Oral Health Group

Endodontic Parousia – Nullius in Verba Redux


April 5, 2011
by ken

The intent of this “article/op-ed/editorial” piece is to see if I can finally shake loose those of you who read this blog, spend time on it and yet don’t post……….the point of this “MASHUP” is to engender “discovery” of information, trends, likes, dislikes et al and to DIALOGUE in the truest manner and context of social networking within this profession.  Read away McDentist and offer your commentary, good, bad or indifferent, but never overlook the opportunity to make your voice heard.

Every
era lives with contradictions that it manages to ignore; the Greeks talked of
justice and kept slaves, the Crusaders preached the gospel of the Prince of
Peace and rode off to annihilate the infidels, and the 17th century
believed in a universe that ran like clockwork, entirely in accord with natural
law, and also in a God who reached down into the world to perform miracles and
punish sinners (1).

Historically,the decision to perform endodontic therapy and restore a tooth or to extract and
replace it in some manner was a relatively “straight line” decision; however,in
the implant driven treatment planning era of the new millennium, dentists now face a multitude of complicating factors,
most notably the irrefutable success of dental implant therapy and the relative
ease and facility of “nuts and bolts” restoration provided the foundational
aspects of surgical placement are met (2).

As
a discipline specifically and as a profession in general, we must ensure that our
process does not engender “rearranging the deck chairs on the Titanic” (3). The
identification and quantification of specific factors that affect
rehabilitative prognosis in individual patients is essential to formulating
standardized treatment protocols and individual treatment plans. Such factors
include bone quantity and quality, caries and periodontal disease risk, as well
as the critically important factor of the amount of remaining tooth structure.  Minor or even moderate differences in overall
treatment outcomes or costs must not impact clinical decisions and must not
sway critical thinking (4).

Endodontics
mandates, as does any discipline, the aggregation and verification of
scientific knowledge and proof in order to create the proficiency inherent in
the desired positive treatment outcomes; it does not manifest as a “paint by
numbers” technical approach whereby the illusion of science is discernible only
in the design and perceived innovation of the equipment or product brought to
market without retrospective studies or meta-analyses of multi-variate
multi-centre treatment outcomes. In a Madoffian world, it is lunacy to be
driven by guru-centric claims and pronouncements.

It
would be disingenuous and gratuitous to suggest that condemnation of salvageable
and healthy teeth has not reached epidemic proportions. Yet, the treatment
outcomes studies on implant survival for the most part report survival as a
binary outcome rather than using the Kaplan-Meier survival analysis which is a
far more accurate reflection of the percentage of success (5). It is because
binary outcome has been the benchmark to justify removal of salvageable teeth
that the pendulum swung too far too fast. Dentistry needs a “Sputnik” moment to
reinvigorate our basic tenets and grounding fundamentals. Sadly, endodontists
are infrequent visitors to the critical thinking treatment planning loop as the
technologic simplification of the discipline is negating its biologic
contribution to the interdisciplinary team approach.

This
“op-ed” piece is being written to illuminate whether or not, endodontics as a
specialty has made a case for true partnership in the landscape of
foundational, interdisciplinary dentistry. 
Its intent is to assess the innovations and iterations in the “toolbox”
of the endodontic discipline and ensure that retention of natural teeth is
keeping pace with biologic reality and not marketing budget driven science.

There
are two historic milestones that bracket our understanding of the myriad
complexities of the root canal system; the first, the work of Hess, was woven
into the fabric of the era of the Focal Infection Theory and stimulated the
annihilation of millions of salvageable teeth and put dentistry firmly back in
the Dark Ages of science (Fig 1). The second, the use of micro CT technology to
map the inner space of teeth, replicated the Hess studies using digital tools
(Fig 2). Unfortunately, the outcome of this renewed awareness has not resulted
in a more sophisticated approach to preservation of natural teeth using a
century of evolutionary advances in material and technique, but rather, has
fostered a “simpler is better” mentality which will inevitably be as
devastating to retention of the natural dentition as Dr. Hunter’s egregious
dental witch hunt of the early 1900’s (6).

The
hard tissue repository of the human dental pulp takes on numerous
configurations and shapes. A thorough knowledge of tooth morphology, careful
interpretation of angled radiographs, use of small FOV cone beam tomography,
proper access preparation and a detailed exploration of the interior of the
tooth are essential prerequisites for a successful treatment outcome. A
thorough understanding of the complexity of the root canal system is essential
for understanding the principles and problems of debridement, disinfection and
root filling for determining the apical limits and dimensions of canal
preparations, and for performing successful microsurgical procedures when
necessary.

And
yet, the past few decades have been entombed in the most egregious nihilistic
Mad Men” description of the technologic wizardry and biologic understanding
necessary to ensure long-term predictable prognosis of the endodontically
treated tooth; “clean, shape, pack”. This has produced a tsunami of product
launches that has now reach it’s crescendo with the impending arrival of the
single file does all launches expected in the spring of this year. 

From
a metamorphosis of instruments borne of angioplasty materials to the enhanced
elasticity of nickel-titanium and its reformulation in newly ground shapes and
its use in reciprocating rather than rotary feed rates, once again market is
driving science and our patients and ultimately our profession will pay the
price for the over-simplification and obtuse denial of the reality we know for
the expediency we are being trained to crave.

Sealers
based on restorative fundamentals were to be the sine qua non of monoblock
creation in the root canal space. Unfortunately, one of the most exhaustive
studies done to evaluate evidence-based support on the merits of their clinical
use concluded that “on the basis of the in vitro and in vivo data available to
date, there appears to be no clear benefit with the use of methacrylate
resin-based sealers in conjunction with adhesive root filling materials at this
point in their development” (7). 

Science
has shown that the direction for eradication of refractory and chronic disease
related to biofilm elimination lies in photodynamic therapy provided clear evidence
of clinical efficacy and applicability continues to be demonstrated (8). And
yet, an array of sonic and ultrasonic products have infused the market with
specious claims to optimize microbial control through innovations in irrigation
protocols designed to disinfect and remove the smear layer of the prepared root
canal space in spite of the fact that their ability to remove mixed-species
biofilms remains unproven.

The
great virtue of mathematics is that its truths alone are certain and
inevitable; in any universe, the shortest distance between two points is a
straight line. And yet, the pundits of the new wave in endodontics would have
us believe that single files regardless of their envelope of motion, be it
reciprocating, rotary or piston-like, can effectively debride the negative
space of the root canal system in defiance of the morphometrics and myriad
complexities of the inner world of teeth. Similarily, insubordinate to the
science of rheology, carrier based obturation is deemed equivalent to the force
generation and resultant gravitometrics of injection molded warm thermo-labile
techniques as described initially by Blaney and made mainstream by Schilder.

And
yet, we have an new wave of carrier based obturation devices that in concert
with simplified instrumentation protocols are being marketed by its developers in
the context that

, “
…..
I have read this argument about making root canal treatment simple. I don’t see
why can’t root canal treatment be simple. Why can’t dentistry be simple?
Dentistry is all about manual skills, and dentists have manual skills.
Therefore, if we can make root treatment simpler for them, I think we are
providing a great benefit to not only the dentists, but more importantly, the
patients (9).”

For
those who would suggest that this “opinion piece” is self-serving, I’d suggest
that you simply replace the discipline cited with any other. Perhaps we have
reached the point that we no longer wish to advance and support the art and
science of (fill in the blanks) with definitive research that will refute the
nattering nabobs of nihilism on the other side of that proverbial line in the
sand. It is time for dentists to acknowledge the gravity of the problem where
industry is the driver and the profession the passenger. We need leadership to
regenerate the science of dentistry before the artistry truly becomes
preplanned and preprogrammed by those outside the profession whose vested
interests lie in profit and loss statements not in eradication of oral disease.

References

1.      
Dolnick E. The Clockwork Universe:  Isaac Newton, the Royal Society and the Birth
of the Modern World. HarperCollins e-books

2.      
White SN, Miklus VG et al. 
Endodontics and Implants, a Catalog of Therapeutic Contrasts. J Evid
Base Dent Pract Mar 2006;6:101-109

3.      
Morton R. Washington Post. The Oxford Dictionary of
Quotations (5th Ed. 1999), page 533

4.      
Creugers NH, Mentink AG, Fokkinga WA, Kreulen CM.
5-year follow-up of a prospective clinical study on various types of core
restorations. Int J Prosthodont 2005;18:34-9

5.      
Chuang
SK, Tian L et al. Kaplan-Meier Analysis of
Dental Implant Survival: A Strategy for Estimating Survival with Clustered
Observations. JDR November 2001;80(11):2016-2020

            6.   Hunter W. Oral sepsis
as a cause of disease. Br Med J 1900;1:215-6

7.                 7.   Young
KK, Grandini S et al. Critical Review on Methacrylate Resin-based Root Canal

Sealers. J Endo March 2010;36(3):383-399

8.                   8.      Soukos NS, Goodson JM. Photodynamic therapy in control of oral biofilms.      

                  Periodontology 2000 February 2011;55(1):143-166

1.                    9.     Quote from interview with Dr.
Julian Webber – Dental Tribune
Mar 25, 2011

Endodontic Parousia¶ – Second
Coming, also called Second Advent, or Parousia, in Christianity, the
future return of Christ in glory, when it is understood that he will set up his
kingdom, judge his enemies, and reward the faithful, living and dead. Early
Christians believed the Advent to be imminent and most
Christian theologians since then have believed that the visible appearance of
Jesus may occur at any moment and that Christians should be ever ready for it.
Such believers find evidence for the Second Coming in the Gospels (Matthew
24,25; Mark 13; Luke 21:5-26; John
14:25-29), in the Book of
Revelations.

Nullius in Verba¶¶ – The Latin phrase for “Take no man’s word
for it” is the motto of The Royal Society of London.

Figure 1:  Walkhoff’s Lehrbuch der
konserierenden Zahnheilkunde – Walter Hess and Otto Walkhoff.  Images of perfusion studies to illustrate the
complexities of the root canal system of all tooth types.

Figure 2.  Micro-CT images of a
molar tooth.  From the Root Canal Anatomy
Project – http://rootcanalanatomy.blogspot.com

Figure 1.jpg

Figure 2.jpg

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