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Inside Dentistry

February 2007, Volume 3, Issue 2
Published by AEGIS Communications


Feb 2007 — Vol. 3, Iss. 2

Getting to the Root of Quality Patient Care

Allison M. DiMatteo

Nearly 4 years ago, a project funded by the American Association of Endodontists (AAE) culminated in a report entitled The Economics of Endodontics. As a part of the American Dental Association (ADA)’s Dental Health Policy Analysis Series, it noted that 75.2% of the total 21.9 million endodontic services rendered were provided by general practitioners; endodontists provided 20.3% of those services, with various other specialists—such as pediatric dentists—providing the remainder.1 The report also stated that although endodontic services comprise less than 2% of total dental procedures, root canal therapy alone accounted for more than 15% of total dental expenditures in 1999, for an estimated $8.2 billion.1

Roger Levin, DDS, the CEO of Levin Group, has observed a slight increase in the number of root canals being performed in the general practice over the last 20 years. He credits much of that increase to advancements in technology that are making the procedures easier to some general dentists. As a result, they’re more comfortable and confident when navigating the canals.

“Depending on whom you quote, somewhere between 80% and 90% of all endodontic procedures are being performed by general practitioners,” says Kenneth A. Koch, DMD, the co-founder of Real World Endo. “So, the profession needs techniques that are not only backed by science but that are also beneficial to both specialists and general practitioners alike.”

Dental product manufacturers are answering that call and have, over the years, introduced less technique-sensitive diagnostic and instrumentation tools. These have included—but certainly aren’t limited to—nickel titanium rotary instruments, apex locators, and sonic instrumentation, as well as materials for reinforcing the tooth (eg, fiber and composite posts for better esthetics and greater strength).

“The dental profession has evolved a great deal in the last 10 to 15 years,” explains John Bernhard, senior products manager for endodontics for Ultradent Products, Inc. “The economics of practicing dentistry have become increasingly important in recent years, and there are not many procedures in dentistry that offer a greater financial yield than a root canal.”

When it comes to profitability, there’s high net income being realized from endodontic therapies because treatment-related expenses are relatively low.1 So, now’s a good time to provide, consider learning how to perform, and/or refer endodontic cases in a more knowledgeable way.

Levin comments that general dentistry is about providing a broad range of services at a standard of care that meets the needs of patients. Those services could include restorative, crown and bridge, cosmetic, dentures, and treatments such as root canals.

“This area of dentistry, like everything else, has witnessed incredible advancements in technology,” Levin says. “We now have a better chance than ever before of realizing excellent diagnosis and treatment.”

Without question, endodontics is an integral part of daily practice, and general dental practitioners should be knowledgeable and skilled in rendering a diagnosis of, treatment planning for, and treating pulpal and/or periradicular disease. This month we present an Inside look at endodontics in the general dental practice. To canvas what’s taking place, we explore the trends; some of the changes in choice materials that make incorporating endodontics in the general practice a predictable proposition; and what dentists should consider adding to their armamentarium. All in all, it’s a glimpse at why the root canal that was once-upon-a-time dreaded by both patients and clinicians should no longer be cause for fear and loathing—by anyone—in the dental practice.

The Difference Between “Doing Endo” and Being an Endodontist

How endodontics is viewed as a discipline has changed over the years, moving from an academic profession to a specialty similar to oral surgery or orthodontics. In fact, in 1982, 83.7% of endodontists were in private practice, but that percentage grew to 90.5% in 2003, which is close to the percentage of general practitioners that were in private practice that same year (94.1%).1

By definition, endodontics is that branch of dentistry concerned with the morphology, physiology, and pathology of the dental pulp and periradicular tissues. According to the AAE, which boasts more than 6,500 members (both endodontists and general practitioners), the study and practice of endodontics involves the basic clinical sciences; the etiology, diagnosis, prevention, and treatment of diseases and injuries of the pulp; and associated periradicular conditions.2

The scope of endodontics is broad and includes differential diagnosis and treatment of oral pain that originates with the pulp and periradicular tissues; vital pulp therapy (eg, pulp capping and pulpotomy); nonsurgical treatment of root canal systems; and surgical removal of pathologic tissues resulting from pulpal pathosis.2 Additionally, endodontics also encompasses intentional replantation of avulsed teeth; surgical removal of tooth structure; retreatment of teeth previously treated endodontically; and treatment procedures related to coronal restorations with posts and/or cores in the root canal space.2

To become an endodontist, 2 or more years of advanced postgraduate education is required, along with receipt of a certificate in endodontics, from an advanced education program accredited by the ADA’s Commission on Dental Accreditation.2 The specialist designation means that the dental professional will limit his or her practice to endodontics. To become board certified, the endodontist must pass the certifying examination administered by the American Board of Endodontics.

Truly differentiating between “doing endo” and being an endodontist, however, is a product of how you define a specialist, believes Marc Balson, DDS, FACD, the immediate past-president of the AAE, who maintains a private practice in endodontics in Livingston, New Jersey. Endodontists do complete an additional 2 to 3 years of postgraduate education, he says, which allows them to do something special. That specialty, he explains, is identifying and treating a variety of cases that others wouldn’t normally be able to see—cases involving a variety of pathology.

The Seeds of Therapeutic Progress in Endodontics

Because root canals offer such a great financial yield, more and more general dentists are demanding endodontic treatment techniques that are easier, more predictable, and quicker, but with just as much reliability as in the past, Bernhard says. Many of the endodontic products available today respond to those requirements and much of the responsiveness to end-user needs—as well as the evolution of materials—is the result of industry-driven factors, he says, not necessarily clinical or scientific-driven factors.

For example, prior to about 18 years ago, endodontics had not changed in more than 50 years, explains Gregori M. Kurtzman, DDS, MAGD, FACD, who maintains a private general practice in Silver Spring, Maryland. Canals were instrumented with hand files and obturated with gutta percha and zinc oxide eugenol (ZOE), calcium hydroxide, or epoxy resin sealers. Then, circa 1988, an evolutionary leap occurred in endodontics when nickel titanium rotary files were introduced and instrumentation became easier, more efficient and, best of all, more standardized in terms of results, he says.

“The standard hand-file mentality of 15 years ago has been replaced by a variety of systems and materials—such as rotary nickel titanium and reciprocating—that allow the clinicians to make choices based on their preference for a particular technique,” Bernhard explains. “Most endodontic materials available today make the practice of endodontics more accessible and practical for many more dentists than ever before.”

Kurtzman further chronicles the evolutionary advancements of endodontic therapies, noting that 6 years ago, another leap forward occurred with the introduction of bondable obturation materials that help to seal the canal and prevent coronal leakage. Prior to that development, coronal leakage had long been ignored as a contributor to endodontic failures, he said. In the past decade, however, an increasing number of peer-reviewed publications demonstrated the importance of sealing the coronal aspect in order to prevent bacterial migration to the apex, he explains.

“Worldwide nonsurgical endodontics is a very hot topic,” observes Koch. “I think the real key for endodontics moving forward is material science, which will continue to change the manner in which canals are filled (eg, resin-, glass ionomer-, and perhaps bioceramic-based filling materials).”

According to Larry Lopez, DDS, who maintains a private general practice in San Antonio, Texas, there are two main goals in endodontics: first, disinfect the canal system and second, seal it so that nothing can get in or out. Perhaps the impact of material science on the manner in which endodontic treatments are performed can best be explained by examining the trends for sealing the canals.

Heated gutta percha, cold gutta percha, different types of pastes, various types of sealers (eg, some with and without bacterialcidal properties) have all been used. As previously mentioned, there are now adhesively bonding materials that can also be placed in the canal, Lopez elaborates.

Techniques also tell an evolutionary tale, and there are advantages and disadvantages to each. For example, the lateral condensation approach—which uses gutta percha points and ZOE or AH 26 sealer—has been tried and tested for years. The ZOE cement inherently contains eugenol, which is bacterialcidal, and the AH 26 sealer contains silver particles and formaldehyde, which are also bacterialcidal, Lopez explains. However, he points out that lateral condensation may result in microfractures in the root that could subsequently lead to root fracture and possibly eventual tooth loss.

Another procedure involves placing heated gutta percha into the tooth with tapered instruments, which provides a better seal and better dispersion of the gutta percha. However, because the gutta percha is injected into the canal at around 200°C to 250°C, the heat could cause thermal stress and expansion to the root, Lopez explains. Then, when it’s compacted using tapered instruments, the thermally stressed tooth structure is now potentially subject to stress fractures in the root that could lead to root fracture and eventual tooth loss, Lopez says.

With today’s “cold” resin systems, heat is not used, Lopez says, and the dispersion of the sealer in the canal is based on hydrophilic attraction. Essentially the bonding agent is pulled into the dentinal tubules by moisture that’s in the canals, without the need for heat or force. The hybridization of the radicular dentin creates a predictable seal and, Lopez says, strengthens the root structure against fracture. However, teeth that are endodontically treated this way the first time may be slightly more difficult to retreat than conventional materials based on difficulty in removing the adhered sealer from the canal.

Sharing Secrets for Endodontic Success
According to Kurtzman, general dentists are in a great position to take advantage of the new bonded obturation materials that have come on the market because they are accustomed to etching, applying adhesives, and using bonded materials for restorative processes. He says moving from using those types of materials coronally to using them within the canal is a natural progression.

“The key to successful endodontics is establishing a good glide path for straightline access to the canals and using hand files to establish working length before using a rotary file,” Kurtzman says. “There are alternate techniques, but my personal experience is that if I use a combination of hand and rotary files, I have fewer instruments separating, especially if I open up the canal to a certain size before entering with rotary instruments. There’s less chance of a file binding deep in the tooth and breaking the instrument.”

Koch explains that access is the first key thing for anybody doing a root canal. Once straightline access is achieved, then the procedure becomes all about shaping the root canal. Some people use rotary instruments and techniques that promote a variable taper sequence and others advocate a constant taper technique. The clinician alone must decide which methodology is going to work best in his or her hands.

Kurtzman also recommends keeping irrigating solutions in the canals when using rotary files, as well as not forcing the file apically. The file should be removed frequently so that debris can be wiped off, he advises, in order to lessen the chances of separating a file in the canal.

According to Ali Allen Nasseh, DDS, MMSc, a clinical instructor at Harvard University School of Dental Medicine, most endodontic systems on the market work effectively, and each has its own unique characteristics. Therefore, it’s important for each practitioner to review and understand as many systems as possible in order to make an informed decision about which products and techniques best match his or her particular preferences for performing treatment.

However, it’s important to note that integrating endodontics into general practice is a gradual process, Nasseh says, starting with the least complicated cases and gradually building skills. He advises all general practices that perform endodontic treatment to visit the AAE Web site (www.aae.org) to obtain the case difficulty assessment form, which he says can serve as a legal reference for assessing the difficulty level of individual cases.

And, don’t forget that endodontic treatment can and should always be performed painlessly. The experience of pain during the procedure is simply a sign of anesthetic failure, Nasseh explains. While conventional anesthesia may fail occasionally due to various anatomic and physiologic reasons, adjunct anesthesia techniques are now available that allow the clinician to manage such cases, he says.

For example, easy-to-use, intraosseous anesthesia delivery devices have been one of the greatest advances in this area of pain control to the extent that the experience of pain at the dentist is now a rare event, and patients are increasingly aware of this, Nasseh points out. What’s more, the increased popularity and ease of access to sedation dentistry has helped many apprehensive patients receive much-needed dentistry while consciously sedated and comfortable during their treatment.

“Good clinicians adhering to these painless principles are gradually debunking the myth of the dreaded root canal,” he says. “Also, practitioners can reduce anxiety by building rapport with their patients and demonstrating genuine concern, as well as believing in their own ability to perform the procedure painlessly. Warmth, empathy, and respect are a winning formula for reducing patient fear.”

When considering treatment possibilities, it’s always best to maintain the natural teeth because of the proprioception they provide—something that is absent with implants, notes Kurtzman. But, he says clinicians must also consider the long-term prognosis for the natural tooth.

“Teeth with internal cracks, molars with furcation issues, and the need to endodontically retreat the tooth may offer lower prognoses than replacement with dental implants, and teeth that require osseous crown lengthening to achieve a ferrule may compromise the adjacent teeth periodontally because you need to remove crestal bone on the tooth medial and distal to the one that requires crown lengthening,” Kurtzman explains. “Extraction and placement of an implant in these situations may help maintain the bone adjacent to the site and yield better esthetic results.”

And, if the case is being referred, general practitioners can still maintain an active role in the case, believes Levin. In addition to the standard information provided on the prescription or referral slip, general dentists can also discuss with the specialist what they want done for the root canal, whether or not there should be post space and what type should be placed, etc.

“GPs should work with an endodontist who is willing to embrace a team approach,” Levin encourages. “This will help ensure the best service possible because, in the end, the most important person in the equation is the patient.”

Conclusion

The endodontic area of dentistry encompasses high-paying, high-yield, reliable procedures for specialists or general practitioners to perform when predictable techniques and materials are skillfully and knowledgeably used. Therefore, integrating endodontics into a general practice can be an additional source of profit, Nasseh says.

However, this profit comes with certain responsibilities to the patient, so it’s important that general dentists know that the standard of care—which is set regionally by endodontists—is based on the effectiveness of the procedure, not its efficiency or profitability. So, general practitioners are advised to focus on developing skills for the fundamentals of success in each case (eg, magnification/ illumination, understanding tooth anatomy, pain control, access/exploration, and irrigation) before focusing on instrumentation and obturation.

“Gadgets, tools, and other technology are never replacements for sound knowledge, understanding, and basic skill sets,” emphasizes Nasseh. “Integration of endodontics into a general practice also requires a good relationship with the broader restorative team. A good rapport and clear communication channels with the practice endodontist would ensure proper triage of cases within the scope of general practice versus those requiring a referral.”

The real obligation, Levin says, is to remain up-to-date with technology and techniques such that what is considered the standard of care for each case or clinical situation can be provided. One of the best resources for information is the endodontist, he says, and general dentists should be comfortable working with endodontic specialists on a regular basis to ensure the quality of the endodontic care they’re providing to patients.


1 Brown LJ, Nash KD, Johns BA, Warren M. The Economics of Endodontics. ADA Health Policy Resources Center Dental Health Policy Analysis Series. Chicago, IL: 2003.

2 American Association of Endodontists. Available at: www.aae.org/dentalpro/Endodontic+Definitions.htm .

The Inside Look FROM...

Issue after issue, the feature presentations in Inside Dentistry deliver coverage of relevant topics specifically affecting the dental profession, as well as oral health care in general. The publishers and staff could not bring the underlying concerns surrounding these timely issues to the forefront without the insights shared by our knowledgeable and well-respected interviewees. For their collective generosity of time and perspectives, we extend our sincere gratitude.

Academia
Ali Allen Nasseh, DDS, MMSc
Clinical Instructor
Harvard University School of Dental Medicine
endoman@MSEndo.com

Education
Kenneth A. Koch, DMD
Co-founder
Real World Endo®
RealWorldEndo@aol.com

A. Utku Ozan, DDS, MS
Executive Director & Chief Executive Officer
Dental Forums, Inc.
drozan@dentalforums.net

Industry
John Bernhard
Senior Product Manager for Endodontics
Ultradent Products, Inc.
John.Bernhard@ultradent.com

Practice Management/Consulting
Roger Levin, DDS
CEO & Founder
Levin Group
rlevin@levingroup.com

Private Practice
Marc Balson, DDS, FACD
Diplomate, American Board of Endodontics
Immediate Past-president, American Association of Endodontists
Private Practice, Endodontics
Livingston, New Jersey
guttadoc@msn.com

Gregori M. Kurtzman, DDS, MAGD, FACD
Private General Practice
Silver Spring, Maryland
Drimplants@aol.com

Larry Lopez, DDS
Private General Practice
San Antonio, Texas
drlarrylopez@sbcglobal.net

To Refer or Not to Refer, and When to Consider Other Options

The American Association of Endodontists (AAE) developed the “Endodontic Case Difficulty Assessment Form” to make case selection more efficient, consistent, and easier to record. Available at the organization’s Web site (www.aae.org), it may also be a useful tool for general practitioners when deciding whether or not to refer cases to an endodontic specialist.

“More and more general practitioners are doing endodontic procedures, and by and large, they are equipping themselves with the tools and knowledge to do them better,” observes John Bernhard. “As a result, endodontists feel compelled to differentiate themselves from general practitioners who perform endodontics, either by collaborating with general practitioners to help identify the simpler cases and referring the more difficult cases to the specialist, or in extreme cases, offering implants.”

Use of the AAE “Endodontic Case Difficulty Assessment Form” makes case selection more efficient, consistent, and easier to record. Available for download at www.aae.org.

And that collaboration can become a beneficial resource when faced with difficult and complex endodontic cases. The AAE form lists conditions that should be considered potential risk factors that could complicate endodontic treatment and/or adversely affect treatment outcomes. Those risk factors can also influence the clinician’s ability to provide care at a consistently predictable and appropriate level. The conditions are organized on the form in such a way that the overall difficulty of the case can be determined (ie, minimal, moderate, high). On the form, the AAE recommends that if the difficulty of a case exceeds the experience and comfort of the clinician that he or she consider referring it to an endodontist.

ASSESS THE CASE—AND YOUR RELATIVE ABILITIES
“I think it’s critical for the general dentist to be able to diagnose potential root canals and answer the question, ‘Can I meet the standard of care?’,” emphasizes Roger Levin. “If they can, general dentists should be very comfortable providing endodontic treatments in their practice. If they can’t, they should refer them. After all, not all root canals are equal, and there may be some very detailed diagnostic factors involved.”

Marc Balson believes that if general practitioners are trained to understand the degree of difficulty associated with a case at hand and honestly assess their skills relative to the needs of the case, then patients can best be served. Stated differently, he notes that if a root canal is not performed properly, it could be a lifetime (ie, permanent) proposition for the patient.

According to Gregori Kurtzman, endodontics can be a satisfying treatment to render to patients when cases are properly selected. A good starting point for referring cases out to a specialist is when canals can’t be visualized on the radiograph. He says it’s better to refer the case than spend time trying to locate and negotiate the canals.

“The worst time to refer a case is after accessing into the tooth and searching for the canals because at that point, all the anatomical references have been lost,” Kurtzman says.

“We really need to work together toward the same goal, which is helping more Americans retain their natural dentition,” Balson says. “Therefore, the decision to treat an endodontic case should be based on honest assessment and whether or not what’s required falls within the envelope of your comfort and skills—such as with cases involving complex anatomy, tooth-within-a-tooth scenarios, or multifactorial pathology.”

AVOIDING THE MISTAKES
According to Ali Allen Nasseh, the primary cause of endodontic failure is missed canals. He elaborates that rushing the access and not using the necessary magnification (ie, at least 3.5 times magnification) and illumination (fiber optic or LED light) to adequately visualize the field prevents clinicians from realizing the proper access.

“We miss root canals when we don’t know the tooth anatomy and canal morphology, when we don’t know where we need to look for additional canals and don’t interpret radiographs properly preoperatively,” Nasseh admits.

For example, the mesial-buccal canals of maxillary first molars have two canals over 90% of the time, explains Balson. Usually one of those canals is not found or looked for, and it’s usually a cause for endodontic failure and the need for retreatment, he says.

“In my opinion, the standard of care in endodontics requires the use of the operating microscope,” Balson says.

Overall, however, mistakes in endodontic treatment can be divided into two categories, explains Nasseh. First, there are mistakes made during the diagnostic phase of the treatment and secondly, those made during the actual clinical treatment of the properly diagnosed case.

From the diagnostic perspective, the most common mistake in diagnosing odontogenic pain is relying too heavily on a clinical radiograph, which does not provide any information regarding the status of the soft tissue related to the tooth. Therefore, when trying to make a diagnosis about early stages of pulpitis—a pathological state that is confined to the pulp space and is generally soft tissue related—radiographs are of limited value, Nasseh explains.

“We must remind ourselves that radiographs are only useful when pulpal disease has progressed enough to include periapical tissues,” Nasseh says. “Not only may considerable time elapse from the onset of acute symptoms until progression of the disease into periapical tissues, but such periapical extensions do not necessarily guarantee radiographic change.”

He explains that adequate cortical bone must be dematerialized and removed as a result of infection before any signs may be apparent. Therefore, infection could be present in the bone without any radiographic evidence, so pulp vitality tests—primarily the cold and hot tests—along with a thorough history of the pain, should be obtained prior to making a decision about which tooth requires root canal therapy, Nasseh says.

The rule of thumb is that no single clinical test is remarkable enough for making a decision about whether a tooth requires root canal therapy, he says. Generally there should be at least two specific signs in order to make a decision about the need for this treatment, and they could be a combination of radiographs and pulp vitality tests; the radiograph and history; and/or risk management issues (eg, pulpal exposures, pre-prosthetic endodontics, etc.).

“In the absence of two verifiable signs, the most common mistake is starting a root canal instead of waiting,” Nasseh explains. “When in doubt, treat symptoms palliatively and monitor symptoms. With the passage of time, acute symptoms tend to localize and additional signs and symptoms become evident, such as when pulpal inflammation reaches the periapical tissues, or a tooth that was previously negative to percussion suddenly becomes sensitive.”

Once a proper diagnosis has been rendered, Nasseh says the most common treatment mistake is not dedicating adequate time to the treatment or using appropriate equipment to prepare the access cavity and explore the canals. Spending adequate time in the presence of magnification and illumination are basic requirements for proper clinical management of endodontic cases, he notes.

The Education You Need When You’re Ready to Branch Out
Like all other skills acquired in life, three things are necessary to learn and master endodontic techniques: knowledge, tools, and desire, explains Ali Allen Nasseh. Endodontic therapy, especially in molars, is a very high skill procedure and, therefore, adequate time and effort should be spent in learning and developing skills for treatment in such areas, he explains.

“These skills can best be acquired by attending small, mini-residency type courses taught by endodontists,” Nasseh says. “The small-group, hands-on, live-patient procedures in such courses provide the most realistic experience for managing a case.”

Alternatively, he says, attending hands-on continuing education (CE) courses offered at various dental organizations, study clubs, and seminars could be a great introduction to an endodontic system. However, such education should be accompanied by textbook follow-up and literature review to refine the fundamental skills necessary to perform root canal therapy, Nasseh advises.

“Most importantly, the new skills must be fine tuned in extracted teeth before moving into live patients,” Nasseh says.

A VARIETY OF VENUES
Whether at dental schools, trade shows, private seminars, or manufacturer-supported programs, there is a multitude of opportunities for clinicians to expand their knowledge of today’s endodontic treatment options and techniques. There is also a fairly significant level of editorial coverage of endodontic techniques presented in industry journals and periodicals, including Inside Dentistry. According to John Bernhard, most endodontic product manufacturers emphasize education, and general dentists are turning to manufacturers for their primary source of education.

“Many manufacturers offer some form of CE seminar or course, or education is included as part of the sale,” Bernhard says. “There is also a handful of high-profile endodontic educators who have their own training courses, tapes, and handbooks, as well as very visible speaking engagements at most of the major trade shows.”

However, at the dental school level—particularly where undergraduates are concerned—educators may need to concentrate on providing more endodontic case experiences, believes Kenneth Koch. There are many general practitioners completing dental school without a particularly high level of endodontic experience and, therefore, they really must consider CE courses in order to broaden their skill set.

In fact, according to Marc Balson, most undergraduates probably only experience two or three endodontic cases by the time they graduate. Endodontic specialists, on the other hand, have seen anywhere from 250 to 300 cases during their postgraduate years.

“You need to specifically attend hands-on courses in person,” Koch advocates. “And, if you are already using a technique or system, be sure to bring those files with you to the program. Everyone who is teaching endodontic CE wants dentists attending their courses to do better root canal procedures, and seeing how things work with what they’re already using is part of the learning process.”

GENERAL PRACTITIONERS NEED TO PRACTICE ENDODONTICS
And specialists are depending on general practitioners to sharpen their endodontic skills. Considering that there are only approximately 4,500 to 5,000 practicing endodontists in the United States, Balson says it would take a 35-hour day and an 8-day work week—plus an extra 48 days or so per year—in order for endodontic specialists alone to be able to treat last year’s 21 million cases.

“We are depending on general dentists to do the large bulk of cases in the appropriate way,” Balson says. “However, it’s the endodontic specialist that can bring his or her extra training to bear on complex and/or difficult cases and see the pathology that’s involved.”

For this reason, the American Association of Endodontists (AAE) offers associate membership to general dentists interested in providing endodontic care to their patients and learning as much as they can about the discipline (www.aae.org). CE programs spanning 3 or 4 days are available on an annual basis during the AAE’s spring session. Additionally, CE programs are also available in the fall, as well as through local districts of the AAE. The organization also publishes two communication vehicles, the Journal of Endodontics and the ENDODONTICS: Colleagues for Excellence bulletin.

Because so much is at stake when endodontic treatment is required, Balson urges general practitioners to take their time and do it right—both in terms of their endodontic training and, ultimately, the therapies they perform on their patients. He says that in his 26 years of practicing endodontics, the more he learns, the slower he treats patients because it’s a complex and potentially difficult endeavor. Therefore, 1-day “instant endo expert” courses aren’t the answer. Rather, courses offered at dental schools—such as the mini residencies previously referred to—afford general dental practitioners the opportunity to learn advanced techniques in a comprehensive manner.

Endodontics vs. Implants: Is It Really a Competition?
Recently there has been debate pitting the treatment choices of endodontics against those of implants. However, these treatment modalities are alternatives, not antagonists.

“Both treatment options may need to be presented to the patients and, ultimately, the patient chooses which direction he or she wishes to pursue,” believes Gregori Kurtzman. “If I were presented with a situation in my own mouth where I had a tooth with a pulpal issue but sufficient coronal structure—and the periodontal condition for that tooth was good—I would choose to have the tooth treated endodontically. But if it would require crown lengthening, the furcation was probable, or a fracture was present apical to the cemento-enamel junction, then—in my own mouth—I would elect to have the implant.”

Given that perspective, it’s not likely that endodontic treatment will be replaced by implants any time soon, if at all. There will always be teeth that can be preserved by endodontic therapy in order to provide continued long-term functionality for the patient.

“I think we will see better methods for reinforcing teeth internally so they can be preserved, and methods to ‘glue’ cracks will improve,” Kurtzman speculates. “Obturation materials will continue to be enhanced, and we’ll be able to seal better, help the tooth resist coronal leakage better, and strengthen teeth.”

And moving forward, that’s something dentistry will be called upon to do more and more.

“Going forward, those of us in endodontics will be completing procedures that not only do a good job of cleaning and shaping the root canal system, but which also extend the life of the natural tooth,” Koch says. “So, it’s of paramount importance for anyone doing endodontics to provide the therapy such that we can restore the tooth, reestablish the occlusion, and have a good long-term prognosis for that endodontically treated tooth.”

But, what’s more, the horizon may hold promise for an even different approach to tooth preservation. According to Marc Balson, researchers are exploring ways to regenerate the pulp in otherwise healthy teeth through stem cell technology and other options. Also, researchers are studying ways to potentially regenerate an entire tooth by creating a tooth bud that can be implanted into the jaw.

What you Need When you Know what to Do
There are many factors that contribute to the success of endodontic treatments, not the least of which are the right instruments, tools, and products appropriately applied to the teeth and canals. Although not all-inclusive, the list here represents some of our interviewees’ top choices for things to consider and explore when you’re ready to put your hands-on endondontic learning to practical use.

1. Magnification—at last 3.5 times—so that you can find all of the canals and also inspect the entire canal shape, including fins. A common mistake being made, according to A. Utku Ozan, is overlooking the MB2 or MB3 canals. Contributing to this problem is not using proper magnification and transillumination.

2. Rotary Instrumentation. According to Kenneth Koch, anybody who is performing endodontics right now should be familiar and comfortable with one of the nickel titanium rotary file systems available, of which there are many. Larry Lopez notes that some of the newer ones have fewer radial lanes, so they’re less apt to break. Lopez also advocates a torque-controlled electric motor.

3. Liquid EDTA. Lopez notes that this is useful to soften the walls of the canals so that they can be opened wider, which helps with the disinfection process by removing the smear layer. He explains that canals should be opened to a minimum size of a #30 file, but that many general dentists stop at a #20. Lopez indicates that research shows that if the canals are opened up to at least a #30, better disinfection and cleansing will result.

4. Rubber Dams. Only about 50% of general dentists are using rubber dam isolation when performing endodontic treatments, but it should be 100%, Lopez believes.

5. Hand Files. Even though everyone should become familiar with rotary instrumentation, hand files are always a valuable adjunct and a part of any overall endodontic technique, our interviewees say.

6. Apex Locators to determine shorter or longer working lengths. Ozan says that new techniques and digital radiographs are providing clinicians with a better understanding of potential problems they may face while delivering endodontic treatment.

7. Proper Irrigation/Activation Tools. Effectively cleaning and irrigating the canal is paramount to the success of endodontic therapy, Ozan says. To this end, sonic instrumentation has been helping in enhancing the irrigation process.

Also, Lopez recommends using chlorhexidine gluconate at a 2% concentration. It has the unique property of being antibacterial for up to 48 hours in the canal, even after it’s washed out, and it doesn’t inhibit bond strengths in the canal. It should be the last rinse before obturation. He says that this is the same active ingredient used by surgeons when cleansing their hands.

8. Filling Materials. Koch says that material science is already playing a significant role in the obturation process. General practitioners should identify a filling material that will give them consistent, predictable, reproducible results. Combined, those attributes lead to success in endodontic therapies, he notes.


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