ROEN0110

08 I I special _ endo-implant algorithm may develop. The resultant inflammatory response will initiate a protective and/or immuno-pathogenic effect. Additionally, it may destroy surrounding tis- sue, resulting in the five classic signs and symptoms of inflammation: calour, dolour, rubor, tumour and penuria.Patientevaluationandtheappropriatediag- nosis/treatment of the source of an infection are of utmost importance. Patients demonstrating signs and symptoms as- sociated with severe endodontic infection (Table I) shouldhavetheroot-canalsystemfilledwithcalcium hydroxideandtheaccesssealed.Intheeventofcopi- ousdrainage,theaccesscanbeleftopenfornolonger than 24 hours, the tooth then isolated with rubber dam, the canals irrigated and dried and calcium hydroxide inserted into the root-canal space, and the access sealed.10 The antibiotic of choice for peri-radicular abscess remains Penicillin VK; however, recent studies have reported that amoxicillin in combination with clavu- lanate(1gmloadingdosewith500mgq8hforseven days) was a more effective therapeutic regimen.11 Systemicantibioticadministrationshouldbecon- sidered if there is a spreading infection that signals failure of local host responses in abating the disper- sion of bacterial irritants, or if the patient’s medical history indicates conditions or diseases known to reduce the host defence mechanisms or expose the patienttohighersystemicrisks.Antibiotictreatment is generally not recommended for healthy patients with irreversible pulpitis or localised endodontic infections (Table II). Numerous studies with well- defined diagnosis and inclusion criteria have failed to demonstrate enhanced pain resolution beyond the placebo effect.12,13 Thesophisticationofendodonticequipment,ma- terials and techniques has been steadily iterated and innovated since the second survey. The microscope firstintroducedtootolaryngologyaround1950,then to neurosurgery in the 1960s, is now the standard of careforthevoyageintothemicrocosmicworldofthe root-canal system. Recursions in the micro-process- ing technologies of electronic foraminal locators be- gat unprecedented accuracy levels, improved digital radiographic sensors and software-enhanced diag- nostic acumen, and ultrasonic units with a variety of tips designed specifically for use when performing both non-surgical and surgical endodontic proce- dures minimised damage to coronal and radicular toothstructureintheefforttolocatethepathwaysof the pulp. The treatment outcome of non-surgical root-canal therapy currently is far more predictable than at any other period in our history. _Diagnosis Of all the technologic innovations embraced by endodontics, digital radiography should have gener- ated the greatest impact; however, its value remains limited in diagnosis, treatment planning, intra-oper- ativecontrolandoutcomeassessment.Flat-fieldsen- sors still require three to four parallax images of the areaofinterestinordertoestablishbetterperception of depth and spatial orientation of osseous or dental pathology. These 3-D information deficits, geometric distortion and the masking of areas of interest by overlying anatomy or anatomical noise are of strate- gic relevance to treatment planning in general and endodontics specifically (Figs. 5a & b).14 Figs. 2a & b_Tooth #4 was determined to be non-salvageable. It was removed, the socket stimulated to regenerate and in four month’s time an ANKYLOS implant inserted, a sulcus former placed and the tissue closed over the site to allow for osseo-integration to occur. Figs. 2c & d_The choice of a natural tooth versus an ortho-biological replacement will increasingly be a powerful force in dental treatment plans. The temptation to select one or the other based on expediency versus complexity, on marketing versus science, will be the sine qua non of the standard of comprehensive care. Fig. 3_The degree of complexity of the root-canal system has been understood for most of the past century. The failure to negotiate the labyrinthine ramifications of the root- canal system has purportedly been a function of technical limitation rather than comprehension and yet, it took until the mid-1970s to appreciate that thermo-labile condensation of an obturating material could demonstrate a greater occlusive degree of the system than any other modality. roots1_2010 Fig. 2a Fig. 2dFig. 2c Fig. 3 Fig. 2b