Endodontics is Far From Dead

Endodontics is Far From Dead

Collaboration, awareness lead the way to excellent treatment

In the past few years, the dental industry has been awash in rumors of endodontics becoming a dying specialty. Why do that root canal, core build-up and crown on a badly broken down tooth when I can place an implant and promise a better prognosis? Surgery and implants are seemingly becoming the default procedure over endodontic considerations.

I even know endodontists in my area who have started placing endosteal implants in lieu of performing root canal therapy. The perception is that we can do better for patients using titanium instead of gutta percha; and the implication is that endodontics is approaching obsolescence. But, if we stop to consider each case, to give each treatment plan the individualized attention it needs, we will discover that root canal therapy and endodontic technology are more appropriate for patients than ever.

There are several key factors to consider when choosing the best course of treatment for a patient. One of the most important is the person’s health history. A patient who has had radiation therapy in the head or neck is not a candidate for dental implants. The risk of osteoradionecrosis makes this choice just too risky. In some cases, even an extraction is contraindicated. With the expanding questions over the use of bisphosponate medications, I am more hesitant to consider surgical procedures as an option for patients on these medications. There also are the patients who suffer from systemic issues such as blood disorders or immune deficiencies. In each of these cases, the health history gives a clear picture that a decision for root canal therapy should be priority over an extraction or implant.

Finances

Accompanying these medical issues, patient finances are driving dental care more than ever, and insurance companies are often dictating the direction. Most dental benefit plans do not offer any benefits for implants. When I present a treatment plan to a patient with a badly broken down tooth, we discuss all aspects of treatment including what treatment options they have, the time involved, the cost of the procedure, how much time it will take, and how much discomfort they will experience. For a patient with dental insurance, a root canal, core buildup and crown covered at 50 percent to 80 percent is much easier to handle financially then a more expensive implant procedure covered at zero percent.

Further, as new and improved technologies impact endodontics, untreatable cases become treatable and prognosis significantly improves. Better irrigants allow for improved cleansing of the canal system and offer better results in eradicating all contaminants. Microscopes offer incredible visibility to completely find every canal. Mechanical instrumentation cleans the canal system more quickly and efficiently, and nickel titanium files can handle the toughest bends. Improved obturation systems more adequately seal even nearly invisible lateral canals and are easier to use than any traditional method. Even newer anesthetics such as Articaine or intraosseous offer improved results. All these improvement add up to faster, more efficient root canal therapy with incredible, predictable results.

Thriving specialty

With all these factors solidifying the need for endodontics, why would anyone consider it to be a dying specialty? The answer lies with us as clinicians. With every year that passes, the dental industry offers more and more treatment options for patients, but none is appropriate for all. Ultimately, it is our responsibility to consider each case individually, and make treatment recommendations based on the specific needs of each patient, rather than following what we believe the market trends to be. At its simplest level, it’s not a question of what we can do, but what we should do.

I recently had a patient who presented with internal resorption on teeth 24 and 25. She was in her early sixties and had no history of trauma to the area. Her medical history was non-contributory, except for her prescription for Fosamax. Even an endodontist will tell you that it is difficult to predict the outcome of internal resorption, but questions over her bisphosphonate medication contraindicated the immediate jump to implants as an option. The first step was a referral to an endodontist to determine if the case was even treatable. This was followed by a surgical consult for consideration of location, bone density, and prognosis of implants. Discussions followed with each of the specialists and a final consultation was done with the patient. She was made aware of all risks, benefits, and alternatives to treatment. Ultimately, she decided to pursue root canal therapy. Eight months later, she is showing good progress. By not immediately skipping this step, we have not delayed the inevitable, but have created better and more complete options for her.

Rather than being a choice of one specialist or the other, there needs to be complete integration of restorative dentist, endodontist and surgeon to help direct the right path. There is no danger of creating too many cooks in the kitchen, but a danger of creating the wrong recipe. These ideas return us to the importance of using the most important dental tool of all: our brains. It is time to start thinking for ourselves and to depart from a method of practice that is influenced and directed solely by a dental company or industry leader. Endodontics—or any other specialty—will die only if our minds die with them.

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