Implants for the endodontist: to place or not to place?

Dr. Rich Mounce shares his evolving view on implants

Endodontists want to save teeth. It’s exciting, fulfilling, creative, and rewarding to relieve pain, help people, and be good at your craft. I believe it’s in our genes to solve the many clinical challenges we face on a daily basis. Removing teeth with the goal of placing implants is not in our nature, whether that nature was ingrained and trained into us as residents and/or developed in most of us through daily practice.

More than one implant surgeon has told me that placing implants is easy; endodontics is hard. My suspicion is that we enjoy the tinkering and mastering the difficulties we face.

Personally, having been an endodontist in full-time private practice since 1991, it is a pleasure to study the literature, take classes, give classes, and exchange information with colleagues. Like many of you, I eat, drink, and sleep endodontics. As the quote goes, “Endodontics is a big issue about a little tissue,” and truer words were never spoken. Hard to believe we as endodontists devote our professional lives to cleaning a very small and complex space that we never truly see. Coming up on 25 years as an endodontist, I know a lot less now than I did when I graduated from residency.

All of this leads us to implants. Would, could, and should we place them? For some endodontists who say yes, the motivation may be financial, especially if their practices are not as busy as they want. For others, the many possible reasons might include patient service and convenience, general practitioner service, and optimized continuity of care in select circumstances, and affection for surgery.

Reasons for not placing implants are myriad and stretch from busyness with purely endodontic cases, resistance to change, the expense of training and materials, and needed staffing systems changes. And of course, removing teeth and placing implants is not what we signed on for.

Whether we place implants or not, my sense is that endodontists are frustrated with the arbitrary removal of many teeth by non-endodontists that otherwise could be treated and/or retreated. A significant number of treatable teeth appear to be extracted for financial gain rather than the clinical benefit of patients.

I do not speak for the AAE or the endodontic community at large, and yet, from my single viewpoint, some patients are not being given all the endodontic options they should be. Calling endodontic therapy “pre-implant treatment” or giving teeth one poor attempt at endodontic therapy followed by extraction cheapens all of our reputation as dental care providers and reduces the public’s trust. The same could be said about indiscriminant endodontic surgery that is poorly treatment planned or carried out to cover for poor orthograde technique. There clearly is a limit of “when to say when.” But, in my view, the pendulum has swung to extraction in cases where endodontic therapy is viable, predictable, and the best natural implant.

Up to this point, I have resisted placing implants and getting trained. My reasons might be slightly different than those above in that I have spent much of my out-of-office professional life teaching and writing in endodontics. To be frank, I never thought much about learning to place implants or the art and science behind the discipline.

And yet recently, I watched a recorded lecture on endodontic surgery where the endodontist stated that he went to many implant courses knowing that 98% of what was being taught was irrelevant to endodontics, but going made him a better endodontic surgeon if he adapted what was relevant. That struck a chord with me. This alone seems reason enough to become fluent in implant placement, and it is a journey I will slowly begin.

Will I ever become an implantologist? No. Will implants ever capture my heart like endodontics? No. But I believe it can make me a better endodontist and a more effective surgeon, and as such, it’s a journey worth embarking on. I welcome your feedback.