We wish to commend Drs. David Brisman, Adam Brisman and Mark Moses ("Implant Failures Associated With Asymptomatic Endodontically Treated Teeth," February JADA) for drawing attention to an area of current interest and controversy.
Although evidence is currently lacking to support their position, we agree that common sense and a basic understanding of bone biology dictates that placement of an implant into an area of known chronic inflammation should be avoided.
We also acknowledge that there is some evidence to support the view that low-grade chronic periapical inflammation may persist in some endodontically treated teeth, even in the absence of symptoms and/or radiographic signs of pathosis. This is where our agreement with the authors ends. As practicing endodontists and educators, we freely admit our views may be perceived as biased. However, we feel strongly that the opinions expressed in this article are not based on sound science and may lead to unnecessary and irreversible treatment.
In our opinion, it is highly unlikely that any of the implant failures presented in this article could be directly attributed to an adjacent endodontically treated tooth. As a starting point, we would need to know the authors’ implant failure rate in areas not adjacent to endodontically treated teeth.
Furthermore, our ability to interpret the images presented is hampered somewhat by the overall lack of diagnostic-quality radiographs and the absence of preoperative radiographs. The quality of the radiographs is well below normal JADA standards. Even so, the information we can glean from the radiographs tells a quite different story from the one presented in the text.
In Case 1, we are presented with an image of an implant apparently placed in close proximity to the root surface of an endodontically treated tooth. After the failing implant was removed, the patient was referred for apical surgery on the endodontically treated tooth. If the problem was truly related to a failing endodontically treated tooth, an apicoectomy with 1 millimeter retrofill could be predictably expected to fail in the future.
If the authors are really concerned that this tooth was placing their implant in jeopardy, we suggest that the new implant may also be at risk (although it should be noted that the second implant appears to be placed in a more appropriate location).
Case 2 is an excellent example of radiographic misinterpretation. The authors claim that the gutta-percha is tracing a sinus tract to the apex of the endodontically treated second pre-molar when in reality the gutta-percha is nowhere near the apex of this tooth, and, as near as we can determine from the radiograph, the endodontically treated tooth appears to have a normal periodontal ligament and intact lamina dura.
The object described in Case 3 as a "gutta-percha cone" (Figure 6) has a radiographic appearance unlike any gutta-percha cone in our experience. It is much more likely to be a metal Hedstrom-type file—an object stiff enough to create its own path rather than follow a sinus tract. Even so, the object points more directly to the apical extent of the implant created defect, not the root apex of the endodontically treated tooth. The initial implant placement in this case also suffers from the same root proximity issue raised in Case 1.
Case 4 is perhaps the most remarkable example of inappropriate attribution. The authors would have us believe that in two weeks time they permanently cured a failing endodontically treated tooth with a single course of antibiotics and an exploratory surgical procedure.
We draw readers’ attention to the different angulation of the radiographs and suggest that the "cure" is probably more artifact than reality.
There are many other issues raised by this series of case reports, but in the interest of brevity we feel we should close here. We also wish to emphasize that we feel implants can provide an excellent tooth replacement service and, with proper diagnosis and surgical technique, will continue to grow in popularity and use.
The role of endodontically treated teeth in the success or failure of implants is an unanswered question and one that we hope will receive more serious consideration in the future.
