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May 17-23, 201018 Implant Tribune United Kingdom Edition Untying the Gordian Knot; Part I Kenneth Serota discusses the Endodontic Implant Algorithm, which provides highlights in the assessment and identification of determinant factors leading to endodontic failures, in order to help in the decision-making process whether or not it is adequate to implement a new endodontic approach vs. extraction and replacement with dental implants O ver the years, endodon- tics has diminished it- self by enabling the pre- sumption that it is comprised of a narrowly defined service mix; root canal therapy purportedly begins at the apex and ends at the orifice. Nothing could be fur- ther from the truth. It is the cata- lyst and precursor of a multiva- riate continuum, potentially the foundational pillar of all phases of any rehabilitation (Fig 1a, 1b, 1c). Early diagnosis of teeth re- quiring endodontic treatment, prior to the development of per- iradicular disease, is critical for a successful treatment outcome (1) . Esthetics, function, structure, biologics and morphology are the variables in the equation of optimal oral health. Interven- tional or interceptive endodon- tics, restorative endodontics, the re-engineering of failing thera- py, transitional endodontics and surgical endodontics encompass a vast scope of therapeutic con- siderations prior to any deci- sion/tipping point to replace a natural tooth. Everything we do as dentists is “transitional”, with the exception of extractions. No result is everlasting, none are permanent; thus our treat- ment plans must reflect this re- ality. Artifice versus a natural state is not a panacea for suc- cessful treatment outcomes (Fig 2a, 2b, 2c, 2d). In 1992, funding from the Cochrane Collaboration was ob- tained for a UK Cochrane Cen- tre based in Oxford to facilitate the preparation of systematic reviews of randomised trials of healthcare (2) . The Cochrane Sys- tematic Review is a process that involves locating, appraising, and synthesising evidence from sci- entific studies in order to provide informative empirical answers to scientific research questions. In 1952, the enterprising son of an inventor named Ron Popeil cre- ated infomercials using 30 to 120 second television spots to sell his inexpensive array of useful prod- ucts, including the Pocket Fisher- man and the Veg-O-Matic food slicer. The singular goal of an infomercial was to get the viewer to a phone immediately and have them place their order. No wait- ing weeks, months or even years for the lofty marketing goals of branding to pay off. Somewhere along the way, dentistry morphed the two concepts. Nowhere is this becoming more apparent than in the debate on the endodontic im- plant algorithm. New treatment modalities Scientific doctrine is the corner- stone of Endodontic therapeutics. However, of late, anecdotal testi- mony has become the default set- ting for new paradigms to justify endodontic treatment modalities and an encomium to technologic advances. The strength of the arch of this or any specialty’s in- tegrity and relevance must rely on a keystone of randomised clinical trials and evidence-based treatment outcomes. Expert opin- ions reflected through the looking glass of business models or global tours cannot replace stringently controlled clinical assessments distilled from exacting independ- ent investigations. Science cannot be applied through a McLuhanis- tic rearview mirror of technology. The two must symbiotically oc- cupy the same space regardless of whether that is antithetical to the Pauli Exclusion Principle, one of the most accepted laws of phys- ics; no two objects can simultane- ously occupy the same space. In December 2004, Salehrabi and Rotstein (3) published an epi- demiological study on endodon- tic treatment outcomes in a large patient population. The outcomes of initial endodontic treatment done by general practitioners and endodontists participating in the Delta Dental Insurance plan on 1,462,936 teeth of 1,126,288 pa- tients from 50 states across the USA were assessed in an eight year timeline. Ninety seven per cent of teeth were retained in the oral cavity subsequent to nonsur- gical endodontic treatment over this period. The combined inci- dence of untoward events such as retreatments, apical surgeries, and extractions was three per cent and occurred primarily within three years from the completion of treatment. Analysis of the ex- tracted teeth revealed that 85 per cent had no full coronal coverage. A statistically significant differ- ence was found between covered and uncovered teeth for all tooth groups tested which is consistent with the findings from numerous investigations (4, 5, 6) . The purpose of this publica- tion is to evaluate current trends and perceptions pertaining to the standard of care in endodontics and provide an evidence-based consensus on their relevance and application. Part II will address the algorithm by which sacrifice of natural structures for orthobio- logic replacements can be vali- dated and the engineering princi- ples and designs that best mimic clinical dictates. Evolutionary paradigm shifts Three surveys have been con- ducted with the membership of the American Association of En- Figs 1a, 1b – Previous endodontic therapy on tooth #2.6 (14) had failed; the clinician chose to correct the problem with a microsurgical procedure on the MB root. This procedure failed over time as well (sinus tract). Radiographic and clinical evidence demonstrate the developing apical lesion. The root canal system was re-accessed, the untreated canal iden- tified, the entire system debrided, disinfected and after interim calcium hydroxide therapy, obturated. One year later, the lesion has healed. While the retrograde amalgam remained in the root end, its presumed ability to effectively seal a complex apical terminal configura- tion was ill-considered. Everything leaks in time; retreatment is always the first choice for resolution of an unsuccessful endodontic procedure where possible. Fig 1c – “Listening to both sides of a story will convince you that there is more to a story than both sides [Frank Tyger]”. The endodontic implant algorithm ensures that philosophy does not obscure pragma- tism and expediency does not denigrate adaptive capacity.