Clinical Research
Degree of Patient Pain, Complications, and Satisfaction after Root Canal Treatment or a Single Implant: A Preliminary Prospective Investigation Mahmoud Torabinejad, DDS, MSD, PhD, Wesam Salha, DDS, MSD, Jaime L. Lozada, DMD, Yuan-Lung Hung, DMD, MS, and Antoanela Garbacea, DDS, MSD Abstract Introduction: Dentists often face the choice between tooth retention with root canal treatment and tooth replacement with implant treatment. To date, there has not been a prospective clinical trial directly comparing nonsurgical root canal treatment and single delayed implant therapy with regard to the degree of preoperative and postoperative pain, complications, and patient satisfaction. Methods: Twenty-four patients had initial nonsurgical root canal treatment, and another 24 had single implant treatment in healed sites. Questionnaires were given at pretreatment, 7 days, 3 months, 6 months, and 12 months. Results: All patients completed the 12-month follow-up period. No significant difference in pain, complications, or overall satisfaction was noted between the 2 groups at any of the time points (P > .05). However, there were differences within each group between the time points. There was more pain at pretreatment for root canal treatment and 7-day post-treatment point for single implant treatment than any other time point. For complications, more were reported at the 7-day post-treatment point than any other time point for both groups. With overall satisfaction, there was no difference from any time point for either group. Conclusions: The results of this study suggest that patients perceive both treatments with high degrees of satisfaction with minimal pain and discomfort. Differences were found at different time points of treatment and were related to the nature of the treatment itself. This information is useful to help patients with treatment decisions. (J Endod 2014;-:1–6)
Key Words Complications, nonsurgical root canal treatment, patient satisfaction, single delayed implant
From the Departments of Endodontics and Implant Dentistry, School of Dentistry, Loma Linda University, Loma Linda, California. Address requests for reprints to Dr Mahmoud Torabinejad, Department of Endodontics, School of Dentistry, Loma Linda University, Prince Hall, 11092 Anderson Street, Loma Linda, CA 92350. E-mail address: [email protected] 0099-2399/$ - see front matter Copyright ª 2014 American Association of Endodontists. http://dx.doi.org/10.1016/j.joen.2014.08.022
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dvances in implant dentistry have affected treatment planning for patients with pulpal or periodontal disease as well as those who have lost their natural teeth because of these diseases or traumatic injuries. The introduction of cylindrical-style endosseous implants to the dental profession has obviated the need for many partial or full coverage restorations on adjacent teeth (1, 2). As in prosthodontics, the new innovations in implant dentistry have also decreased reliance on high-risk periodontal procedures for tissue preservation and regeneration for teeth with moderate to severe periodontal disease (3). This paradigm shift in periodontics is evident in a survey conducted by the American Academy of Periodontology in 2004. This survey shows that 63% of periodontists are placing their primary emphasis on periodontics, and 27% are placing their primary emphasis on implants (4). The high success rates of implants have also affected the thinking of clinicians for patients with pulpal and/or periapical pathology. Clinicians are asking: Should a pulpally/periapically involved tooth be extracted and replaced with a dental implant? Clearly, there are many factors involved during treatment planning decision-making as to whether a tooth receives root canal treatment or is extracted and a dental implant placed (5). Outcomes assessment and patient satisfaction are among these factors. In a systematic review, Torabinejad et al (6) compared the outcomes of endodontically treated teeth with those of single dental implant supported crown, fixed partial denture, and no treatment after extraction. At 97%, the long-term survival rate was essentially the same for implant and endodontic treatments. Both were superior to extraction and replacement of the missing tooth with a fixed partial denture. Iqbal and Kim (7) have reported similar findings when they compared the survival of restored endodontically treated teeth with single implant–supported restorations. The psychosocial effects of these treatments have been reported differently. Pretreatment apprehension and post-treatment discomfort were commonly addressed in endodontic literature (8–15). Chewing performance and esthetics were commonly reported in the implant literature (16–29). Esthetic outcomes were often examined in the dental implant literature. Very high levels of patient satisfaction were reported (16–28). Patient perceptions of implant complications were rarely reported; the vast majority of patients believed that the numbers of complications were acceptable (30). The most commonly reported problem was related to loose abutment screws. Goodacre et al (31) could not calculate an overall complications incidence for implant prostheses because there was not an adequate number of clinical studies that have evaluated all or most of these complications. On the basis of their literature search, they report a trend toward a greater incidence of complications with implant prostheses than single crowns, fixed partial dentures, all-ceramic crowns, resin-bonded prostheses, and posts and cores. Endodontic studies have not separately addressed complications. An endodontic study found that more than 90% of subjects would choose to have another endodontic treatment (10). Cost, distantly followed by pain, was the most important factor for those who would not have another endodontic treatment (10). Eighty-eight percent of implant patients would choose the same treatment again (18, 21, 28, 32), and 94% of patients who have had implants would recommend it to others (18, 28, 32). Overall subject
Patient Satisfaction after Root Canal or a Single Implant
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Clinical Research satisfaction ratings for both implant and endodontic treatments were above 90% (9, 18). Complications can affect both the practitioner’s and the patient’s assessment of the success of the treatment and, therefore, should be considered in reports evaluating these treatments. We found only 1 article in the literature that directly compared the single implant and root canal treatment clinical outcomes and complications (33). On the basis of their findings, the authors concluded that restored endodontically treated teeth and single implant–supported restorations had similar survival rates. In regard to complications, they reported a higher incidence of postoperative complications for single implants requiring subsequent treatment intervention. Our search of literature showed absence of any prospective study that directly compared the degree of pain, patient satisfaction, and complications after root canal treatment and implant treatment. The purpose of this preliminary prospective study was to compare the degrees of pain, patient satisfaction, and complications after nonsurgical root canal treatment and single implant treatment.
Materials and Methods Degree of preoperative and postoperative pain as well as patient satisfaction and complications after treatments with initial nonsurgical root canal treatment and single dental implant treatment in healed sites were assessed with a questionnaire (Fig. 1). Complications included in the endodontic procedures were endodontic flare-ups (unscheduled appointment for severe pain and/or swelling) and accidental procedures during cleaning and shaping, obturation, and post placement after root canal treatment. Complications included in the implant group were unscheduled appointment for severe pain and/or swelling procedures after implant placement, surgical complications such as severe bruising, neurologic sensory disturbance, implant loss, bone loss, soft tissue complications, mechanical complications, as well as esthetic/phonetic complications. A total of 48 consecutive patients were recruited for this study. Twenty-four consecutive patients who were referred to the Loma Linda University Graduate Endodontic Clinic
seeking initial nonsurgical root canal treatments were selected for participating in this study as the endodontic group (RCT). The other 24 patients comprised the implant group (IMP) and were consecutively selected from those who had been referred to the Loma Linda University Graduate Periodontic Clinic for single implant treatments in healed sites.
Inclusion Criteria Men and women older than the age of 18 in good general health (American Society of Anesthesiologists I or II) were included in this study. Endodontic Group (RCT). The primary criterion for inclusion of subjects in this group was the presence of signs and/or symptoms of pulpal pathosis and/or periapical pathosis. The teeth included in the RCT group were periodontally sound and restorable. Implant Group (IMP). The primary criteria for inclusion of subjects in this group were the absence of a single tooth and the patient’s choice of a dental implant as a replacement regardless of the reason why the tooth was missing. The edentulous healed site was ready to receive an implant without adjunctive surgical procedures such as sinus augmentation, guided bone regeneration, or connective tissue grafting that might alter the patient’s perception of treatment. General Exclusion Criteria Patients were excluded from the study if they had any of the following: 1. 2. 3. 4. 5. 6. 7.
Compromised immune system Uncontrolled diabetes Age younger than 18 years Pregnancy Inability to give informed consent to participate in this study History of alcohol or drug abuse as noted in patient records History of depression or psychological problems
Pre- and Postoperative Pain: ______ day 0
______ 7 days
______ 3 months
______6 months
______12 months
0 = No problem 1–3 = Mild problem 4–6 = Moderate problem 7–9 = Severe problem Pre- and posttreatment pain
None 0
Mil d 1-2-3
Mod er ate 4-5-6
Se vere 7-8-9
Patient Satisfaction after Treatments: ______ 7 days
______ 3 months
______6 months
______12 months
0 = Unsatisfied 1–3 = Mildly satisfied 4–6 = Moderately satisfied 7–9 = Very satisfied Degree of overall satisfaction Pre- and posttreatment pain
Unsatisfied
Mildly satisfied
0
1-2-3
Moderately satisfied 4-5-6
Very satisfied 7-8-9
Figure 1. Ordinal scales used for assessing the degree of pre- and postoperative pain as well as patient satisfaction following treatments.
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Clinical Research Exclusion Criteria for Endodontic Group (RCT) Patients were excluded from the RCT group if the tooth in question had any of the following: 1. 2. 3. 4. 5. 6. 7. 8.
.05) (Table 1). A significant difference in pain was reported for the IMP group among the 5 time points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .001). Strong evidence for differences in pain was observed before and after treatment: pretreatment versus 7 days (P = .157), pretreatment versus 3 months (P = .157), and pretreatment versus 6 months (P = .157). Patient Satisfaction after Root Canal or a Single Implant
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Clinical Research Treatment Complications. No significant difference in treatment complications is noted between the 2 groups (IMP and RCT) at any of the time points (Mann-Whitney U, P > .05) (Table 2). There was a significant difference in treatment complications for the IMP and RCT groups separately among the 4 time points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .029). Strong evidence for differences in severity of treatment complications was observed before and after treatment: pretreatment vs 7 days (P = .502), pretreatment vs 3 months (P = .502), and pretreatment vs 6 months (P = .502). More complications were noted in pretreatment versus 7 days, 3 months, and 6 months. Patient Satisfaction. No significant difference in overall satisfaction was noted between the 2 groups (IMP and RCT) at any of the time points (Mann-Whitney U, P > .05) (Table 3). No significant difference in overall satisfaction was noted for the IMP group among the 4 time points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .195). No significant difference in overall satisfaction was noted for the RCT group among the 4 time points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .590). A statistically significant difference in pain was noted between the time points (Fdf=4 = 0.00, P = 1.0). No statistically significant difference in the outcome measure was noted between the treatment groups (Fdf=1 = 0.171, P = .681). No statistically significant interaction was noted between time and treatment groups (Fdf=4 = 0.118, P = .733). No statistically significant differences in complications after treatment or overall satisfaction were noted between the time points or groups (P > .05).
TABLE 1. Descriptive Statistics for the Degree of Pain at Baseline and 4 Time Points after Treatments Group IMP Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 RCT Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75
Pain day 0
Pain day 7
Pain 3 mo
Pain 6 mo
Pain 12 mo
0.38 0.00 0 0.824 0.679 3 0 3
0.50 0.00 0 1.063 1.130 4 0 4
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0.00
0.00 0.00 0.75
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
1.67 0.00 0 3.046 9.275 9 0 9
0.17 0.00 0 0.637 0.406 3 0 3
0.50 0.00 0 1.615 2.609 7 0 7
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 2.75
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
IMP, implant group; RCT, endodontic group.
A significant difference in reported pain was also detected for the RCT group among the 5 points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .001). Strong evidence was observed for differences in reported pain at pretreatment versus 7 days (P = .110) and pretreatment versus 6 months (P = .110).
Discussion The results of this study show a high degree of patient satisfaction in both treatments and mild perception for pain and complications throughout the treatment. Also, there were no significant differences
TABLE 2. Descriptive Statistics for the Number of Complications per Patient after Implant Placement and Root Canal Treatment Group
Complications 7 days
Complications 3 mo
Complications 6 mo
Complications 12 mo
0.38 0.00 0 1.135 1.288 5 0 5
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.54 0.00 0 1.587 2.520 6 0 6
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
IMP Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 RCT Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 IMP, implant group; RCT, endodontic group.
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Clinical Research TABLE 3. Descriptive Statistics for Reported Patient Satisfaction at 4 Points after Treatments Group
Satisfaction day 7
Satisfaction 3 mo
Satisfaction 6 mo
Satisfaction 12 mo
8.00 8.00 8 1.818 3.304 9 0 9
8.46 9.00 9 0.833 0.694 3 6 9
8.04 9.00 9 1.601 2.563 7 2 9
8.54 9.00 9 0.884 0.781 4 5 9
8.00 8.00 9.00
8.00 9.00 9.00
8.00 9.00 9.00
8.00 9.00 9.00
8.83 9.00 9 0.816 0.667 4 5 9
8.63 9.00 9 1.279 1.636 6 3 9
8.92 9.00 9 0.408 0.167 2 7 9
8.92 9.00 9 0.282 0.080 1 8 9
9.00 9.00 9.00
9.00 9.00 9.00
9.00 9.00 9.00
9.00 9.00 9.00
IMP Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 RCT Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 IMP, implant group; RCT, endodontic group.
between groups when compared at any of the time points for any of the outcome measurements. In the study, pain in the IMP group was mild at the 7-day posttreatment and almost disappeared by the follow-up appointments. This supports previous findings in the literature about pain or discomfort duration and after implant therapy (16, 21, 27). In a study by Schropp (16), patients reported their experience for implant placement in ‘‘immediate-delayed versus delayed’’ protocols. Patients in both groups reported minimal pain and high degrees of satisfaction at 1.5 years after implant placement. Moberg et al (21) recorded a small percentage of patients having orofacial pain in the recall visit after implant crown was delivered, with no persistent symptoms thereafter. In a retrospective study by Andersson et al (27), about 90% of patients described the implant treatment as pain-free or with minimal pain. This was recorded for 2-year post-implant treatment. In the RCT group, pain was at its highest degree at the pretreatment appointment, then significantly decreased by the 7-day post-treatment, and disappeared in the following appointments. The endodontic literature reports similar observations, although most of the studies looked at pain for up to 48 hours after treatment only (9, 37, 38). In a retrospective study by Dugas et al (9), 97% of patients reported physical pain before endodontic treatments, 75% of whom had their pain relieved after the treatment. Polycarpou et al (37) reported that 12% of the patients had persistent pain after endodontic treatment for at least 3 months. They reported absence of pain in the 6- or 12-month recall appointments for these patients. This study population had 29% pretreatment pain and 8.3% pain at 7-day post-treatment. In a systematic review, Pak and White (38) reported similar results. Sixty-eight percent of patients in this study had pretreatment pain, and less than 10% of them had post-treatment pain at 7 days. Patient perception of complications was minimal in both groups and was observed at 7-day post-treatment only. In the implant literature as well as in the endodontic literature, patient perceptions of complications were rarely reported. However, the vast majority of patients believed that the number of complications was
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acceptable, even when high frequencies of complications were recorded, especially with some studies describing prosthetic complications (6). Patients reported a high degree of satisfaction for both the IMP and the RCT groups, with no significant difference comparing different time points during the treatments in each group. Many studies reported similar results in the implant literature. Implant treatment improved patients’ chewing ability, esthetics, and quality of life in general with longterm high success rates, which explain the consistently high degree of satisfaction in the literature (16, 18, 21, 22, 25, 27). The same can be said about the high satisfaction rates after endodontic treatment (9, 10, 14, 37, 38, 39) even when post-treatment symptoms were still reported. This may be a result of the great reduction of discomfort and the understanding of the expected time needed for healing after treatment (6). One of the limitations of this study is the relatively small number of patients who were included. Under the inclusion and exclusion criteria outlined for the present study, many patients were not able to be included in the study. The procedures of this study were performed under strict protocol by a single operator in each group in a school setting, which does not relate exactly to settings for clinicians with different skill levels or protocols in private practice. Another factor that might be of importance is that the distribution of patients in the 2 groups was not even because selection into the groups was based on necessity of treatment and consecutive selection of patients. More men than women were included in the RCT group, and the converse was true in the IMP group. Multicenter prospective studies with more patients and operators are needed to confirm these results. To our knowledge, this is the first prospective study that directly compares the degree of pain and satisfaction of patients after root canal treatment or implant treatment. Clearly, there are differences between indications and contraindications of the 2 treatment modalities (5). Patients who seek root canal treatment usually present with preoperative pulp and/or periapical inflammation and pain. In contrast, patients who need implants have missing teeth where a dentist will be doing a surgical procedure that has the potential to
Patient Satisfaction after Root Canal or a Single Implant
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Clinical Research induce postoperative pain. Teeth with pulpal and/or periapical pathosis, sound periodontium, and restorable crowns are indications for root canal treatment. Root canal treatment on teeth with nonrestorable crowns or teeth with severe periodontal conditions is contraindicated, and other options such as implant placement should be considered for their treatment. In addition to differences between indications and contraindications of these 2 treatment modalities, initial root canal treatment is a nonsurgical procedure in contrast to the implant treatment, which is a surgical treatment with its inherent potential surgical sequelae such as bruising, hematoma, and paresthesia. Because of the inherent differences between the 2 procedures, it is difficult to compare them, but it is often done by the public and the professionals. A fair comparison might be between microsurgical endodontic retreatment and singletooth implant procedure. This study has followed the patients from pretreatment conditions throughout the healing phase and beyond. The results of this study showed no statistically significant differences in the outcome measurements between groups at any of the time points. A retrospective study by Gatten et al (40) reported a qualitative comparison between patients who had endodontic treatment or implant placement or both. Patients in that study described a high degree of satisfaction with positive effects on their quality of life. Although some patients mentioned that the implant felt different than their other teeth, they stated that they became accustomed to that feeling.
Conclusion The results of this study suggest that patients perceive both treatments with high degrees of satisfaction with minimal pain and complications. Differences were found at different time points of treatment and were related to the nature of the treatment itself. More prospective studies with larger sample sizes are needed to confirm the results of this preliminary prospective investigation.
Acknowledgments The authors thank the American Academy of Implant Dentistry (AAID) Foundation for its financial support of this research project. The authors deny any conflicts of interest related to this study.
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12. Stabholz A, Peretz B. Dental anxiety among patients prior to different dental treatments. Int Dent J 1999;49:90–4. 13. Udoye CI, Oginni AO, Oginni FO. Dental anxiety among patients undergoing various dental treatments in a Nigerian teaching hospital. J Contemp Dent Pract 2005;6:91–8. 14. Watkins CA, Logan HL, Kirchner HL. Anticipated and experienced pain associated with endodontic therapy. J Am Dent Assoc 2002;133:45–54. 15. Wong M, Lytle WR. A comparison of anxiety levels associated with root canal therapy and oral surgery treatment. J Endod 1991;17:461–5. 16. Schropp L, Isidor F, Kostopoulos L, Wenzel A. Patient experience of, and satisfaction with, delayed-immediate vs delayed single-tooth implant placement. Clin Oral Implants Res 2004;15:498–503. 17. Levin L, Pathael S, Dolev E, Schwartz-Arad D. Aesthetic versus surgical success of single dental implants: 1- to 9-year follow-up. Pract Proced Aesthet Dent 2005; 17:533–8. quiz 40, 66. 18. Pjetursson BE, Karoussis I, Burgin W, et al. Patients’ satisfaction following implant therapy: a 10-year prospective cohort study. Clin Oral Implants Res 2005;16: 185–93. 19. Johnson RH, Persson GR. Evaluation of a single-tooth implant. Int J Oral Maxillofac Implants 2000;15:396–404. 20. Wannfors K, Smedberg JI. A prospective clinical evaluation of different single-tooth restoration designs on osseointegrated implants: a 3-year follow-up of Branemark implants. Clin Oral Implants Res 1999;10:453–8. 21. Moberg LE, Kondell PA, Kullman L, et al. Evaluation of single-tooth restorations on ITI dental implants: a prospective study of 29 patients. Clin Oral Implants Res 1999; 10:45–53. 22. Andersson B, Odman P, Lindvall AM, Branemark PI. Five-year prospective study of prosthodontic and surgical single-tooth implant treatment in general practices and at a specialist clinic. Int J Prosthodont 1998;11:351–5. 23. Andersson B, Odman P, Lindvall AM, Branemark PI. Cemented single crowns on osseointegrated implants after 5 years: results from a prospective study on CeraOne. Int J Prosthodont 1998;11:212–8. 24. Andersson B. Implants for single-tooth replacement: a clinical and experimental study on the Branemark CeraOne System. Swed Dent J Suppl 1995;108:1–41. 25. Chang M, Odman PA, Wennstrom JL, Andersson B. Esthetic outcome of implantsupported single-tooth replacements assessed by the patient and by prosthodontists. Int J Prosthodont 1999;12:335–41. 26. Chang M, Wennstrom JL, Odman P, Andersson B. Implant supported single-tooth replacements compared to contralateral natural teeth: crown and soft tissue dimensions. Clin Oral Implants Res 1999;10:185–94. 27. Andersson L, Emami-Kristiansen Z, Hogstrom J. Single-tooth implant treatment in the anterior region of the maxilla for treatment of tooth loss after trauma: a retrospective clinical and interview study. Dent Traumatol 2003;19:126–31. 28. Vermylen K, Collaert B, Linden U, et al. Patient satisfaction and quality of single-tooth restorations. Clin Oral Implants Res 2003;14:119–24. 29. Sonoyama W, Kuboki T, Okamoto S, et al. Quality of life assessment in patients with implant-supported and resin-bonded fixed prosthesis for bounded edentulous spaces. Clin Oral Implants Res 2002;13:359–64. 30. Ekfeldt A, Carlsson GE, Borjesson G. Clinical evaluation of single-tooth restorations supported by osseointegrated implants: a retrospective study. Int J Oral Maxillofac Implants 1994;9:179–83. 31. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent 2003;90:121–32. 32. Gibbard LL, Zarb G. A 5-year prospective study of implant-supported single-tooth replacements. J Can Dent Assoc 2002;68:110–6. 33. Doyle SL, Hodges JS, Pesun IJ, et al. Retrospective cross sectional comparison of initial nonsurgical endodontic treatment and single-tooth implants. J Endod 2006;32:822–7. 34. Appropriateness of Care and QualityAssurance Guidelines, 3rd ed. Chicago: American Association of Endodontists; 1998. 35. Guidelines for the provision of dental implants. Int J Oral Maxillofac Implants 2008; 23(Suppl):471–3. 36. Torabinejad M, Cymerman JJ, Frankson M, et al. The effectiveness of various medications on postoperative pain following complete instrumentation. J Endod 1994; 20:345–54. 37. Polycarpou N, Ng YL, Canavan D, et al. Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing. Int Endod J 2005;38:169–78. 38. Pak JG, White SN. Pain prevalence and severity before, during, and after root canal treatment: a systematic review. J Endod 2011;37:429–38. 39. Segura-Egea JJ, Cisneros-Cabello R, Llamas-Carreras JM, Velasco-Ortega E. Pain associated with root canal treatment. Int Endod J 2009;42:614–20. 40. Gatten D, Riedy CA, Hong SK, et al. Quality of life of endodontically treated versus implant treated patients: a university-based qualitative research study. J Endod 2011;37:903–9.
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Degree of Patient Pain, Complications, and Satisfaction after Root Canal Treatment or a Single Implant: A Preliminary Prospective Investigation Mahmoud Torabinejad, DDS, MSD, PhD, Wesam Salha, DDS, MSD, Jaime L. Lozada, DMD, Yuan-Lung Hung, DMD, MS, and Antoanela Garbacea, DDS, MSD Abstract Introduction: Dentists often face the choice between tooth retention with root canal treatment and tooth replacement with implant treatment. To date, there has not been a prospective clinical trial directly comparing nonsurgical root canal treatment and single delayed implant therapy with regard to the degree of preoperative and postoperative pain, complications, and patient satisfaction. Methods: Twenty-four patients had initial nonsurgical root canal treatment, and another 24 had single implant treatment in healed sites. Questionnaires were given at pretreatment, 7 days, 3 months, 6 months, and 12 months. Results: All patients completed the 12-month follow-up period. No significant difference in pain, complications, or overall satisfaction was noted between the 2 groups at any of the time points (P > .05). However, there were differences within each group between the time points. There was more pain at pretreatment for root canal treatment and 7-day post-treatment point for single implant treatment than any other time point. For complications, more were reported at the 7-day post-treatment point than any other time point for both groups. With overall satisfaction, there was no difference from any time point for either group. Conclusions: The results of this study suggest that patients perceive both treatments with high degrees of satisfaction with minimal pain and discomfort. Differences were found at different time points of treatment and were related to the nature of the treatment itself. This information is useful to help patients with treatment decisions. (J Endod 2014;-:1–6)
Key Words Complications, nonsurgical root canal treatment, patient satisfaction, single delayed implant
From the Departments of Endodontics and Implant Dentistry, School of Dentistry, Loma Linda University, Loma Linda, California. Address requests for reprints to Dr Mahmoud Torabinejad, Department of Endodontics, School of Dentistry, Loma Linda University, Prince Hall, 11092 Anderson Street, Loma Linda, CA 92350. E-mail address: [email protected] 0099-2399/$ - see front matter Copyright ª 2014 American Association of Endodontists. http://dx.doi.org/10.1016/j.joen.2014.08.022
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dvances in implant dentistry have affected treatment planning for patients with pulpal or periodontal disease as well as those who have lost their natural teeth because of these diseases or traumatic injuries. The introduction of cylindrical-style endosseous implants to the dental profession has obviated the need for many partial or full coverage restorations on adjacent teeth (1, 2). As in prosthodontics, the new innovations in implant dentistry have also decreased reliance on high-risk periodontal procedures for tissue preservation and regeneration for teeth with moderate to severe periodontal disease (3). This paradigm shift in periodontics is evident in a survey conducted by the American Academy of Periodontology in 2004. This survey shows that 63% of periodontists are placing their primary emphasis on periodontics, and 27% are placing their primary emphasis on implants (4). The high success rates of implants have also affected the thinking of clinicians for patients with pulpal and/or periapical pathology. Clinicians are asking: Should a pulpally/periapically involved tooth be extracted and replaced with a dental implant? Clearly, there are many factors involved during treatment planning decision-making as to whether a tooth receives root canal treatment or is extracted and a dental implant placed (5). Outcomes assessment and patient satisfaction are among these factors. In a systematic review, Torabinejad et al (6) compared the outcomes of endodontically treated teeth with those of single dental implant supported crown, fixed partial denture, and no treatment after extraction. At 97%, the long-term survival rate was essentially the same for implant and endodontic treatments. Both were superior to extraction and replacement of the missing tooth with a fixed partial denture. Iqbal and Kim (7) have reported similar findings when they compared the survival of restored endodontically treated teeth with single implant–supported restorations. The psychosocial effects of these treatments have been reported differently. Pretreatment apprehension and post-treatment discomfort were commonly addressed in endodontic literature (8–15). Chewing performance and esthetics were commonly reported in the implant literature (16–29). Esthetic outcomes were often examined in the dental implant literature. Very high levels of patient satisfaction were reported (16–28). Patient perceptions of implant complications were rarely reported; the vast majority of patients believed that the numbers of complications were acceptable (30). The most commonly reported problem was related to loose abutment screws. Goodacre et al (31) could not calculate an overall complications incidence for implant prostheses because there was not an adequate number of clinical studies that have evaluated all or most of these complications. On the basis of their literature search, they report a trend toward a greater incidence of complications with implant prostheses than single crowns, fixed partial dentures, all-ceramic crowns, resin-bonded prostheses, and posts and cores. Endodontic studies have not separately addressed complications. An endodontic study found that more than 90% of subjects would choose to have another endodontic treatment (10). Cost, distantly followed by pain, was the most important factor for those who would not have another endodontic treatment (10). Eighty-eight percent of implant patients would choose the same treatment again (18, 21, 28, 32), and 94% of patients who have had implants would recommend it to others (18, 28, 32). Overall subject
Patient Satisfaction after Root Canal or a Single Implant
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Clinical Research satisfaction ratings for both implant and endodontic treatments were above 90% (9, 18). Complications can affect both the practitioner’s and the patient’s assessment of the success of the treatment and, therefore, should be considered in reports evaluating these treatments. We found only 1 article in the literature that directly compared the single implant and root canal treatment clinical outcomes and complications (33). On the basis of their findings, the authors concluded that restored endodontically treated teeth and single implant–supported restorations had similar survival rates. In regard to complications, they reported a higher incidence of postoperative complications for single implants requiring subsequent treatment intervention. Our search of literature showed absence of any prospective study that directly compared the degree of pain, patient satisfaction, and complications after root canal treatment and implant treatment. The purpose of this preliminary prospective study was to compare the degrees of pain, patient satisfaction, and complications after nonsurgical root canal treatment and single implant treatment.
Materials and Methods Degree of preoperative and postoperative pain as well as patient satisfaction and complications after treatments with initial nonsurgical root canal treatment and single dental implant treatment in healed sites were assessed with a questionnaire (Fig. 1). Complications included in the endodontic procedures were endodontic flare-ups (unscheduled appointment for severe pain and/or swelling) and accidental procedures during cleaning and shaping, obturation, and post placement after root canal treatment. Complications included in the implant group were unscheduled appointment for severe pain and/or swelling procedures after implant placement, surgical complications such as severe bruising, neurologic sensory disturbance, implant loss, bone loss, soft tissue complications, mechanical complications, as well as esthetic/phonetic complications. A total of 48 consecutive patients were recruited for this study. Twenty-four consecutive patients who were referred to the Loma Linda University Graduate Endodontic Clinic
seeking initial nonsurgical root canal treatments were selected for participating in this study as the endodontic group (RCT). The other 24 patients comprised the implant group (IMP) and were consecutively selected from those who had been referred to the Loma Linda University Graduate Periodontic Clinic for single implant treatments in healed sites.
Inclusion Criteria Men and women older than the age of 18 in good general health (American Society of Anesthesiologists I or II) were included in this study. Endodontic Group (RCT). The primary criterion for inclusion of subjects in this group was the presence of signs and/or symptoms of pulpal pathosis and/or periapical pathosis. The teeth included in the RCT group were periodontally sound and restorable. Implant Group (IMP). The primary criteria for inclusion of subjects in this group were the absence of a single tooth and the patient’s choice of a dental implant as a replacement regardless of the reason why the tooth was missing. The edentulous healed site was ready to receive an implant without adjunctive surgical procedures such as sinus augmentation, guided bone regeneration, or connective tissue grafting that might alter the patient’s perception of treatment. General Exclusion Criteria Patients were excluded from the study if they had any of the following: 1. 2. 3. 4. 5. 6. 7.
Compromised immune system Uncontrolled diabetes Age younger than 18 years Pregnancy Inability to give informed consent to participate in this study History of alcohol or drug abuse as noted in patient records History of depression or psychological problems
Pre- and Postoperative Pain: ______ day 0
______ 7 days
______ 3 months
______6 months
______12 months
0 = No problem 1–3 = Mild problem 4–6 = Moderate problem 7–9 = Severe problem Pre- and posttreatment pain
None 0
Mil d 1-2-3
Mod er ate 4-5-6
Se vere 7-8-9
Patient Satisfaction after Treatments: ______ 7 days
______ 3 months
______6 months
______12 months
0 = Unsatisfied 1–3 = Mildly satisfied 4–6 = Moderately satisfied 7–9 = Very satisfied Degree of overall satisfaction Pre- and posttreatment pain
Unsatisfied
Mildly satisfied
0
1-2-3
Moderately satisfied 4-5-6
Very satisfied 7-8-9
Figure 1. Ordinal scales used for assessing the degree of pre- and postoperative pain as well as patient satisfaction following treatments.
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Clinical Research Exclusion Criteria for Endodontic Group (RCT) Patients were excluded from the RCT group if the tooth in question had any of the following: 1. 2. 3. 4. 5. 6. 7. 8.
.05) (Table 1). A significant difference in pain was reported for the IMP group among the 5 time points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .001). Strong evidence for differences in pain was observed before and after treatment: pretreatment versus 7 days (P = .157), pretreatment versus 3 months (P = .157), and pretreatment versus 6 months (P = .157). Patient Satisfaction after Root Canal or a Single Implant
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Clinical Research Treatment Complications. No significant difference in treatment complications is noted between the 2 groups (IMP and RCT) at any of the time points (Mann-Whitney U, P > .05) (Table 2). There was a significant difference in treatment complications for the IMP and RCT groups separately among the 4 time points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .029). Strong evidence for differences in severity of treatment complications was observed before and after treatment: pretreatment vs 7 days (P = .502), pretreatment vs 3 months (P = .502), and pretreatment vs 6 months (P = .502). More complications were noted in pretreatment versus 7 days, 3 months, and 6 months. Patient Satisfaction. No significant difference in overall satisfaction was noted between the 2 groups (IMP and RCT) at any of the time points (Mann-Whitney U, P > .05) (Table 3). No significant difference in overall satisfaction was noted for the IMP group among the 4 time points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .195). No significant difference in overall satisfaction was noted for the RCT group among the 4 time points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .590). A statistically significant difference in pain was noted between the time points (Fdf=4 = 0.00, P = 1.0). No statistically significant difference in the outcome measure was noted between the treatment groups (Fdf=1 = 0.171, P = .681). No statistically significant interaction was noted between time and treatment groups (Fdf=4 = 0.118, P = .733). No statistically significant differences in complications after treatment or overall satisfaction were noted between the time points or groups (P > .05).
TABLE 1. Descriptive Statistics for the Degree of Pain at Baseline and 4 Time Points after Treatments Group IMP Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 RCT Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75
Pain day 0
Pain day 7
Pain 3 mo
Pain 6 mo
Pain 12 mo
0.38 0.00 0 0.824 0.679 3 0 3
0.50 0.00 0 1.063 1.130 4 0 4
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0.00
0.00 0.00 0.75
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
1.67 0.00 0 3.046 9.275 9 0 9
0.17 0.00 0 0.637 0.406 3 0 3
0.50 0.00 0 1.615 2.609 7 0 7
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 2.75
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
IMP, implant group; RCT, endodontic group.
A significant difference in reported pain was also detected for the RCT group among the 5 points at which this outcome was collected (Friedman 2-way analysis of variance by ranks, P = .001). Strong evidence was observed for differences in reported pain at pretreatment versus 7 days (P = .110) and pretreatment versus 6 months (P = .110).
Discussion The results of this study show a high degree of patient satisfaction in both treatments and mild perception for pain and complications throughout the treatment. Also, there were no significant differences
TABLE 2. Descriptive Statistics for the Number of Complications per Patient after Implant Placement and Root Canal Treatment Group
Complications 7 days
Complications 3 mo
Complications 6 mo
Complications 12 mo
0.38 0.00 0 1.135 1.288 5 0 5
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.54 0.00 0 1.587 2.520 6 0 6
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0 0.000 0.000 0 0 0
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
IMP Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 RCT Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 IMP, implant group; RCT, endodontic group.
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Clinical Research TABLE 3. Descriptive Statistics for Reported Patient Satisfaction at 4 Points after Treatments Group
Satisfaction day 7
Satisfaction 3 mo
Satisfaction 6 mo
Satisfaction 12 mo
8.00 8.00 8 1.818 3.304 9 0 9
8.46 9.00 9 0.833 0.694 3 6 9
8.04 9.00 9 1.601 2.563 7 2 9
8.54 9.00 9 0.884 0.781 4 5 9
8.00 8.00 9.00
8.00 9.00 9.00
8.00 9.00 9.00
8.00 9.00 9.00
8.83 9.00 9 0.816 0.667 4 5 9
8.63 9.00 9 1.279 1.636 6 3 9
8.92 9.00 9 0.408 0.167 2 7 9
8.92 9.00 9 0.282 0.080 1 8 9
9.00 9.00 9.00
9.00 9.00 9.00
9.00 9.00 9.00
9.00 9.00 9.00
IMP Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 RCT Mean Median Mode Standard deviation Variance Range Minimum Maximum Percentiles 25 50 75 IMP, implant group; RCT, endodontic group.
between groups when compared at any of the time points for any of the outcome measurements. In the study, pain in the IMP group was mild at the 7-day posttreatment and almost disappeared by the follow-up appointments. This supports previous findings in the literature about pain or discomfort duration and after implant therapy (16, 21, 27). In a study by Schropp (16), patients reported their experience for implant placement in ‘‘immediate-delayed versus delayed’’ protocols. Patients in both groups reported minimal pain and high degrees of satisfaction at 1.5 years after implant placement. Moberg et al (21) recorded a small percentage of patients having orofacial pain in the recall visit after implant crown was delivered, with no persistent symptoms thereafter. In a retrospective study by Andersson et al (27), about 90% of patients described the implant treatment as pain-free or with minimal pain. This was recorded for 2-year post-implant treatment. In the RCT group, pain was at its highest degree at the pretreatment appointment, then significantly decreased by the 7-day post-treatment, and disappeared in the following appointments. The endodontic literature reports similar observations, although most of the studies looked at pain for up to 48 hours after treatment only (9, 37, 38). In a retrospective study by Dugas et al (9), 97% of patients reported physical pain before endodontic treatments, 75% of whom had their pain relieved after the treatment. Polycarpou et al (37) reported that 12% of the patients had persistent pain after endodontic treatment for at least 3 months. They reported absence of pain in the 6- or 12-month recall appointments for these patients. This study population had 29% pretreatment pain and 8.3% pain at 7-day post-treatment. In a systematic review, Pak and White (38) reported similar results. Sixty-eight percent of patients in this study had pretreatment pain, and less than 10% of them had post-treatment pain at 7 days. Patient perception of complications was minimal in both groups and was observed at 7-day post-treatment only. In the implant literature as well as in the endodontic literature, patient perceptions of complications were rarely reported. However, the vast majority of patients believed that the number of complications was
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acceptable, even when high frequencies of complications were recorded, especially with some studies describing prosthetic complications (6). Patients reported a high degree of satisfaction for both the IMP and the RCT groups, with no significant difference comparing different time points during the treatments in each group. Many studies reported similar results in the implant literature. Implant treatment improved patients’ chewing ability, esthetics, and quality of life in general with longterm high success rates, which explain the consistently high degree of satisfaction in the literature (16, 18, 21, 22, 25, 27). The same can be said about the high satisfaction rates after endodontic treatment (9, 10, 14, 37, 38, 39) even when post-treatment symptoms were still reported. This may be a result of the great reduction of discomfort and the understanding of the expected time needed for healing after treatment (6). One of the limitations of this study is the relatively small number of patients who were included. Under the inclusion and exclusion criteria outlined for the present study, many patients were not able to be included in the study. The procedures of this study were performed under strict protocol by a single operator in each group in a school setting, which does not relate exactly to settings for clinicians with different skill levels or protocols in private practice. Another factor that might be of importance is that the distribution of patients in the 2 groups was not even because selection into the groups was based on necessity of treatment and consecutive selection of patients. More men than women were included in the RCT group, and the converse was true in the IMP group. Multicenter prospective studies with more patients and operators are needed to confirm these results. To our knowledge, this is the first prospective study that directly compares the degree of pain and satisfaction of patients after root canal treatment or implant treatment. Clearly, there are differences between indications and contraindications of the 2 treatment modalities (5). Patients who seek root canal treatment usually present with preoperative pulp and/or periapical inflammation and pain. In contrast, patients who need implants have missing teeth where a dentist will be doing a surgical procedure that has the potential to
Patient Satisfaction after Root Canal or a Single Implant
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Clinical Research induce postoperative pain. Teeth with pulpal and/or periapical pathosis, sound periodontium, and restorable crowns are indications for root canal treatment. Root canal treatment on teeth with nonrestorable crowns or teeth with severe periodontal conditions is contraindicated, and other options such as implant placement should be considered for their treatment. In addition to differences between indications and contraindications of these 2 treatment modalities, initial root canal treatment is a nonsurgical procedure in contrast to the implant treatment, which is a surgical treatment with its inherent potential surgical sequelae such as bruising, hematoma, and paresthesia. Because of the inherent differences between the 2 procedures, it is difficult to compare them, but it is often done by the public and the professionals. A fair comparison might be between microsurgical endodontic retreatment and singletooth implant procedure. This study has followed the patients from pretreatment conditions throughout the healing phase and beyond. The results of this study showed no statistically significant differences in the outcome measurements between groups at any of the time points. A retrospective study by Gatten et al (40) reported a qualitative comparison between patients who had endodontic treatment or implant placement or both. Patients in that study described a high degree of satisfaction with positive effects on their quality of life. Although some patients mentioned that the implant felt different than their other teeth, they stated that they became accustomed to that feeling.
Conclusion The results of this study suggest that patients perceive both treatments with high degrees of satisfaction with minimal pain and complications. Differences were found at different time points of treatment and were related to the nature of the treatment itself. More prospective studies with larger sample sizes are needed to confirm the results of this preliminary prospective investigation.
Acknowledgments The authors thank the American Academy of Implant Dentistry (AAID) Foundation for its financial support of this research project. The authors deny any conflicts of interest related to this study.
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