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23ClinicalJuly 12-18, 2010United Kingdom Edition F our thousand years ago, a number of Babyloni- an legal decisions were compiled in what came to be known as the Code of Hammu- rabi. The one referencing the con- struction of dwellings and the re- sponsibility for their safety begins; if a builder engineers a house for a man and does not make it firm, and the structure collapses and causes the death of the owner, the builder shall be put to death. We are all builders or en- gineers of sorts; we calculate the path of our arms and legs with the computer of our brain and we catch baseballs and footballs with greater depend- ability than the most advanced weapons system intercepts mis- siles. In our professional lives however, in contradistinction to the paradigm of evidence-based dentistry, our efforts as builders often rely solely upon personal experience, intuitive cognition and anecdotal accounts of suc- cessful strategies. Vigilant interaction The challenges posed by implant- driven treatment planning man- date vigilance of the interaction between those involved in re- search and development, manu- facturing and distribution and the leaders of ideologically diverse disciplines. Temporal shifts and trends in the service mix are part of the evolution of the art and sci- ence of dentistry; to some degree, the implant-driven vector has captured the heart and minds of those who seek to nullify preser- vation of natural tooth structure in the oral ecosystem and deify orthobiologic replacement. The corporate entities from which we derive our tools too often fail to distinguish the point where sci- ence ends and policy begins. By positioning advocates and acolytes at the vanguard of their marketing campaigns, they ef- fect change; however, their sup- port for education is directed to- wards dissemination of product, not the fundamentals and rudi- ments of biologic imperatives. Prospective large cohort clinical trials with clearly defined crite- ria for survival, with and without intervention, quality of life infor- mation and economic outcomes are essential to compare alter- native foundational treatments. These studies will require exper- tise, time, and financial support from the various stakeholders, professional and corporate alike (1) . According to Cicero, ‘The au- thority of those who teach is often an obstacle to those who want to learn.’ Sacrificing teeth The prosthodontic pundits main- tain that the spiraling costs of saving endodontically retreated teeth, where extraction may well prove to be the common endpoint, begs the question of whether such teeth should be sacrificed early. Ruskin et al concluded that implants have greater success than endodontic therapy, are more predictable, and cost less when you consider the “inevitable” failure of initial root canal treatment, retreat- ment, and periapical surgery (2) . Is it responsible therapeutics or irresponsible expediency that justifies the removal and restora- tion of such teeth from the outset with an implant-supported resto- ration? Can one ethically argue that extraction is warranted as the financial cost of orthodontic extrusion/soft tissue surgery, en- dodontic retreatment and post/ core/crown fabrication is greater than extraction with an implant- buttressed restoration, and in all likelihood, more predictable (3) ? Jokstad et al (4) identified over 220 implant brands in 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) as- sessed the reporting of biologic Back to the Egg; Part I Kenneth Serota continues his look at the Endodontic Implant Algorithm Fig 2a. The use of dyes, colouring agents and micro-etching is invaluable in visualizing 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. [J Am Dent Assoc 2003; 134(4)434-441]. page 26DTà Fig 1: The term tipping point refers to the moment of critical mass, the threshold, the boiling point. The colour sequence highlights the diagnostic steps to be followed in each tipping point algorithm for the listed pathologic states. page 26DTà