international magazine of oral implantology

20 I implants1_2011 I special _ endo-implant algorithm flammation: calour, dolour, rubor, tumour and penuria.Patientevaluationandtheappropriatediag- nosis/treatment of the source of an infection are of utmost importance. Patients demonstrating signs and symptoms as- sociated with severe endodontic infection (Table I) shouldhavetheroot-canalsystemfilledwithcalcium hydroxideandtheaccesssealed.Intheeventofcopi- ousdrainage,theaccesscanbeleftopenfornolonger than 24 hours, the tooth then isolated with rubber dam, the canals irrigated and dried and calcium hydroxideinsertedintotheroot-canalspace,andthe access sealed.10 The antibiotic of choice for peri-radicular abscess remains Penicillin VK; however, recent studies have reported that amoxicillin in combination with clavu- lanate(1gmloadingdosewith500mgq8hforseven days) was a more effective therapeutic regimen.11 Systemicantibioticadministrationshouldbecon- sidered if there is a spreading infection that signals failure of local host responses in abating the disper- sion of bacterial irritants, or if the patient’s medical history indicates conditions or diseases known to reduce the host defence mechanisms or expose the patienttohighersystemicrisks.Antibiotictreatment is generally not recommended for healthy patients with irreversible pulpitis or localised endodontic infections (Table II). Numerous studies with well- defineddiagnosisandinclusioncriteriahavefailedto demonstrate enhanced pain resolution beyond the placebo effect.12,13 The sophistication of endodontic equipment, ma- terials and techniques has been steadily iterated and innovated since the second survey. The microscope first introduced to otolaryngology around 1950, then to neurosurgery in the 1960s, is now the standard of care for the voyage into the microcosmic world of the root-canalsystem.Recursionsinthemicro-processing technologies of electronic foraminal locators begat unprecedented accuracy levels, improved digital radi- ographic sensors and software-enhanced diagnostic acumen,andultrasonicunitswithavarietyoftipsde- signedspecificallyforusewhenperformingbothnon- surgical and surgical endodontic procedures min- imised damage to coronal and radicular tooth struc- tureintheefforttolocatethepathwaysofthepulp.The treatment outcome of non-surgical root-canal ther- apycurrentlyisfarmorepredictablethanatanyother periodinourhistory. _Diagnosis Ofallthetechnologicinnovationsembracedbyen- dodontics, digital radiography should have generated thegreatestimpact;however,itsvalueremainslimited indiagnosis,treatmentplanning,intra-operativecon- trolandoutcomeassessment.Flat-fieldsensorsstillre- quirethreetofourparallaximagesoftheareaofinter- estinordertoestablishbetterperceptionofdepthand spatial orientation of osseous or dental pathology. These 3-D information deficits, geometric distortion and the masking of areas of interest by overlying anatomyoranatomicalnoiseareofstrategicrelevance to treatment planning in general and endodontics specifically(Figs.5a&b).14 Cone-beam computed tomography (CBCT) pro- duces up to 580 individual projection images with isotropic sub-millimetre spatial resolution enhanced Figs. 2a & b_Tooth #4 was determined to be non-salvageable. It was removed, the socket stimulated to regenerate and in four month’s time an ANKYLOS implant inserted, a sulcus former placed and the tissue closed over the site to allow for osseo-integration to occur. Figs. 2c & d_The choice of a natural tooth versus an ortho-biological replacement will increasingly be a powerful force in dental treatment plans. The temptation to select one or the other based on expediency versus complexity, on marketing versus science, will be the sine qua non of the standard of comprehensive care. Fig. 3_The degree of complexity of the root-canal system has been understood for most of the past century. The failure to negotiate the labyrinthine ramifications of the root- canal system has purportedly been a function of technical limitation rather than comprehension and yet, it took until the mid-1970s to appreciate that thermo-labile condensation of an obturating material could demonstrate a greater occlusive degree of the system than any other modality. Fig. 2a Fig. 2dFig. 2c Fig. 3 Fig. 2b