I strongly object to the conclusion favoring retreating or extracting asymptomatic endodontically treated teeth with no clinical or radiographic evidence of pathology prior to placing implants adjacent to them, as advanced in "Implant Failures Associated With Asymptomatic Endodontically Treated Teeth" by Drs. David Brisman, Adam Brisman and Mark Moses (February JADA).
Most practitioners would certainly consider retreatment of endodontic cases that are symptomatic or cases that have either areas of new pathology or older pathology that are not healing, whether or not implants are to be placed in the area. Nowhere in this article are there preoperative X-rays that demonstrate absence of radiographic pathology prior to implant surgery. Yet the main thrust of their argument rests on this stated presumption. Furthermore, the literature cited was related to cases where the adjacent endodontically treated teeth had radiographic pathology.
The authors mention several studies of apical inflammatory disease including one using beagles (with root and apical anatomy that is entirely different and that represent different, though difficult, treatment challenges). These studies, both human and animal, indicate that inflammatory pathology can occur in a significant percentage of cases that are asymptomatic and radiographically negative.
Why do they assume that retreatment will clean these up? A more logical statistical assessment would conclude that the well-accepted 90 percent to 95 percent success rate in root canal therapy demonstrates that even in the presence of some chronic inflammation, endodontic therapy is successful as measured by negative X-ray findings, lack of symptoms and a functioning tooth. Of course, underfilled and poorly treated teeth should always be considered for revision.
Why retreat prophylactically asymptomatic and radiographically well-filled endodontically treated teeth adjacent to a proposed implant? Even if the clinician accepts the authors’ questionable thesis, I know of no study that demonstrates that such treatment will result in an essentially sterile and inflammation-free apex. In fact, good clinical judgment would dictate waiting six months to a year before placing the implant. Needless flare-ups and even tooth loss can result from retreatment errors, broken instruments, perforations and so on.
The other alternatives, including the "possible extraction" of these teeth, as mentioned in the Clinical Implications section, in my view are even too radical to discuss.
I am very surprised that JADA published a case report that bases its extreme treatment suggestions and conclusions on four questionable cases. Are we revisiting the "focal infection" legend?
