Endodontic Treatment—Viable as Ever
Inside Dentistry interviews Endodontics Section Editor Allen Ali Nasseh, DDS, MMSc, president and CEO of Real World Endo
Inside Dentistry (ID):What are the latest trends you have observed in endodontics?
Allen Ali Nasseh, DDS, MMSc (AAN):There are several trends. Usually, endodontics goes back to the concept of the endodontic triad, which includes cleaning, shaping, and obturation. There have been some new innovations and developing trends in each of these areas.
For cleaning, there are better irrigation protocols, thinner vented needles, and the addition of surfactants to irrigants. In terms of irrigant activation, the use of ultrasonic waves has been a great innovation, and some new technology on the horizon, although currently not proven, could potentially enhance irrigation in the near future.
With regard to shaping, most of the innovation during the past 25 years has been driven by the development of nickel titanium files, which have subsequently evolved into a variety of different metallurgic combinations, including heat-treated and non-heat-treated varieties as well as shape-shifting files that offer 3-dimensional instrumentation capabilities.
In terms of obturation, the major innovations have involved changes to the cements, specifically in the area of bioceramics. In the past 10 years, there has been a great change from some of the older, conventional concepts of obturation to newer, more cement-based obturation techniques. Combined with a growing body of literature that supports a better understanding of case selection to optimize success, these bioceramic materials have helped to enhance bonding when we are retro-filling the apex during an apicoectomy. These newer materials are more biocompatible, they chemically bond, and they are in every way superior to the previous generation of cements that endodontists were using.
ID:What elements of this specialty have remained constant throughout the years and will continue to remain constant?
AAN:The endodontic triad that I mentioned earlier is the main modality through which we address endodontic disease, which is always microbial in nature. That has not changed for nearly 100 years, and it will remain the same. What has changed is the different technology used to provide treatment. The core concepts of decontamination and the prevention of recontamination of a root canal through the proper seal also will remain the same.
Dentists now have a better understanding of the role of restorative materials and how the restoration of the endodontically treated tooth is an integral part of its long-term success. Previously, endodontists would look at an x-ray image, and if it looked great at the time of the endodontic procedure, then the conclusion would be made that the case was successful. Now, there is a better understanding of the fact that endodontics is only one link in the chain of endodontic and restorative procedures, and that without the placement of a proper coronally-sealing restoration on top of the root canal after the completion of therapy, the endodontic procedure will predictably fail in the long run.
ID: What patterns are you observing with regard to which procedures are being referred to specialists and which ones general practitioners (GPs) are doing in-house?
AAN: On the one hand, the relationship between the endodontist and the general dentist is the strongest it has ever been because now GPs have a better understanding, especially in solo practices, that this interdependence creates great continuity of care for the patient and helps better serve the patient's needs, overall. On the other hand, with some of the corporate models of dentistry that are becoming more widespread, the relationship is weaker because dentists are being encouraged to perform more endodontic therapy in-house, and new technology is making it possible for some easier cases to be better handled by GPs. In the future, the endodontist should be prepared to handle a larger percentage of the more difficult cases and encourage better communication with his or her referral sources to improve their diagnostic skills and ability to triage cases for referral. At the end of the day, if it is a patient-centric practice, the goal is to do what is in the best interest of the patient.
ID:In what areas of endodontics have you seen a need for more education?
AAN:What is great is that endodontic education has never been more accessible. Today, you can access a world of information shared by various people and associations from the palm of your hand. High-production-value information about endodontic therapy and different techniques is readily available online. The key is being able to decipher the signal from the noise in some of these areas to obtain quality education from trusted sources.
The increasing access to education is helpful, particularly because it provides a better understanding of why endodontic cases are successful or will be successful. With access to this information, practitioners have a much better understanding of endodontic therapy in terms of what it can do to save teeth.
ID:In what areas is there controversy or disagreement among dentists?
AAN:There has been a bit of a shift on some fronts toward minimally invasive access preparations, which tend to increase the level of complexity of the treatment. Personally, I believe that any recommendation that increases the complexity of a procedure should be met with skepticism; the burden of proving that the benefits outweigh the potential problems lies with the people who are advocating for the increase in complexity. Of course, minimally invasive preparations can result in better outcomes, and I would assume that nobody is deliberately trying to be more invasive. The question is where to draw the line. When attempting to optimize the success rate in this manner, endodontists must ensure that they do not predispose a tooth that has been minimally accessed to missed root canals, broken instruments, or other potential side effects that can result from underpreparation.
The issue of implants versus root canals was a more prevalent controversy 10 years ago. Today, most people understand that endodontic therapy has an excellent success rate. In the past, people assessed the overall success of treatment differently based on the varying definitions of success used by endodontists and implant specialists. Criteria for endodontic success were significantly stricter than those for implant success. Based on the numbers alone, one might think that endodontic therapy has a lower success rate than implant therapy; however, endodontic therapy actually has a higher success rate. When you understand the role of peri-implantitis in implants that have been deemed successful and how this disease process is biologically indistinguishable from periapical infection, which indicates a failed case in endodontics, it becomes apparent that implant success rates are far below those of endodontic therapy and have been highly exaggerated. This knowledge has swung the pendulum back toward endodontics in recent years, and I am sure we will continue to see a reemergence of people trying to save their teeth rather than replace them with titanium cylinders.
ID: What developments do you foresee on the horizon in this specialty?
AAN:Any of the three areas in the endodontic triad could potentially see a breakthrough at any time. A significant amount of emphasis has been placed on instrumentation for shaping canals with various types of metallurgy and designs. Continued improvements in cement technology for obturation will be important, too, as will those for irrigation.
Perhaps the most important emerging phenomenon will be the realization that endodontic therapy is effective and has a great success rate. That alone would be a big accomplishment, allowing us to put our minds together and get back to doing what we have done for ages—saving teeth.
Allen Ali Nasseh, DDS, MMSc
President and CEO
Real World Endo
Department of Restorative Dentistry and Biomaterial Sciences
Harvard University School of