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The paradigm shift in endodontics

26 July 2013

The paradigm shift in endodontics

Sometimes as an Endodontist I feel a little unloved by my colleagues who see me as a bit of a dinosaur. This leads me to wonder, do they know something that I don’t?

I’ve been working in dentistry since the 1980s now, and have certainly seen a lot of changes come over the profession. One of the most significant has unquestionably been the great advances we’ve made in the field of Implantology. Indeed, if many of my Implantologist friends are to be believed, many of them are placing implants with a success rate of anything up to 95 per cent! In contrast our own ‘success’ rates in Endodontics have barely changed since the 1960s, despite the introduction of the dental microscope, new file systems, irrigations techniques and so on.

The problem it would seem comes from how we use this word ‘success’. For an Implantologist the term ‘success’ very often means simply ‘survival’. In other words, is the implant still in place? In Endodontics however, the question is a little greyer as we have no standardisation, not even in terms of definition. When recording ‘success rates’ over time we also note that case selection can lead to a significant variation in results, and there is no standard model we can use to properly measure the impact of certain developments or approaches on our clinical outcomes.

Another issue that has also come to light in a (limited) study in 2004 by Alley et al. is the question of success rates when comparing specialists to general dentists. While the study found success rates with specialists were significantly higher than with general dentists, again we have to wonder how case selection impacts upon these results. For example, you can expect specialists to generally be dealing with more complex cases, but we must also wonder at the complexity of the cases dealt with by the general dentists. What about their experience levels? How often do they carry out root canal treatments? For us, success is very much measured in terms of patient expectations, and the reason for performing the treatment in the first place. All of this ties in with what we would describe as the ‘big picture’ of a patient’s oral wellbeing, so even from this brief discussion you can see how success is rarely, if ever, as simple as it may seem. 

Yet despite this, success is becoming easier to achieve. While our Implantologist friends certainly grab more headlines than us Endodontists, with patients living longer, and technology advancing year on year, we are starting to see a new paradigm shift in Endodontics that I believe will herald a new age for the diagnosis and treatment of oral pain and infection.

Take digital imaging for example. When diagnosing re-treatments in the past our diagnosis would be based on the patient’s history, examination, special tests, and crucially, the radiograph. While 2D radiographs have undoubtedly been one of our most important tools in years gone by, we are now seeing a shift towards 3D imaging that provides a far more comprehensive overview of the patient’s tooth anatomy. With imaging now moving into the third dimension instrumentation is also striving to keep up.

For years we’ve struggled with stainless steel hand files and stainless steel rotary instruments, trying to negotiate narrow curved canals. Of course then NiTi files came along and we realised just how much difference new technology can make.

NiTi was a major shift in our paradigm. NiTi files are highly flexible and fast, and make the shaping of canals significantly easier. Yet still NiTi is not the final answer. After all, root canals are far more complex than many people might imagine. Though NiTi has certainly made a difference to how we approach root canal treatments, NiTi in itself does not remove debris, which can often be splattered into fins and groves in the canals. As the years have gone by then, we have come to place more emphasis on the need for irrigation and/or the use of ultrasonics. Some have suggested the next ‘big thing’ in file technology is the Self-Adjusting File (SAF) – a file that irrigates as it goes. I must say this looks to be an exciting development in our field. Though there is clearly work yet to do to I do believe this is another fine example of how exciting the future is for Endodontics, and how our paradigm is shifting over time.

As we have seen, success figures in Endodontics can be misleading, and certainly don’t quite provide the complete picture. With the latest advances in terms of both technology and training, we can form better, clearer diagnoses, and we are consistently improving in the way we are able to clean and shape canals. Though we are certainly not as flashy as our Implantologist colleagues, we have a real and important role within the profession, and with the latest paradigm shift, are able to perform really good treatments, time and time again.

For further information please call EndoCare on 020 7224 0999

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Dr Michael Sultan BDS MSc DFO FICD is a Specialist in Endodontics and the Clinical Director of EndoCare. Michael qualified at Bristol University in 1986. He worked as a general dental practitioner for 5 years before commencing specialist studies at Guy’s hospital, London. He completed his MSc in Endodontics in 1993 and worked as an in-house Endodontist in various practices before setting up in Harley St, London in 2000. He was admitted onto the specialist register in Endodontics in 1999 and has lectured extensively to postgraduate dental groups as well as lecturing on Endodontic courses at Eastman CPD, University of London. He has been involved with numerous dental groups and has been chairman of the Alpha Omega dental fraternity. In 2008 he became clinical director of EndoCare, a group of specialist practices.

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