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I 07 special _ endo-implant algorithm I roots2_2010 The prosthodontic pundits maintain that the spiralling costs of saving endodontically retreated teeth, for which extraction may well prove to be the common endpoint, bring into question whether such teethshouldbesacrificedearly.Ruskinetal.concluded that implants have greater success than endodontic therapy, are more predictable, and cost less when one considers the ‘inevitable’ failure of initial root-canal treatment, retreatment and peri-apical surgery.2 Is it responsible therapeutics or irresponsible expediency thatjustifiestheremovalandrestorationofsuchteeth from the outset with an implant-supported resto- ration? Can one ethically argue that extraction is warranted because the financial cost of orthodontic extrusion/soft-tissue surgery, endodontic retreat- ment and post/core/crown fabrication is greater than extraction with an implant-buttressed restoration, andinalllikelihood,morepredictable?3 Jokstadetal.4 identifiedover220implantbrandsin the dental marketplace. With variability in surface, shape, length, width and form, there are potentially more than 2000 implants for any given treatment situation. A systematic review by Berglundh et al.5 assessed the reporting of biological and technical complications in prospective implant studies. Their findings indicated that while implant survival and loss were reported in all studies, biological difficulties, such as sensory disturbance, soft-tissue complica- tions, peri-implantitis/mucositis and crestal bone loss, wereconsideredinonly40to60%ofstudies.Technical complications such as component/connection and superstructure failure were addressed in only 60 to 80%ofthestudies.Areweasaprofessionstandingidly by and watching marketing pressures force treatment decisions to be made empirically, with untested mate- rials and techniques? There is an unsettling similarity between these events and the early days of implant development.6 The endodontic pundits argue that major studies publishedtodatesuggestthereisnodifferenceinlong- term prognosis between single-tooth implants and restored root-canal treated teeth. In fact, regardless of the similarity of treatment outcomes, the prepon- derance of post-treatment complications favours endodontic therapy. Therefore, the decision to treat a toothendodonticallyortoplaceasingle-toothimplant should be based on criteria such as restorability of the tooth,qualityandquantityofbone,aestheticdemands, cost-benefit ratio, systemic factors, potential for adverseeffectsandpatientpreferences.7–11 Areviewof endodontic treatment outcomes by Friedman and Mor12 used radiographic absence of disease and cli- nical absence of signs and symptoms as the defining parameters for success. They suggested that the chance of having a tooth extracted after failure from initial endodontic treatment, retreatment and apical surgerycollectivelywouldberoughly1in500cases. The dialogue comparing endodontic treatment to implanttherapyjarringlyoverlooksthecrucialfactthat itisoftenthecalibreoftherestorationanditsprogno- sis, and not the endodontic prognosis per se, that is the determinant of the treatment outcome. The pri- marybiologicalmandateofanydentalprocedureisthe retention of the orofacial ecosystem in a disease-free state. Surgical and non-surgical endodontic therapies Fig. 2a_The use of dyes, colouring agents and micro-etching is invalu- able in visualising a suspected crack in tooth structure. Cohen et al. found that when premolars were used as bridge abutments, a surprising number of these abutments sustained a VRF.61 Fig. 2b_The dental literature reports a statistically higher level of accuracy using CBCT (cone-beam computed tomography) scans for detecting VRF than with the use of peri-apical radiography alone. Fig.2c_Themultivariatenatureof theendo-implantalgorithmmandates theuseofCBCTtodetectandevaluate thedegreeofperi-apicalpathosis. Analysisofthesize,extent,nature andpositionofperi-apicaland resorptivelesionsinthreedimensions isessentialfortheoptimallevelof standardofcareindiagnosis. Fig. 2b Fig. 2c Fig. 2a