The Future of Endodontics

The discipline of endodontics has played an important role in clinical dentistry for decades, and its core purpose is to save teeth. Many changes have taken place in other dental disciplines—including the growing role of implant dentistry in replacing teeth as well as advanced restorative techniques that allow more endodontically treated teeth to be restored successfully—and the clinician is often faced with challenges when deciding which of many treatment options to use in individual situations. As clinical dentistry continues to evolve, what is the future of endodontics and its place in the treatment armamentarium? How will endodontics itself evolve?
Dentistry Today turned to 2 leaders in the field of endodontics, Drs. Kenneth Koch and Dennis Brave, to address these and related questions in an exclusive interview. Dr. Koch received both his DMD and certificate in endodontics from the University of Pennsylvania School of Dental Medicine. He is the founder and past director of the New Program in Postdoctoral Endodontics at the Harvard School of Dental Medicine. Prior to his endodontic career, Dr. Koch spent 10 years in the Air Force and held, among various positions, that of chief of prosthodontics at Osan AFB and chief of prosthodontics at McGuire AFB. In addition to having maintained a private practice limited to endodontics, Dr. Koch has lectured extensively in both the United States and abroad. He is the author of numerous articles on endodontics, and is a co-founder of Real World Endo.

Dennis Brave, DDS, (left) and Kenneth Koch, DMD, (right) with Ali Nasseh, DDS, MMSc, clinical director of Real World Endo.

Dr. Brave is a Diplomate of the American Board of Endodontics and a member of the College of Diplomates. He received his DDS from the Baltimore College of Dental Surgery, University of Maryland, and his certificate in endodontics from the University of Pennsylvania. In endodontic practice for more than 25 years, he has lectured extensively throughout North America and holds multiple patents, including one for the Visi Frame. Formerly an associate clinical professor at the University of Pennsylvania, Dr. Brave currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on endodontics, Dr. Brave is a co-founder of Real World Endo.

Figure 1. Dr. Brave describing how to prevent file separation.	Figure 2. Dr. Koch demonstrating the differences in taper.

According to Drs. Koch and Brave (Figures 1 and 2), Real World Endo is an endodontic education company that is committed to the philosophy of a patient-based practice. Its goal is to develop concepts, techniques, and products that are sophisticated enough to be simple. Its mission, simply stated, is this: to develop concepts and techniques that give the greatest majority of clinicians the ability to produce superior endodontic results. They believe this is achievable through the creation of predictable, consistent, and reproducible techniques and procedures. Real World Endo teaches endodontic success through all-inclusive lectures and hands-on courses. Its faculty members have been selected for their knowledge of endodontics and desire to share that knowledge.

DT: With the increasing popularity and predictability of implant treatment, will endodontics become obsolete?

Dr. Koch: It’s a good question. It is also a question that was initially broached to us 8 years ago by the president of a leading European endodontic company. His concern was, “Are implants going to totally replace endodontics?” What created his concern at that time was that many European clinicians were placing dental implants instead of performing root canals. A further contributing factor (at that point in time) was that some countries had decent reimbursement for surgical procedures but very little for nonsurgical endodontics. Additionally, the endodontic skill of the average European dentist at that time was not at the quality level it is today. Consequently, there was an existing concern about the endodontic failure rate, which was viewed as being greater than with implants.
Interestingly enough, as the quality of European endodontics has dramatically improved, the tendency to place implants (particularly in necrotic cases) has reversed itself. Patients now want to save their natural teeth, if at all possible. Consequently, as the result of better endodontic care, patients are now taking the opportunity to save their natural teeth and are choosing endodontic procedures over implant placement.
Nonetheless, this issue of endodontics becoming obsolete is a very good question, and it has more application today than ever before in North America. But why is this such a hot topic, and how can we resolve this dilemma? To address this issue fully, we need to look at this from multiple perspectives.

Dr. Brave: Recently, the University of Minnesota completed a study that compared 196 single-tooth implants with 196 nonsurgical endodontic procedures. The conclusion was that restored endodontically treated teeth and single-tooth implants had similar failure rates (6.1%), although the implant group displayed a longer time to function and an increased incidence of postoperative complications. This study did not address the financial differential that exists between the 2 treatment modalities. It is our opinion (and the opinion, we believe, of the majority of dentists) that when viewed in a nonbiased manner, indications exist for both treatment modalities. The key is that whichever treatment modality you choose, perform the procedure in such a manner that you enhance the long-term retention of the tooth (or implant).
But we must ask ourselves another question, “Why have implants suddenly become so popular?” There are probably a number of reasons for this gain in popularity, but one that stands out is that many endodontically treated teeth have had excessive coronal enlargement, which compromises their structural integrity and long-term prognosis. When the coronal third of the radicular dentin has been cored out, the long-term prognosis of that tooth is significantly reduced, and an implant may be the better choice. It certainly is interesting that if you ask most dentists today whether they are seeing more fractured endodontically treated teeth than in the past, the answer is yes. The key is not to destroy the structural integrity of the tooth while performing a root canal procedure. Shaping should achieve the intended biologic goals of cleaning and debridement without compromising the tooth.
Our main emphasis at Real World Endo is to do endodontics (whatever system you use) in such a fashion that you address the biologic requirements of doing a root canal but do it in such a manner that you do not overly weaken the tooth. Endodontics done in such a manner will have a long-term retention rate equal to or better than that of implants.

DT: What is the most immediate challenge facing organized endodontics today?

Dr. Koch: Education. The AAE (American Association of Endodontics), and endodontics in general, must make a concerted effort to educate dentists about the benefits of good root canal therapy. The concept of having general dentists learn more about endodontics is not a threat to the specialty. Implants also are not a threat to the specialty. What is a threat is not educating general practitioners on good endodontics and how it may benefit their patients. This issue of endodontic education is particularly critical in undergraduate dental curricula where students (in some schools) seem to be getting less clinical experience than ever before. It is very common now to meet recent dental graduates who endodontically treated only 2 or 3 teeth during their undergraduate experience.
Also, part of this challenge is for all those involved in endodontics to take the time to teach and demonstrate to general practitioners which procedures they should be doing. With appropriate case selection, correct philosophy, and good technique many procedures should be performed by the general practitioner. We’ve had a good 10 to 15 years of endodontic commentary on the immense complexity of the root canal system. Some, in fact, have even attempted to discourage general dentists from doing endodontics because it is so complicated. Well, maybe that worked years ago when there was no viable option to doing a root canal. But now there is an option: simply extract the tooth and place an implant. Dentists should not be frightened by endodontics. They must understand how good-quality endodontics can benefit their patients.
The truth is that we have had high success rates in endodontics prior to this discourse on complexity. Now, we have all types of adjunctive procedures and products that do everything from opening up lateral canals to removing biofilm. This is fine, but the real questions are these: How necessary are these additional procedures, and are they removing an excessive amount of tooth structure, which may weaken the tooth and compromise its long-term retention? The failures that we now see in endodontics are more commonly coronal in nature, not apical. Additionally, we have even witnessed some endodontic programs taking apical preparations in mesial-buccal canals of molars to a minimum size 55. Hold on here folks… We cannot render a tooth sterile regardless of how much tooth structure we remove or how many medicaments we place into the system. Without question, we absolutely can satisfy all the biologic requirements of doing a root canal and do it in such a manner that we do not compromise the structural integrity and long-term retention of the tooth.

Dr. Brave: Endodontics should be taught (and performed) in such a manner that it allows the greatest majority of dentists to achieve excellent results. Simplicity, predictability, and efficiency will be the key to teaching future endodontics. Endodontic education will not be productive if it allows only 10% to 15% of clinicians to get great results. And please do not confuse any of the above with a lack of quality.

DT: Can you elaborate on your last statement of not confusing simplicity with poor or mediocre results?

Dr. Brave: We need to understand the difference between quick and efficient to get a handle on this issue. Quick has nothing to do with quality, and, in most cases, when a sophisticated procedure is done quickly, something is often compromised. Efficient has everything to do with quality and, in fact, specifically addresses quality in its definition. Efficiency has no meaning unless measured against a known outcome. The outcome must be the same or better for the word efficient to have any meaning at all. The outcome of any procedure that is less than what it is being measured against cannot be defined as efficient. Something done poorly and quickly is just that…poor and quick. A good outcome (the same or better) achieved predictably and consistently through better technology and techniques can truly be said to be efficient. This is what Real World Endo is all about. Predictable, consistent, and reproducible results achievable by the majority of clinicians who choose to use our techniques.

DT: What are the most significant changes anticipated in endodontics over the next 3 years?

Dr. Koch: We believe that the near future will see an increased concentration on what we call the Endo-Restorative Continuum. Think about it for a second. The general dentist placing a post in a root canal is in the same space as the clinician who did the endodontics. In fact, a strong case can be made that the best post drill is an endodontic rotary file. It must be established that there exists an intimate connection between doing endodontics in a nondestructive fashion and the long-term prognosis of the tooth.
We further anticipate that there will be a continued effort to reduce the width of the coronal portion of the overall endodontic preparation. Accordingly, we fully expect to see more practitioners perform a constant .04 taper preparation (orifice to apex) rather than a constant .06 preparation or a variable taper technique. In addition to minimizing the loss of tooth structure, the constant .04 taper preparation meets all the requirements of thorough irrigation as well as permits the use of heated gutta-percha obturation techniques. However, a .04 taper preparation is a lot kinder to the tooth.
Real World Endo has been talking about this need to reduce coronal enlargement for nearly 2 years, and we are now sensing an increasing wave of acceptance. Certainly, while we would like all dentists to use our system, this is at its essence a generic story. Do root canal therapy (whatever system) in such a way that it is not merely endodontics, but more importantly, is part of an Endo-Restorative Continuum. We must say this again. If you do a root canal but destroy the tooth in the process, then nothing really has been accomplished.

Figure 3. Endodontic Synchronicity created between final root canal shape and the eventual restoration.

Real World Endo has specifically addressed this challenge (of the Endo-Restorative Continuum) by creating a post system that matches the shape of the post to that of the instrumented root canal (EndoSe-quence [Brasseler USA]; Figure 3). Consequently, there is no need for a post drill or any alteration of the canal shape. Because the dual-cure resin cement used to bond the post to the canal wall is the same material used to create the buildup, we actually think of this “post system” as an intraradicular core buildup with a rebar.

DT: Do you foresee any dramatic long-term changes in the way endo-dontics is performed?

Dr. Brave: In the long term we do see some significant changes from the way endodontics is currently performed. While we can anticipate new alloys and materials on the instrumentation side, we really expect the big changes to occur on the obturation front. It is very reasonable to expect that in the next decade we will see endodontics performed where the entire root canal space is filled with a cement-like substance. This material may be a Portland cement-like substance, a bone cement, or possibly even a bioceramic material. Regardless of the specific material utilized with such a technique, there will be a decided interest in filling root canals in such a manner. But why will this technique gain acceptance?

Dr. Koch: First, we must ask ourselves, “Do we fill a root canal to get the best possible seal or do we obturate a root canal to make it retreatable?” As we move into the future, we see the world of endodontic retreatment diminishing.
If an endodontic case fails in the future, some practitioners may choose to do an implant (or apical surgery). Thus, complete obturation of the root canal space (with a cement-like substance) will become a technique that must be user-friendly as well as one that will produce excellent sealing ability and simultaneously strengthen the tooth. While we recognize this is a significant departure from current protocol, we see any widely accepted obturation technique of the future being one that will favor ease of use and better sealing ability over retreatability.

DT: What will be the role of the endodontic specialist in the future?

Dr. Brave: Endodontics is not going away! In fact, the role of the endodontist will become greater and more important than ever before. In addition to being an education resource for the general dentist, future endodontists will be more intimately involved in the overall treatment planning process. Who better than the endodontist to help in the decision-making process of root canal or implant? Consequently, in addition to providing excellent endodontic skills, the future endodontist must also be well-versed in conservative surgical procedures. This expanded surgical knowledge will include the indications of use for both dental implants and crown lengthening.
While we are not proponents of most endodontists placing dental implants, we do believe that there is a need for endodontists to perform crown lengthening and tooth extrusion. Part of this rationale is based on the current lack of these procedures being performed, when in reality, in many cases they are just what the doctor should be doing rather than an implant.
Finally, let us restate that it is absolutely critical that the future endodontic specialist understand the intimate connection that exists between a well-done root canal and the restoration of the tooth. Endodontics must be done in such a way as to enhance the long-term retention of the tooth. Real World Endo is resolute in our confidence that endodontics will remain a robust specialty, and one that will continue to be a critical component of the dental team.