international magazine of oral implantology

I 19implants1_2011 special _ endo-implant algorithm I In1952,theenterprisingsonofaninventornamed RonPopeilcreatedinfomercialsusing30-to120-sec- ondtelevisionspotstosellhisinexpensivearrayofuse- ful products, including the Pocket Fisherman and the Veg-O-Matic food slicer. The singular goal of an in- fomercial was to have the viewer phone immediately and place his or her order—no waiting weeks, months orevenyearsfortheloftymarketinggoalsofbranding to pay off. Somewhere along the way, dentistry mor- phed the two concepts. Nowhere is this becoming more apparent than in the debate on the endodontic implant algorithm. “We have met the enemy ... and he isus.”(ThePogoPapers) Scientificdoctrineisthecornerstoneofendodontic therapeutics. However, of late, anecdotal testimony has become the default setting for new paradigms to justify endodontic treatment modalities and an en- comiumtotechnologicaladvances.Thestrengthofthe arch of this or any specialty’s integrity and relevance must rely on a keystone of randomised clinical trials andevidence-basedtreatmentoutcomes.Expertopin- ions reflected through the looking glass of business modelsorglobaltourscannotreplacestringentlycon- trolled clinical assessments distilled from exacting in- dependent investigations. Science cannot be applied through a McLuhanistic rear-view mirror of technol- ogy.Thetwomustsymbioticallyoccupythesamespace regardless of whether that is antithetical to the Pauli Exclusion Principle, one of the most accepted laws of physics:notwoobjectscansimultaneouslyoccupythe samespace. In December 2004, Salehrabi and Rotstein3 pub- lished an epidemiological study on endodontic treat- ment outcomes in a large patient population. The outcomes of initial endodontic treatment by general practitioners and endodontists participating in the Delta Dental Insurance plan on 1,462,936 teeth of 1,126,288 patients from 50 states across the US were assessedinaneight-yeartimeline.Subsequenttonon- surgicalendodontictreatmentoverthisperiod97%of teeth were retained in the oral cavity. The combined incidence of untoward events, such as re-treatments, apicalsurgeriesandextractions,was3 %andoccurred primarily within three years from the completion of treatment. Analysis of the extracted teeth revealed 85 %hadnofullcoronalcoverage.Astatisticallysignif- icant difference was found between covered and un- coveredteethforalltoothgroupstested,whichiscon- sistentwiththefindingsofnumerousinvestigations.4–6 The purpose of this publication is to evaluate cur- renttrendsandperceptionspertainingtothestandard of care in endodontics and provide an evidence-based consensus on their relevance and application. Part II willaddressthealgorithmbywhichsacrificeofnatural structures for ortho-biological replacements can be validated and the engineering principles and designs thatbestmimicclinicaldictates. _Evolutionary paradigm shifts Three surveys have been conducted with the membership of the American Association of Endo- dontists since the late 1970s. The first reflected what is now an anachronistic view of emergency proce- dures and the standard of care defining non-surgical therapyduringthatperiod.7 Thesecond,donepriorto the technological advances of the last decade of the twentieth century, was hallmarked by a dramatic de- crease in leaving pulpless teeth open in emergency situations and a significant decline in the use of cul- turing prior to obturation.8 Thereportonthesecondsurveyindicatedthatthe concept of debridement and disinfection versus cleaning and shaping was now the focus of the bio- logical therapeutic imperative and the need for ex- pansive microbial strategies was recognised as being ofparamountimportance(Fig.3).Theprimarypatho- physiologic vectors of pulpal disease and the myriad complexityoftheroot-canalsystemhadalwaysbeen understood; as the century closed, clinicians were provided with new tools and technology to expand the boundaries and limitations of endodontic treat- ment procedures (Figs. 4a & b). Root-canal infections are polymicrobial, charac- terised predominantly by both facultative and obli- gateanaerobicbacteria.9 Thenecroticpulpbecomesa reservoirofpathogens;toxicconsequencesandtheir resultantinfectionareisolatedfromthepatient’sim- mune response. Eventually, the microflora and their by-products will produce a peri-radicular inflamma- tory response. With microbial invasion of the peri- radicular tissues, an abscess and cellulitis may de- velop.Theresultantinflammatoryresponsewilliniti- ate a protective and/or immuno-pathogenic effect. Additionally, it may destroy surrounding tissue, re- sulting in the five classic signs and symptoms of in- 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 pragmatism and expediency does not denigrate adaptive capacity. Fig. 1c