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References 1. Torabinejad M, Anderson P, Bader J et al. Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: A systematic review. J Prosth Dent 2007;98(4):285-311. 2. Ruskin JD, Morton D et al. Clinical controversies in Oral and Maxillofacial Surgery: Part One. Failed root canals: The case for extraction and immediate implant placement. J Oral Maxillofac Surg 2005;63:829-831 3. Moiseiwitsch J, Caplan D. A cost-benefit comparison between single tooth implants and endodontics. J Endod 2001;27:235. 4. Jokstad A, Braegger U, Brunski JB et al. Quality of dental implants. Int Dent J 2003;53:409-443. 5. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Peri- odontol 2002;29 Suppl 3:197-212. 6. Brånemark PI. On looking back with Per-Ingvar Branemark. Interview. Int J Prosthodont 2004;17:395-396. 7. Christensen GJ. Implant therapy versus endodontic therapy. J Am Dent Assoc 2006;137:1440-3. 8. Morris FM, Kirkpatrick TC et al. Comparison of nonsurgical root canal treatment and single tooth implants. J Endo Oct 2009;35(10):1325-1330. 9. Torabinejad M, Kutsenko D et al. Levels of evidence for the out- come of nonsurgical endodontic treatment. J Endod 2005;31:637-46. 10. Torabinejad M, Bahjri K. Essential elements of evidenced-based endodontics: steps involved in conducting clinical research. J Endod 2005;31:563-9. 11. Ricucci D, Grosso A. The compromised tooth: conservative treatment or extraction. Endo Topics 2006;13:108-122. 12. Friedman S, Mor C. The success of endodontic therapy: healing and functionality. J Calif Dent Assoc 2004;32:493-503. 13. Friedman S. Considerations and concepts of case selection in the management of post-treatment endodontic disease (treatment failure). Endod Topics 2002;1:54-78. 14. Foster KH, Harrison E. Effect of presentation bias on selection of treatment option for failed endodontic therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:36-9. 15. Tamse A, Fuss Z, Lustig J, Kaplavi J. An evaluation of endodontically treated vertically fractured teeth. J Endod 1999;25:506-8 16. Aquilinio SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosth Dent 2002;87(3):256-263. 17. Zadik Y, DMD, Sandler V, Bechor R. Analysis of factors related to extraction of endodontically. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:31-35. 17. Chugal N, Clive J, Spångberg L. A prognostic model for assessment of the outcome of endodontic treatment: Effect of biologic and diagnostic variables. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology & Endodontics 2001;91(3) 342-352. and technical complications in prospective implant studies. Their findings indicated that while implant survival and loss were reported in all studies, biologic difficulties such as sensory disturbance, soft tissue complications, peri- implantitis/mucositis and cre- stal bone loss were considered in only 40 to 60 per cent of studies. Technical complica- tions such as component/con- nection and superstructure failure were addressed in only 60 to 80 per cent of the studies. Are we as a profession standing idly by and watching market- ing pressures force treatment decisions to be made empiri- cally, with untested materials and techniques? There is an un- settling similarity between these events and the early days of im- plant development (6) . Favouring endodontics The endodontic pundits argue that major studies published to date suggest there is no dif- ference in long-term prognosis between single-tooth implants and restored root-canal-treated that in the comprehensive care decision making process. Salvaging teeth Whenever possible, the treat- ment choice should be an at- tempt to salvage a tooth us- ing a multidisciplinary team approach, putting aside pre- conceived notions and biases. Finances should not dictate the advice proffered. Further- more, it is advisable to forego being clinically “conservative”. Treatment should not be initi- ated in the absence of a critical evaluation of the potential for all contributing factors to equate with a positive outcome. When needed, care must be taken to carry out every diag- nostic procedure available, even those of a more invasive nature (see Fig 1). Before arriving at a definitive diagnosis and treat- ment plan, the clinician should obtain consent from the patient to remove any restoration in order to analyse the residual tooth structure and assess the potential to carry out reliably predictable treatment. The pa- tient must understand in detail, the feasibility of and margin for success of each treatment option presented (14) . There are few studies in the endodontic literature ana- lysing the reasons for extraction of endodontically treated teeth. Root-filled teeth are invariably prone to extraction due to non- restorable carious destruction and fracture of unprotected cusps. Tamse et al found that mandibular first molars were extracted with greater frequen- cy than maxillary first molars; the most significant causal dif- ference was the incidence of vertical root fracture (VRF – 1.8 per cent maxillary molar, 9.8 per cent mandibular molar) (15) . Teeth not crowned after obtura- tion are lost with six times the frequency of those restored with full coverage restorations (16) . Procedural failure, iatro- genic perforation or stripping, idiopathic resorption, trauma, and periodontal disease all contribute to a lesser degree. The major biologic factor in- fluencing endodontic treatment outcome failure with the pos- sibility of extraction appears to be the extent of microbio- logical insult to the pulp and periapical tissue, as reflected by the periapical diagnosis and the magnitude of periapical patho- sis (17) . (See Table I and Fig 2a, 2b and 2c). Parts 2 and 3 to be published in further issues of Dental Trib- une UK. DT Size Success 0mm 87.6% 1-5mm 65.7% + 5mm 56.2% Table I. As reported by Chugal et al, the most significant vector impacting on post-operative healing is the presence and magnitude of pre-operative apical periodontitis. About the author Kenneth S Serota, DDS, MMSc graduated from the University of Toronto, Faculty of Dentistry in 1973 and was awarded the George W Switzer Memorial Key for excellence in Prosthodontics. He re- ceived his Certificate in Endodontics and Master of Medical Sci- ences Degree from the Harvard-Forsyth Dental Center in Boston, MA. A recipient of the recipient of the American Association of En- dodontics Memorial Research Award for his work in nuclear medi- cine screening procedures related to dental pathology, his passion is education and most recently e-learning and rich media. Ken pro- vided an interactive endodontic program for the Ontario Dental Association from 1983 to 1997 and was awarded the ODA Award of Merit for his efforts in the provision of continuing education. He was selected for Fellowship in the Pierre Fauchard Academy and is a Fellow of the Academy of Dentistry International. The author of over sixty publications, he has lectured on Endodontics internationally. He is on the editorial board of Endodontic Practice, Endodontic Tribune and Implant Tribune. The founder of ROOTS – an online educational forum for dentists from around the world who wish to learn cutting edge endodontic therapy, he recently launched IMPLANTS (www. rximplants.com) and www.tdsonline.org in order to provide a clear understanding of the endodontic/implant algorithm in foundational dentistry. As well, he lectures on the empowerment digital technologies provide to the sophistication of the dental team and the propagation of comprehensive care. page 23DTß Fig 2c. The multivariate nature of the endodontic implant algorithm mandates the use of cbCT to detect and evaluate the degree of periapical pathosis. Analysis of the size, extent, nature and position of periapical and resorptive lesions in three dimensions is essential for the optimal level of standard of care in diagnosis. Fig 2b. The dental literature reports a statistically higher level of accuracy using cbCT (cone beam volumetric tomography) scans for detecting vertical root fractures than with the use of periapical radiography alone. ‘Whenever possible, the treatment choice should be an attempt to salvage a tooth using a multidisciplinary team approach, putting aside preconceived notions and biases.’ ‘The endodontic pundits argue that major studies published to date suggest there is no difference in long-term prognosis between single-tooth implants and restored root-canal-treated that in the comprehen- sive care decision making process.’ July 12-18, 201026 Clinical United Kingdom Edition