implants Flashcards Preview

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1
Q

Endodontics is NOT merely restricted to root canal treatment (RCT). Below shows us other endo- associated procedures and tx (e.g. sometimes failed tx requires a “redo” that may be done in a surgical or non-surgical way).

• We’ll learn more about these later on (after the exam)
• Follow these arrows from diseased tooth (assume apical periodontitis) to extraction to dental
implant and conventional restoration.
• Sometimes we have to make the call whether to extract or save a tooth, do an RCT or
implant. Many factors bear on the decision-making process: amount of remaining ____, broken file in the tooth, extent of ____.
• Debate (~15 yrs) on implants – critiques the position in dentistry that “implant is better” – just take out and replace the tooth with an implant that “lasts forever.” Growing body of research (w/in last few yrs), however, supports that retaining the ____ tooth at certain periods of human life-cycle may have better outcomes.

A

tooth structure
apical periodontitis
natural tooth

2
Q

Endodontic Outcome

  • no clinical signs and ____
  • reconstitution of ____
  • intact ____

What kinds of criteria would we include to evaluate and gauge successful endo tx objectively and predictively (e.g. so we know another patho won’t occur later)?
• Resolution of ____ - Pt doesn’t present with any follow-up symptoms at any period.
• ____ measures - AP presents as a radiolucency, so we want to see this go away. More affirmatively, we’d like to see no inflammation but rather marked healing of the PDL structure.

A
symptoms
PDL
lamina dura
symptoms
radiographic
3
Q

Endodontic Outcome

Discussions on endodontic outcomes go hand-in-hand with surgical procedures and prognosis. Will talk about changes in tx protocols, modern techniques, etc. and also surgical re-treatments.

Key issue – Most of the time, from an historic outcome analysis, ppl were looking at strict outcome criteria. What’s the biological goal of successful endo tx? Prevention and elimination of ____.

• In the past, people scrutinized and evaluated the outcome of said biological goal. Hence, they looked at cases where AP was present. To what % rate, after tx, did we cure that periodontitis in terms of preventing future AP occurrence? With an irreversible pulpitis (IP), what’s the % probability that we are able to prevent subsequent AP to occur?
• First of all, how/why would AP occur after you treat a tooth with IP?
(a) ____ (e.g. microbes may be introduced via contaminated files or other equipment) and/or
(b) faulty ____ (e.g. placing a weaker temp vs permanent restoration; or in the future, restoration degrades permitting microbial infiltration via ____.

A

apical periodontitis
iatrogenically
restoration
coronal leakage

4
Q

Endodontic Outcome

And, it’s exactly these 2 criteria (above), that ppl in the past examined more formally encompassed by the ____ Criteria (1956) when doing regular endo tx including initial tx and non-surgical retreatment (e.g. follow-up RCT). The ____ (PAI) by Norwegian Dr. Ostervik also includes these outcome criteria.

  • Caveat – PDL may be ____x wider than normal: both indices take into account limitations of less biocompatible filling materials in the past. Therefore, in a sense, a foreign body (filler) is still present in RC. This is why PDL is permitted to be ____ in some areas where filler is located. Nonetheless, want to see dramatic return of PDL.

Continued (previous slide): Want to see Pt is free from any clinical signs & symptoms (S&S).
• No ____: Check to see if Pt has any tenderness to percussion, palpation, or even without any
stimulus.
• Painless ____: Sinus tract (see image in previous slide)

A

stringdberg criteria
periapical index
2
wider

pain
indications

5
Q

Below show the results of meta-analyses focusing on outcome (success & failure) evaluations of endo tx.
• “Why is it imp for us to do meta-analyses in dentistry?” Gives us more ____, valid results.
◦Problem in dentistry - frequently small studies are published, but ____ sample sizes are challenged w obtaining statistically significant results between 2 diff outcomes.
‣ Hypothetical example of a study comparing the efficacy of a new vs old endo sealer: (a) small study - if findings reveal 8% difference between Intervention A (n=50) and B (n= 35), would not be statistically significant; but in the context of a (b) ____ study that yields same 8% difference btw A (n=600) and B (n=600), results would be significant!

A

accurate
smaller
larger

6
Q

Summarizing the issue in dentistry: In medicine, it would be much easier to find a large # (~1000) of willing patients to participate in a study of a new vs old diabetes drug. However, if you were to do a clinical trial comparing 2 interventions in dentistry, it’d be much more difficult to standardize, treat, and recruit comparable # of subjects and follow them longitudinally, etc. This is why we have much more ____ sample sizes.
Not very good for us mainly for 2 reasons:
(1) Tells us there was a lack of designing adequate ____ trials in the past (2) Evidence level we have is ____.

A

smaller
clinical
low

7
Q

Mentions article sent by librarian from “Atlantic” illustrating impact of low evidence-based dentistry:

(1) Ethical issues assoc w “over-treatment” - describes situation of 1 California provider who grossly over-treated Pts; would do xs # of RCTs and cap with lots of crowns for majorty of patients raising ethical issues of how much we should treat. Without much evidence-based dentistry, difficult to ascertain how ____ tx should be.
(2) There’s actually a very low level of acknowledging and following ____-based procedures in dentistry. ** Doesn’t actually like the article, says there are inaccuracies. Whatev.

A

extensive

evidence

8
Q

• Shows the positive, success outcome (68-85% in which AP healed or was prevented) of initial endo tx (including vital cases) based on an MA of studies from 1950s - 2000s. 63 studies met inclusion criteria.

Criticism takes issue with the lack of ____ among studies bc endo techniques evolved over time; thus, a variety is represented in this MA. Still, this is all we have. No one has done a repeatable new study on the effects of modern endo techniques and equipment (e.g. microscope, nickel-titanium instruments). Studies are being done but haven’t been ____ for whatever reasons.

A

homogeneity

published

9
Q

RCT: obsolete techniques included in meta-analyses

Main idea: It’s hard to compare and apply old studies to ____:
• In the 50s - there were no rotary instruments, Gate’s burs, nickel-titanium files - things that came out in
the 90s. There was nothing like IOS standardization (e.g. companies produced their own kinds of files with their respective labels and sizes) - “it was totally wild.” At some point, professionals in the field decided on standard file sizes (10, 15, 35, etc.), tapers (0.02, etc.), 16mm working-end, etc. so methods could be comparable. Main idea: Makes these studies harder to compare to ____ studies.
• 60s - Still doing hand instrumentation. Difficult to work with less flexible stainless steel files with curvy roots, so couldn’t instrument to the extent that we can now and clinicians were more prone to ____ RCs (see image w circle). Consequently, couldn’t ____ as much bacteria. Not imp to know specific details, but again challenging to compare these old studies with today.

A

modern times/conditions
modern day
perforate
eliminate

10
Q

Success Rates (Green figure)

Irreversible pulpitis (IP): Based on very strict outcomes outlined in Strindberg Criteria or PAI, successful initial endo tx occurs in more than ____% of vital cases w IP - meaning the infection was successfully eliminated out of the RC system, the PDL remained free of inflammation around periapical tissues, and AP did not develop after tx.

Necrosis / AP: Success rates in MA vary across time; more modern and isolated studies often report success rates over ____% of healing of AP. If we sort out and compile all the necrosis/AP studies out of the MA shown previously, we find about a ~____% success rate will heal the AP typically over the course of 1yr (the follow-up time we have) and ~____% still present with AP (may be less severe, asymptomatic).

A

90
90
75
25

11
Q

Survival rate (red figure): People looked at the long-term functionality of a tooth post-RCT ignoring any aspects of ____ healing (e.g. size of lesion, whether still present, etc.). Just concerned w whether tooth is still there and functioning. These survival criteria are actually comparable to most implant studies out there, if you know that ____% of teeth post-RCT still survive 8-12yrs later.

So, based on the studies we have, we can tell a Pt, recommended for RCT, that s/he will most likely still have that tooth in their mouth - ____ - ____ years later! Nice.

A

AP
93-97
asymptomatic
10

12
Q

Indeed, ~10yrs ago, implants were touted as the “ultimate” tx in the field. Below summarizes criteria put forth by an influential clinician in restorative dentistry and implantology.
• Reads all the points. Main idea: There are many reasons to extract and not save!

◦Extract:
‣ PAR = periapical ____
‣ “These numbers by the way are completely arbitrary and have no meaning in the context of AP healing.
◦Save: Only 2 situations listed! Both of which sound sketch.
In sum: He’s not opposed to implants, but in the context of over-treatment, we need to critique this position by looking at the most recent literature in order to find out other tx avenues.

A

radiolucency

13
Q

Extract

  • If perio surgery will reduce ____ tissue
  • If surgery will compromise the ____
  • If patients need RCT & post & crown & crown lengthening under previous crown
  • If patient has a high ____ rate
  • If patient is prone to periodontitis
  • Preservation may risk more ____ loss because of future infection
  • If tooth needs RCT and has a 5 mm PAR
  • Tooth and post will not withstand ____ without risk of fracture

Save

  • If two implants will be ____ to each other, then save one [tooth] if possible
  • If the patient has an ____ breakdown when you mention the word extraction
A
facial
papilla
decay
bone
occlusion

adjacent
emotional

14
Q

Here’s case from Philly: A GP referred Pt to a periodontist
Patient presents w mesial pocket (green arrow) on #12 (slides says 24 - that’s wrong).
Periodontist says: “Must be a perforation on the post after the RCT. That’s why there’s a lateral lesion on that premolar, or there’s a fracture.”
What to do? If you take a CT, it would show you if there was a post-peforation but not a fracture.
◦Long story short… they extracted the tooth and did an implant. Also placed an implant in the edentulous space for the 1st molar. There was ____ wrong with it though.

Also extracted #13 bc from a prosth point-of-view, it had an ____ root, which is not great for placing crowns. So, it was replaced with a 3rd implant.

‣ What do you see when we look at the #13 implant? It appears to be in the ____ (cou be but can’t tell for sure bc it’s a 2D image).

A

nothing
S-shaped
sinus

15
Q

3mo later, Pt developed periapical sinus tract on the 3rd implant that was placed.
• Why? Periodontist and oral surgeon said it could have been due to (a) over-____ of implant while it
was placed, or (b) the ____ - there may have been an infection before tx or introduced during tx

Finally, there was NO fracture or perforation on #12. So, what would you do? I would take the implant out. But, what they did was “cut it off at the ____,” which is ridiculous bc imagine the heat generated drilling through 3.8mm of titanium! And also, it didn’t do anything bc the infection still persisted in the periapical area of the remaining implant structure. So, in the end, they had to remove it!

Over-placement of implants could have been prevented bc, in the end, they concluded that the initial presentation (4-5mm mesial pocket on #12) was an oral hygiene and periodontal issue. In fact, given the concavity of their roots, maxillary premolars often present with lesions encountered in this case. Because of over-confidence and over-tx, Pt has 2 implants (3rd taken out). Sad outcome.

A

treatment
sinus
end

16
Q

Do we know enough about the long-term success of implants?
… most implants function year after year without any problem. Then there are a few patients who lose their implants and why not? All spare parts that you place in the body are associated with some complications….

The drawback is of course that many dentists find it ____ to remove a tooth and place an implant than to use the data in the literature to treat the tooth for its conditions. So maybe there is an ____ of implants in the world and an underuse of teeth as targets for treatment…

Reads excerpt: “Do we know…?”
◦Draws attention to the implant debate.
‣ Over-implanting is also profit-driven. There’s more money for private practices to do them. They’re also easier to do than ____ for natural teeth.
Summarizes red text.

A

easier
overuse
treatment planning

17
Q

Long-term Success?

Implants do not exceed the life ____ of natural teeth at 10 years, including endodontically treated or periodontally compromised teeth.

Over 5-10 years 16-28% of implant patients suffer from ____, with a higher percentage associated with ____ implants.

The loss rate of teeth is ____ than that of dental implants implants in patients that are clinically well-maintained.

A

expectancy
peri-implantitis
multiple
lower

18
Q

… until this 2013 systematic review shook things up.
• JADA is a reputable journal in the field with wide reach. Could not do an MA bc studies in the literature were not sufficiently ____.
◦One of their inclusion criteria were studies with follow-up periods of +____yrs (super difficult to find!). Also included cases that were perio, endo, and prosth-involved.

Key issue identified: Loss rate of natural teeth over 15yrs was ____ than dental implants.

A

homogeneous
15
lower

19
Q

Moreover… they didn’t just focus on only 1 particular aspect of the treatments but also noted that there are a lot of issues with system compatibles.
• What? Meaning a lot of ppl didn’t know what kind of ____ was placed. Without being identifiable, no one could consult the right corresponding implant company for ____. Thus, many implants were rendered unrepairable.

◦There’s now a website, whatimplantisit.com, to help identify an implant among the hundreds of lesser known “fringe” systems that currently on the market on top of the 5-6 well-knowns.
‣ Clinicians that provide “fringe” implants may create problems for Pt if the company goes bankrupt and a replacement part can’t be ____. He recalls situations like this in the past.

A

implant
repairs
repaired

20
Q

Major recommendation of paper focuses on young ppl - There are reasons we should attempt to preserve teeth for this demographc.
• Growth of facial tissues continues after ____ (even in your 30s!) - e.g. super eruptions of teeth may occur and changes in cranio-facial skeleton. This has major implications on esthetics. For instance, if you place an implant, it is ankylosed to the bone via osseous integration and will, thus, not move around. However, in young pts, adjacent teeth may still ____ and super-erupt leading to unesthetic outcomes (e.g. high-low-high “step” pattern of teeth.

A

puberty

migrate

21
Q

• Reads text in blue box - extrapolating from this, if a young pt were to lose the first implant, placing a 2nd implant in that same spot would be more difficult. For instance, an implant may have peri-implantitis with 3-5mm of bone attachment in the apical portion. A natural tooth in this situation would have mobility and can be extracted very easily (thanks to degraded PDL). But with an implant w no mobility, you’d have to ____ it out due to osseointegration! So you’d need a special (sounds like “Threffing”) bur to remove it. However, you’ll create a bone ____ (larger than before) in the process requiring augmentation procedure and a lengthy ____ stage.
◦Unfortunately, some studies have demonstrated that bone grafting outcomes tend to be ____ in these types of implant cases.

In light of the findings of an estimated “life-expectancy” of 20 yrs for implants, if you give a young pt an implant around 35yrs, they’d have to get a replacement at 55yrs, 75yrs, etc. Bc natural teeth last longer and subsequent implant replacement has ____ outcomes, it’s better that we try to preserve rather than extract teeth.

A
drill
defect
healing
lower
poorer
22
Q

Relevant part:
Looking into the incidences of peri- implantintis and marginal gingivitis on implants. This article was controversial b/c of the incidence rate of peri- implantitis.

They did studies on thousands of patients and implants and a meta analysis that they did on all the studies published previously, and there is true evidence out there that there is a high rate of ____.

A

peri-implantitis

23
Q

“The erroneous belief of implants yielding a better long-term prognosis has now clearly been ____ in several comparative studies….”

A

rejected

24
Q

Peri-implantitis

The typical radiographic sign is:
You normally want to see the bone level to the ____ thread (upper red line), but if it recedes further (lower red line), then you get an area that is ____ to clean. And if the patient has an infection then it is something that is very difficult to clean.

A

first

difficult

25
Q

Relevant info: Out of the over a thousand patients they had, randomly 588 of them presented with ____. This is an extremely high rate.

“….a call to action to re- visit the long history of success of tooth main- tenance to preserve the ____ dentition without rush to extract teeth and replace with ____”

A

peri-implantitis
natural
implants

26
Q

Branemark invented implants for totally different applications such as attaching ____ parts: hip implants and artificial ears, etc. Dental implants were a spin off to that. This guy did his research on bone circulation and physiology at Columbia University at the same Dr Kim was doing pulp biology and physiology in the same lab.

Dr. Kim went to Sweeden invited by Dr. Branemark and in Sweeden became one of the first dentists to practice implanvology.

Dr Setzer refers to the old implants as the blade implants and the fibrous-osseous integrated type. And as “implants” to the osseous-integrated ones we now have today. Osseo-integration came from a rabbit femur experiment, a bit of an accidental experiment.

A

body

27
Q

We do an excursion to other types of prognosis b/c there is much more to saving an actual tooth, and comparing it to an implant, than just endodontics. We have to look at the tooth as a whole including the ____ of the tooth plus the ____ of the tooth plus the ____ you have on the tooth afterwords, and how it is integrated into the whole ____ rather than just looking at an apical periodontitis. People are using the outcome rates for apical periodontitis healing to compare to implant survival.

A

periodontal status
restorability
restoration
arch

28
Q

Compromised Teeth

Questionable Prognosis
Greater than ____% attachment loss, Class ____ or Class ____ furcation involvement and difficulty to maintain, ____+ mobility or greater

Hopeless Prognosis
____ attachment to maintain the tooth, ____ suggested

A
50
III
II
2
inadequate
extraction
29
Q

Compromised Teeth

They were actually very predictable in terms of the first ____ categories, but unpredictable to really say that a tooth with a questionable prognosis would truly be going to be lost after ____ years. They surprised themselves that actually of the teeth that were questionable were still ____.
All of the teeth on the slide were questionable or hopeless. They are from a patient of Dr. Mortom Amsterdam in the 60s.
B/c person has advanced bone loss, the teeth are compromised and extraction is recommended.

A

three
five
there

30
Q

So in 1968 (first row on radiograph) there were only a few options for this patient: extract all teeth and do complete dentures, extract some teeth and do partial dentures, or try to save them.

For research purposes Dr. Amsterdam tried to save them, although Dr Setzer would not necessarily recommend we do that because the person has ____ bone loss. The point of Dr. Amsterdam’s study is to show that classic ____ treatment (SRP, hygiene, restoration of the teeth) is something that works.

In 1971 (fourth row), bone levels have re-established themselves. The splinted the teeth so they are supporting each other. They took roots out that were \_\_\_\_, they did endo treatment, and large restorative treatment. The patient is coming for a meticulous follow-up to prevent periodontal disease from reoccurring.
1988 follow up, dentition is still \_\_\_\_. This is not something Dr. Setzer recommends b/c we now have other treatment options.
So, \_\_\_\_ disease is not necessarily a very bad predictor for the long term survivability of the tooth.
A
advanced
periodontal
hopeless
there
periodontal
31
Q

Periodontal Prognosis

Biologic Factors – Treatment of periodontal disease is highly ____ except for ____ teeth

After the hopeless teeth are actually extracted, for those teeth that they did perio treatment on eventually, is somewhere between ____% to over 95% of the teeth are still going to be there. So perio and hygiene treatment along with patient compliance, are highly successful.

A

successful
questionable
90

32
Q

“Furcation involvement”

So you hear about this issue with furcation involvement. It used to be an automatic ____. It used to be, even at Penn, that for any furcation involvement in a molar, the tooth has to come out. This is something that is very dependent, in terms of survival of the tooth, on patient ____, etc.

A

death sentence

compliance

33
Q

Furcation Involvement

Decision making: ____ of the tooth / root resection / extraction
Influencing factors: tooth ____, tooth position, lack of occlusal ____

A conservative approach to the molars with even deep furcation invasions may show a high long-term success rate with ____ care.

With the right treatment and right indication for maintaining the teeth, only maintenance of those that they saved (over 2/3 of them), after 8-12 years 96% of them were still in function. And almost 90% of the ones they they did a root were still in function.

Almost 75% of those molar with a furcation involvement over a period of 8-12 years were still ____ if you treat the patient correctly, the tooth correctly, and have the maintenance.

A

maintenance
mobility
antagonism

maintenance
there

34
Q

If it’s not even a perio issue, furcation involvement has to be diagnosed by ____, etc, not only by ____.

A

probing

radiograph

35
Q

Limiting factors: restorability

What is absolutely correct is: one of the most important issues for the long term survival of a tooth, besides the periodontal disease, is ____ of the tooth.

A resident was told it would be a crime to try to save the tooth on the x-ray, b/c there was some furcation probing. But if you look at the remaining tooth structure, Dr. Setzer has no idea why the tooth should be non-

So a root canal treatment is done, there is no sign of any apical periodontitis, there was only some minimal probing in the furcation.

You don’t even need crown lengthening because it has sufficient crown level. And when working on this tooth no one should be ____ because of restorability.

A

restorability

limited

36
Q

Limiting factors: Restorability
- Biological factors

Patients with a history of recurring caries may be better off with implants

When we look at restorability of the tooth is #1. The loss of tooth structure (internal such as inside the root structure, or external such as when a cusp is gone), so if there is too much ____ gone and you have many procedures necessary (crown lengthening, etc), sometimes it is better to ____ the tooth.

We could always do a root canal treatment but it may not make sense b/c too much ____ already destroyed the tooth and you have loss of tooth structure.

A

structure
extract
caries

37
Q

Limiting factors: restorability
- biological factors

This is something also with limitations to it. You cannot save the tooth if too much is gone

____ involvement?
Deep nom eradicable ____
Extensive ____ loss
____ with pocketing and bone loss

A

furcation
pocket
bone
mobility

38
Q

Limiting factors: restorability

Now the restorative aspects. If you have a broken instrument, furcation issue, perforation and the red area (circled in yellow) is loss of tooth structure: that is a tooth that really needs to be ____ out.
This tooth, Dr. Setzer did the root canal treatment and the tooth has mesial-buccal root canal splits. Today, Dr. Setzer would never do the root canal treatment again. One year later, the patient had not had the tooth restored and walks around with the buildip

So you can look at it from two different aspects:
(1) Tooth is functional but (2) most likely the person is gonna get a lot of ____ problems b/c the tooth was deeply destroyed and has a lot of loss of tooth structure. So Dr. Setzer should have looked at ____ from the very beginning to actually be able to establish sound crown margins and acceptable biological width to ensure the patient stays healthy with the tooth. Dr. Setzer ignored how much tooth structure was gone on this case.

A

taken
periodontal
restorability

39
Q

Implant outcome

“… long term studies n confirm a success rate of over ____% after 10 years…”

… careful ____, proper implant placement, regular ____ … and good oral hygiene are significant factors that influence the long term success …

Dr. Setzer comments: Success implies everything is great. 95% after 10 years is really awesome. But then you read the small print (in red). So all things have to be perfect in order to get the 95%

There is a lot more issues with implants than just blank numbers. There is hardly any agreement what success actually means in implanvology and most of these studies actually have an extremely selected patient population when the studies were done.

A

95
treatment planning
follow-ups

40
Q

Inclusion and Exclusion Criteria

Patients with a high risk of implant failure - excluded
- ____ habits Bain & Moy, JOMI, 1993; deBruyn & Collaert, COIR, 1994 31 % implant failure insmokers
- ____ abuse Galindo-Moreno et al., COIR, 2005
more bone loss around implants than smoking
- inferior ____ quality Jaffin & Berman., JOMI, 1991 16 - 35 % implant loss in type IV bone
- unsatisfactory oral ____
Schou et al., COIR, 2002; Jovanovic SA, Adv Dent Res,1999
- medical ____, e.g.diabetes mellitus)

A
smoking
alcohol
bone
hygiene
compromise
41
Q

Inlcusion and Exclusion Criteria

These are the patients that we know are having issues with a long term survivability and the health of dental implants.

If they are smokers, most of the studies would have smokers excluded from the studies other than to evaluate the influence of smoking.

Alcohol abuse, studies show that there is more marginal bone loss in those patients than people who smoke moderately.

Inferior bone quality: placement of implants in the area of the maxillary sinus.
Continues reading slide and adds (referring to last sentence on slide): Now we know ____ patients can have successful long term implants, but you have to be careful during the ____ phase.

A

diabetes mellitis

healing

42
Q

Tooth preservation or implant placement

Comorbidity and combined risk factors enhance the ____ of experiencing implant failure or associated diseases.

Example: a patient who isa current smoker with a history of ____ disease might need an augmentation procedure before undergoing implant treatment.

One issue this study found is that a lot of them time when implants are being lost, it is not for a particular, single reason that an implant is lost or compromised, but it is because of ____ and combined risk factors that are coming together. And this is underreported in the other studies.

Often a patient who has bad oral hygiene, smoker, and drinks. So these are the patients who would not be ____ in a study for implant placement. They are also less likely to follow up with you.
So comorbidity and combined risk are actually responsible for implant loss in the past.

A

risk
periodontal
comorbidity
selected

43
Q

“Classic” Implant Success

  1. Individual unattached implant is ____.
  2. No ____ evidence of peri-implant radiolucency.
  3. Bone loss less than ____ mm annually after first year of service year of service.
  4. No persistent ____, discomfort or infection is attributable to the implant.
  5. Implant does not preclude placement of ____ or prosthesis with satisfactory appearance to patient and dentist.
  6. A minimum of success is a ____% success rate after 5 years and a 80% success rate after 10 years.
A
immobile
radiographic
0.2
pain
crown
85
44
Q

Implant success

Sleeping implants “…preferably not ____…”
But if you have a sleeping implant. A sleeping implant is an implant that they placed somewhere, and they never loaded or restored it afterwards. For example, you placed an implant somewhere and then you realize it was so crooked when the implant was placed that you cannot integrate it in your prosthesis, so just leave it there (let it sleep), and don’t restore it. We should not include ____ implants in our outcome evaluation for implants.

“Only ____ implants should be evaluated…”
Only implants that are osseointegrated should be part of our success rate that we calculate. So if an implant ____ before it actually osseointegrates, then it would not be reported as a failed implants.

“…the implants must have been under functional load”
Implants must have been under a ____. Now we are wearing until the implants are going through the loading phase and if it is successfully loaded, then we restore it, and we include it in our outcome evaluation for the success rate of implants. Any implants that have been extracted before would not count toward our failed implant category

A

included
sleeping

osseointegrated
fails

functional load

45
Q

One of the studies that they did is to actually compare only the difference in how you count implant evaluation:

From the beginning after the implant is placed or if you really just look at it and count implant outcome after the loading phase:
1. About 3% of implants are lost (according to studies from Gothenberg) just in the ____ phase.
2. When you look into the loading phase, according to Morris et al., 2900 implants followed up for 3 years from 32 study centers, if you counted from the very beginning after the implants are placed, before they are loaded, you have:
2.1 In completely ____ applications 85% of those survive
G2.2 But if you counted after the ____ phase, then 95% as we discussed before
There is a 10% difference between 2.1 and 2.2
2.3 Same for the ____, almost a 6% difference, it doesn’t sound like a lot, but it is enough to bring the number down below 90% what everybody is looking for as the outcome of procedures.

A

osseointegrations
edentulous
loading
posterior mandible

46
Q

Anesthesia, paresthesia or perforation of sinus, nasal cavity or mandibular nerve canal are not considered ____

Implants like this (see slide images), like the one that was resected before, you have an issues with the sinus cavity, nasal cavity, etc. they do not count as implant ____.

In other words, implants that have been placed like when the patient has permanent ____ (Pic 2), or when the tooth needed a root canal treatment (Pic 1; circled) because it ____ the nerve tissue. Or this patient (Pic 3) that had permanent ____ whenever she touched her mucosa on the side, and they thought it came from an apical periodontitis on the tooth right next to it (Pic 4; circled), a surgery was performed (Pic 3) and the flap exposed the threads (Pic 3; circled). So whenever the patient pressed the mucosa, she had pain because the sharp bits were hurting her in the soft tissues inside.

These would be considered ____ under these revised criteria they had. In reality you are not looking at success but at ____.

A

failures
failures

paresthesia
devitalized
pain
success
survival
47
Q

Success v. Survival

Survival does not follow success criteria, implant or tooth is ____.

Most implant studies investigate ____ and not success rates.

In reality, you are not looking at success these days, you really are looking at ____ most of the time. This is something that should not be compared to ____. This is unfortunately what a lot of people do, and if you really have to compare this fairly, then you have to compare survival vs. survival, and not different types of criteria toward each other.

A

present
survival
survival
endo outcome rates

48
Q

Endodontic vs. Implant Survival

You would want to compare survival vs. survival. These are studies that have been done for endodontics as a reply to all these survival analyses that you have in implanvology. And if you look into some of the outcomes, and these are typical survival outcomes for implants.

SC means single crown implants.
FPD is multiple implants splinted together.

Outcome for 6-7 years for thousands of implants is between ____%, and this is excellent.

Other than complications and issues that are under-reported, this is labeled a success, but that is ____ not the case.

A

96-97

truly

49
Q

Endodontic v. Implant Survival

You have endo studies that looked into the survival as he said before. You would want to tell the patient that after 10 years they have a very good chance that over 90% of endo ____ teeth are still there, and this is the evidence for this (see slide).

These are studies that were done looking into insurance data with patients that have to come back to the same group of practitioners. Because these patients were part of the same insurance group then it is known whether the patient went back for endodontic treatment related to: (1) surgical retreatment, (2) non-surgical retreatment, or (3) extraction. The data came from Delta Insurance from California and the patients are part of the same insurance group.

2001 study with 44,000+ endodontically treated teeth followed up over 3.5 years and survival was over ____%. Survival for the 2001 study meant not that the tooth came out, just survival with the original root canal treatment. They actually discounted any ____ (surgical or non-srugical) that actually the tooth is still there, but they would actually put them in the failure category for those that are just survival without any other intervention. For the endodontic treatment it was over 94%

The 2004 study is over 8 years and has a survival of ____% for the first time root canal treatment. 1.46 million teeth are investigated. That is more than any implant study combined together.

The 2007 Taiwan study by Chen is over 5 years with over 1.5 million teeth and 93% survival of these teeth.

These studies are all over 90% by far. For the exam you don’t have to know exact numbers, but you have to know ranges.

A

treated
94
retreatment
97

50
Q

Outcome Endodontics vs. Implant

196 matched pairs of single implants versus initial NSRC T
Data from 1993 to 2002
Implants by oral surgeons, periodontists and residents RCT by endodontists, residents and dental students All implants and teeth were restored

The interesting thing is that they are at the same institution university in Minnesota and they have about 200 matched pairs of teeth that are endodontically treated and restored in comparison to around 200 implants that have been placed and restored

They had those 200 implants, and based on those 200 implants and implant patients, they went to the database of the university and they randomly pulled 3 patients that have had a root canal treatment and a tooth restored in exactly the same ____ as the one implant they are trying to compare it to. Example, you have somebody who lost #3 and they replaced #3 with an implant and restored it.

A

location

51
Q

Outcome endodontics vs. Implant

They went to the database and they looked for somebody within the same year that had root canal treatment on #3, tooth restored with a crown, and they random drew 3 patients with that. And now they look at the patient and compared the patient that was the closest in terms of age, medical history, etc.

Of those 3 that they pulled to the patients that had the implant placed, they came up with 196 matched pairs where the patients were very close, and where implants and root canal treated teeth were restored and treated in the same locations. So what they did is they looked into different aspects:

  1. ____, meaning everything was really great
  2. ____
  3. ____, AKA the unit tooth or the implant were extracted, meaning out of the mouth

For survival they also subdivided these into 2 categories: 2.1 Survival without ____
2.2 Survival with ____

A
success
survival
failure
intervention
intervention
52
Q

Outcome Endodontics v. Implant

What this means is that it is not success. There is something wrong with that particular implant or tooth or restoration on each of those two units, but we didn’t have to do anything on it. We just watched it, left it as it is. It is not perfect, it is not success, but it is survival without intervention.

But if they could save the tooth or the implant with the restoration, they have to do something about it. They had to do an intervention like: a ____, a retreatment, a loose or broken screw replacement, a new restoration, then this is something where I have to do an intervention where now we talk about this other category that they had (next slide).

A

root surgery

53
Q

Survival with intervention (retreatment, complications)

Implants: longer time to function higher incidence of complications

Now we talk about the other category that they had:

  1. Matched pairs, same institution, failure rate. Exactly the same that the units are lost between the teeth and the implants
  2. Success, higher for the ____ tooth
  3. Survival without intervention, higher for the ____ tooth in comparison to the restored implant
  4. Vastly higher survival with intervention for the restored ____ in comparison to the natural teeth

So this is something that not only them actually recognized, but also took the patients longer to accept and get used to the implant restoration in their mouth, but this issue of complications is also smoothing that historically is very often neglected in the studies about outcome of implants.

A

nautral
nautral
implants

54
Q

Restorative Prognosis - Implants

More complications with implant ____ compared to conventional restorations.

____ incidence of biological and technical complications with dental implants.

Almost 40 % of patients experienced any ____.

5-year abutment survival rate of 97.5%. Incidence rate for ____ complications 11.8% (95% CI: 8.5% to 16.3%) and ____ complications 6.4% (95% CI: 3.3% to 12.0%). Esthetic complications not reported.

Higher survival rates and lower complication rates reported in more ____ clinical studies. The incidence of esthetic, biologic, and technical complications, however, is still high.

A
prostheses
underestimated
complication
technical
biologic
recent
55
Q

Restorative Prognosis - Implants

Goodacre et al. (2003) and Berglunh et al. (2002) meta-analyses. There is an ____ of biological, mechanical, and technical complications with dental implants. Something chips off, the restoration is not ok and has to be replaced, screw broken, peri-implantitis, all of these goes in there. Because most of the time what is reported is survival and not success.

What people have found out is that is there is a disparity between the implant itself, the fixture of the implant in the bone, in terms of the long-term ____ and success in comparison to the restoration.

This is mostly due to the fact that you don’t have a cushion (____) on an implant, so it always has very hard occlusion and you would have to reduce the occlusion that this is buffered in. Take into consideration when you have adjacent teeth that actually have a periodontal ligament, it can impress into the alveolar socket when you actually have occlusion or chewing function and the patient bites down.
This is what they could show (pjetursson et al. (2002) and Zemic et al. (2014)), for implants in comparison to their prosthetic abutment, typically after 5-10 years you would see a ____ opening up. In terms of the functionality, the survival of the implant fixture with the ____ actually has many more problems in the long run than the implant fixture itself.

The study from 2014 (pjetursson et al.), you still have these complications, although you get a little bit less due to modifications with implants and implant placement, but you still have these issues out there.

A
under-report
survivability
periodontal ligament
gap
restoration
56
Q

Something that is very often neglected is ____ is placing the implant and who is doing the root canal treatment. We are all doing root canal treatments in dental school, but how many plants have you placed when you are done with dental school? ZERO

So we have an education that much more covers endodontics procedures than implants, and what you see is that the survival of a tooth that gets an endodontic treatment by a general practicer in comparison to an endodontist, there is some difference in the survival. A general dentist doing a root canal treatment, after 5 years ____% of the teeth are typically surviving. Endodontist specialist ____%. There is some difference in between but it is not that great.

A

who
90
98

57
Q

When you compare this for dental implants, there is a significant greater gap between somebody who is placing implants on a regular basis and is experienced with it (there is no real implantologist), but these are people who are proficient and doing it on a regular basis. Compared to somebody who is placing implants once in a while. One of the biggest issues is the ability to cope with ____ throughout surgical procedures, and to deal with complications after your treatment is done.

A

complications