image-guided endodontics: the role of the endodontic … · image-guided endodontics: ... 50 years...

CONTINUING EDUCATION

Image-Guided Endodontics: The Role of the Endodontic Triad

Volume 35 No.8 Page 94

Authored by John A. Khademi, DDS, MS; Michael Trudeau, DDS; Pushpak Narayana, MDS; Robby M. Rabi, DMD; and Steven D. Baerg, DMD

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of Endodontics. He has been a committee member of the American Association of Endodontists and is a past endo dontic specialty examiner for the North East Regional Board Examination. He can be reached at [email protected].

Disclosure: Dr. Baerg reports no disclosures.

INTRODUCTIONFor hundreds, if not thousands, of years, there was universal agreement on the Cosmological Triad of the Heavens (sha-mayim), the Earth (erets), and the Underworld (sheol). According to the Flat Earth Society, the Earth is floating on water, with heaven above and the underworld below. Some still believe this triad today, citing scientific experiments, evidence, and experi-ence that demonstrates the earth is flat.1,2

With little change, one can see the parallels in endodontics dominated by the Endodontic Triad for Success during the past 50 years based on “shaping canals, cleaning in 3 dimensions, and filling root canal systems.”3-7 The quintessential goals of endo dontic procedures have been stated to be elimination all organic substrate and bacteria and filling root canal systems,4 as the purpose of endodontics has been stated to be the preven-tion or treatment of apical periodontitis.5,8,9 Throughout the decades, 2 broad schools of thought3 have emerged prescribing the intervention parameters that are thought to best achieve these treatment objectives. Shaping was accomplished by the use of sharp, stiff, untapered, unforgiving stainless steel hand instruments. Cleaning was done by hand with passive irriga-tion. The case was then packed by hand, generally using mul-tiple waves of pluggers or spreaders and cones. However, the focus of both camps has always been on eliminating the bac-teria (Figure 1).

The observations of the surviving stream of long-term, 20-plus year surviving cases present a completely different picture than either camp would allow. The surviving cases as a group are devoid of evidence of any of these traditionally required procedural objectives from either camp (Figure 2).

This presents difficulties for endodontists and endodon-tics as these observations contradict the scientific pillars used to support treatment protocols such as the Five Mechanical

Image-Guided Endodontics: The Role of the Endodontic TriadEffective Date: 8/01/16 Expiration Date: 8/01/19

Dr. Khademi received his DDS from the University of California San Francisco (UCSF) and his certificate in endodontics and did his MS on digital imaging at the University of Iowa. He is in full-time private practice in Durango, Colo, and was an associate clinical professor in the department of maxillofacial imaging at the University of Southern California and is an adjunct assistant professor at St. Louis University. As a Radiological Society of North America member for more than 20 years, his background in medical radiology allows him a perspective shared by few dental professionals. He can be reached via the

email address [email protected].

Disclosure: Dr. Khademi discloses a financial interest in SS White and Carestream Dental.

Dr. Trudeau received his DDS from the University of the Pacific School of Den-tistry. He earned a certificate in endodontics at the Albert Einstein IB Bender Division of Endodontics. He maintains a private practice limited to endodontics in Suffolk, Va. Dr. Trudeau is a specialist member of the ADA, the Suffolk Dental Society, the Tidewater Dental Society, and a founding member of the Interna-tional Academy of Endodontics. He can be reached at [email protected].

Disclosure: Dr. Trudeau reports no disclosures.

Dr. Narayana completed his endodontic training at the Rutgers School of Dental Medicine receiving a master’s degree and a certification in endodontics. He is also a Diplomate of the American Board of Endodontics. He can be reached at [email protected].

Disclosure: Dr. Narayana reports no disclosures.

Dr. Rabi obtained his BS in biology at Nova Southeastern University and his doctor of medicine in dentistry at the University of Florida. He practiced as a general dentist and taught part-time at the University of Florida for 7 years before obtaining his endodontic training at UCSF. He maintains a private practice in New York City. He can be reached via email at [email protected].

Disclosure: Dr. Rabi reports no disclosures.

Dr. Baerg practices in Gig Harbor, Wash. He is an affiliate assistant professor at the University of Washington in the department of endodontics. He is a Diplomate of the American Board of Endodontics and a past president of the Washington State Association of Endodontists and the International Academy

About the Authors

Figure 1. The time-hon-ored traditions of the Endodontic Triad for Success have been focused on elimination of organic substrate, microbial control, and prevention of reinfection of root canals.3-5,8,9,13,14 What if those efforts actually reduce outcomes?

PACK

CLEAN SHAPE


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Objectives, Washington Mon-ument, and others, all based on the constructs of the End-odontic Triad for Success. This cognitive dissonance10 was raised 50 years ago in the seminal paper by Seltzer and Bender11 that would do all endodontists well to read again. Nature seems to have a different triad (Figure 3).

Regardless of the philo-sophical camp, endodontic access, shaping, and size have been foundationally prescrip-tive in nature, ascribing geo-metric form and approaches irrespective of individual morphology. Protocols have been based on the tooth type, not specifically tailored, nor executed in appreciation of the morphologic and ana-tomic uniqueness routinely encountered. They have been drawn as if we were treating intact, unrestored, caries-free teeth.12 Many of these geo-metric forms, instruments, and procedural steps have not changed in more than 50 years!13

Courses that continue teaching clinical techniques ask partic-ipants to bring “already accessed teeth.” This bypasses one of the most important steps and illustrates the focus on the endo dontic objectives while being unaware of the restorative consequences. Subsequent steps are performed with a set of instruments in a pre-scribed order and then those protocols are deployed on the wide range of variability in the clinician’s population of patients.14

Tailoring Care: Image-Guided TreatmentPrecision medicine (PM) refers to the tailoring of medical treat-ment to the individual characteristics of each patient.15 Imag-ing has become a crucial part of PM during the last decade. PM takes into account and aims to exploit the specific profile of the patient’s unique biology and problem.15 Imaging plays an important role by providing morphologic and functional information, focusing and guiding treatment and assessing

response to therapy.16 Image-guided treatment (IGT), or here specifically image-guided endodontics, is not a strategy that tries to optimize 3-D cleaning, shaping and disinfection, and filling root canal systems. It does not have a “role” for the traditional Endodontic Triad any more than a flat earth has a role in the Heliocentric model. This is not an update on traditional endo-dontic access, or shape/clean/pack as the authors believe the traditional approach to endodontic access is fundamentally flawed.17 Importantly, IGT is not about simply making a smaller access or smaller shape. It is about strategic dentin preservation (Figure 4). It is about restoring balance. It is about planning access, planning shape using a directed approach, and evalu-ating the response to treatment. Traditional endodontic treat-ment has been convenience-driven and endo dontic-centric, primarily focused on operator needs, and has been decoupled from the restorative needs and tooth needs.17


Figure 2. A sample of 20-plus-year-old cases (done elsewhere) gathered from the lead author’s practice. A careful evaluation of the surviving stream of 20-plus-year-old cases viewed through the lens of the Endodontic Triad reveals no evidence that any of the pillars supporting the triad were accomplished.


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In the Viewpoint18 article in this issue, the authors (including the lead author of this article) review the history of our science and its progression, and why endodontists struggle so much with what is often immediately obvious to the restorative dentist.

Why We’ve Been Stuck For 50 YearsScientific progress is generally hindered by trying to take the past into account as a way to move forward. The elimination of bac-teria, an unreasonable and unachievable endpoint, has become the objective of end-odontic treatment with clinicians and educators going so far as to say that prevention or removal of microbes from the root canal system is the fac-tor that determines if the treatment will be success-ful or not.19 What if that is not why cases are suc-cessful?20-25 We have been misled by culturing, mis-taking lack of evidence of growth for “removed” or “killed” or “bacteria-free.” Microbial dormancy may result from the formation of persister cells as well as viable-but-non-culturable cells that resist traditional cultur-ing techniques.20 It is likely then, that our success may come more from altering the microbial environment and inducing bacterial dormancy as opposed to killing and removal. Per-haps a different, more conservative set of procedural objec-tives might be sufficient to induce dormancy? Considering dormancy as a possible explanation, one may now appreci-ate how cases shown in Figure 2 may be working despite not having achieved the biomechanical requirements of the Endodontic Triad.20 Furthermore, microbial dormancy and the persistence model20 suggest that all these efforts directed toward reduction or removal may have done little or nothing to improve outcome. Instead, they have come at the cost of competing considerations, including struc-tural and restorative considerations, which are likely more important for long-term tooth preservation. Our thinking

was constrained by our biological understanding of disease, our materials, instruments, and techniques. Even as materials,


Figure 3. Technology and updated tools allow the shape/clean/pack tasks shown in Figure 1 to be accomplished in a completely different manner.

Figure 4. Preservation of the pericervical dentin (PCD) is focus of the new triad.

PACK

CLEAN SHAPE

Figure 5. Endodontic access is planned, not prescribed. We use imaging to look at the platform width, platform depth, and chamber height. These factors help determine the convergence profile that factor into the directed approach to access.

Figure 6. Varying platform widths and canal convergence profiles allow a completely different conceptualization of an orifice-directed approach to straight-line access. The actual access requirements for the directed approach are in teal, with the dark gray demonstrating banked PCD. The leftmost cases may benefit from a stepped access in the already restored case. See clinical cases in Figures 8 to 10.

Figure 7. The Directed Approach to plan endodontic access. The first step is to iden-tify liabilities that will need to be removed. Using imaging, identify the anatomic fea-tures in the key pericervical area as discussed in Figure 6. Then in the mind’s eye, construct a virtual access that maximally leverages the liabilities identified in Step 1, and balances the subtractive sacrifices made to the key pericervical anatomy.

Directed Approach Access

1. IDENTIFY LIABILITIESCariesFailing Restorative

2. IDENTIFY PERICERVICAL ANATOMYChamber DetailsPlatform WidthCanal Convergence Profile

3. BALANCE SUBTRACTIVE SACRIFICE


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instruments, and techniques progressed, our thinking stayed the same. Einstein is quoted as saying, “We can’t solve problems by using the same kind of thinking we used when we created them.” The authors view the continued controversy as to the minimal mechanical requirements for achieving disinfection as an immaterial distraction, as these philosophical debates stem from a disinfection-based biological model of endodontics derived from a Kochian, planktonic, acute-disease view of apical periodontitis with the traditional goal of endodontic treatment being to pre-vent or cure apical periodontitis. The authors in this article see endodontics as a branch of restorative dentistry whose primary purpose is the preservation of the natural denti-tion for the length of a patient’s life.

The intention of this article is threefold: 1. To invite readers to take a critical look at the cases in

their own practice that are surviving 20-plus years and see if the requirements of the Endodontic Triad for Success have been met.

2. To introduce a new Endodontic Triad based upon the evidence present in the actual stream of long-term surviving cases.

3. To introduce the language, thinking, and armamentar-ium available that we believe adequately addresses both the old and new Endodontic Triads.

We wish to introduce the language and concepts on some prototypical cases to show what a growing minority of endodontists are thinking and where endodontics is heading. The Viewpoint article18 reviews where endodontics has been and introduces the principles and reasons why this growing minority has adopted these ideas. The reader is referred to Best Practices in Endodontics: A Desktop Reference26 for a more complete description of the clinical techniques.

The New Endodontic TriadThe convergence of 3 pieces of technology has allowed a com-plete shift in the practice of endodontics: the microscope; low-dose focused field CBCT; and root-form appropriate, heat-treated NiTi instruments. This new triad is now focused not on removal of bacteria, but on preservation of the pericervical dentin (PCD). The microscope allows the preparation of a much smaller and more precise access. Dramatically smaller than traditional access, often individualized per root, or even per canal. Of course these smaller accesses might hinder the clinician’s ability to locate clinically relevant anatomy, and have been a primary objection to the minimally invasive strategy. Second, very, very small shapes are cut with coronally conservative, heat-treated

NiTi and Ca(OH)2 is placed in the prepared canals. These root-form appropriate variable taper files allow for safe and effective instrumentation and obturation of canals without unneces-sarily weakening the tooth. Some might bring up the concern that these smaller shapes might hinder the clinician’s ability to “cleanse and shape the canal properly.” Third, the in-office CBCT is the last but crucial piece of the puzzle.

These legitimate concerns are addressed by IGT. An interim or mid-treatment CBCT study can be ordered to allow the clinician to inspect the case nondestructively for possible undiscovered anatomy as the already addressed anatomy is readily demonstrated by the radiopaque Ca(OH)2. The CBCT imaging guides treatment in a way that complements the microscope. The access can be precisely extended if needed to address the additional anatomy. The access extension is minimized, as the direction and distance is known, guided from the imaging study.

Regarding the concerns with conservative canal preparation and the clinician’s need to “cleanse and shape the canal properly,” it is imperative to remember that these are the clinician’s needs, not the tooth’s needs. The amount of cleaning and shaping (if any) required for radiographic evidence of resolution of apical periodontitis is simply not known a priori. The CBCT often allows rapid 3- to 4-month semi-quantitative assessment of periapical radiodensity change to infer that the biological requirements have been met. Proper utilization of the CBCT addresses these concerns and is a requirement in a state-of-the-art endo dontic practice.

The New Language of the PCDThe pulp chamber and root canal orifice projections appear unique in every clinical scenario. Pulp chamber morphology,

Figure 8. CBCT imaged-guided treatment (IGT). A stepped access is created with a more generous access through the restorative material until dentin is seen. Then using visual cues, a smaller access through dentin is cut to gain access to the pulp chamber. Canals located with initial search are minimally shaped, Ca(OH)2 is placed, and a CBCT imaging study is ordered. Extensive searching for additional canals is not conducted at this time. The imaging study suggests an MB2 canal approximately 2.0 mm to the palatal of the already located MB1. At a subsequent visit, the MB2 canal is located and shaped to a SS White VTaper 17/V.04 and Ca(OH)2 is placed in all 4 canals. Symptoms resolved and the case was completed. Periapical (PA) projection radiograph is the follow-up (post-op PA not shown).


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when reviewed in 3 dimen-sions, can be described to have height, width, and depth that ultimately forms a platform shape utilized for retention in subsequent restor-ative procedures (Figures 5 and 6). Two of these dimen-sions are visible on periapical (PA) or bite-wing (BW) imag-ing and may be used to plan or guide treatment. Platform width is the line joining between the mesial and distal root canal sys-tem, platform depth is the line joining between buccal and lingual root canal systems, and chamber height is the distance between the furcation floor and roof of the pulp cham-ber. Access is planned using a directed approach taking these relationships into account (Figure 7). With a very ample platform width, an individ-ualized access approach can be utilized for a specific canal with the system (Figure 7, rightmost). For the interested reader, Best Practices26 has more in-depth discussions on these topics by some of the co-au-thors of this paper (MT, PN, SB).

To practice endodontics at the highest level, a CBCT and microscope are required. Figures 8 to 10 show what can be done with image-guided principles and these crucial pieces of tech-nology. However, as the cases from my 2 restorative colleagues clearly demonstrate in Figure 11, these image-guided princi-ples can be applied in general practice with PA projection or BW radiography. In both cases, the entire access is confined to the mesial half of the tooth.

Figure 9. IGT: Endodontist Dr. Charles Maupin (Lubbock, Tex) uses imaging and clinical assessment to plan the access to the canals. Palatal decay is removed, gaining access to both the palatal canal—and through the distal-angle orifice-directed approach—the MB2 canal as well (shown obturated with gutta-percha). A separate entrance allowed access to the MB and DB canals.

Figure 10. IGT: Here we use pre-op PA imaging to identify in the pericervical anatomy of a tooth with a very wide platform with minimal canal convergence similar to Figure 6 (rightmost). We plan to create a dual access retain-ing a truss. Clinical closeups show the MB (top) and ML canal orifices. Shaping to minimal size, Ca(OH)2 placed, and the CBCT guides the search for any additional anatomy for which there was none. Post-op with final shapes with SS White VTaper 2 and follow-up.


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Note the exceptionally narrow necks to the pulp chambers, and the subtle extension at the cavosurface alone access to the MB system in the maxillary molar. The distal chamber and horns are not unroofed. This simply removes healthy tooth structure and damages the tooth. The teeth are restored with composite resin. Notable in both restorative practices is that neither tooth received an indirect restoration. Both of these restorative clinicians are well aware of what works and of the damage created by drill-ing on teeth and removal of sound tooth structure, a lesson endodontists and endodontics would do well to learn. As Dr. John Kois27 has said: “Creat-ing more conservative access openings can reduce the risk of tooth loss related to weak-ened tooth structure. Signifi-cant problems are more related to the loss of tooth structure more than the endodontic procedures themselves.” There is academic evidence to support conservative access openings as well.28

CLOSING COMMENTSWe would like to summarize this article for both our restorative and endo dontic colleagues. My long-time friend, colleague, practice partner, and restorative dentist-turned-endodontist, Dr. Glen Doyon of Scottsdale, Ariz, said it best:

“It’s harder for the endodontist to accept controversy over accepted dogma. After practicing general dentistry for 20 years before specializing in endodontics, I come from a different place than the straight-up endodontist. It’s easier for general dentists to really understand and get this idea of minimally invasive endodontics because they see how these endodontic legacy concepts have affected long-term tooth retention. Endodontists don’t see their failures and the general dentists do.

“One of the problems of the legacy endo dontic culture is that they don’t really know what works and what does not work long-term…I’m talking more than 4 years, for the patients. The general dentists see and have the follow-ups because the patients come back

to their office. People come back to the general dentist all the time to have their teeth cleaned, so the general dentists see what goes wrong. Endodontists don’t really know what works and what doesn’t over a long period of time. Endodontists think lack of evidence of failure is success. If you ask them, they think their cases are 95% successful. They just don’t know.”F

References1. Voliva WG. Is the earth a whirling globe? Flat Earth News. March 1979:2.2. Schadewald RJ. Six “flood” arguments creationists can’t answer. Creation

Evolution Journal. 1982;3:12-17.3. Ruddle CJ. Endodontic triad for success: the role of minimally invasive

technology. Dent Today. 2015;34:76-80.4. Ruddle CJ, Machtou P, West JD. Endodontic canal preparation: inno-

vations in glide path management and shaping canals. Dent Today. 2014;33:118-123.

5. West JD. The role of endodontics in interdisciplinary dentistry: are you making the right decisions? Dent Today. 2014;33:80-85.

6. West JD. The three Fs of predictable endodontics: “finding, following, and finishing.” Dent Today. 2016;35:90-96.

7. American Association of Endodontics. Obturation of root canal systems. Endodontics: Colleagues for Excellence. Fall 2009:1-8.

Figure 11. (a) Projection radiography guided treatment from restorative dentists Dr. Pasquale Venuti (Benevento, Italy) (shown) and (b) Dr. Nareg Apelian (Montreal, Canada) (shown). Following the Directed Approach, they have used PA projection radiography imaging to identify the caries to the mesial as a liability, as well as identify the plat-form width and the canal convergence profile. The imaging guides a planned, caries-leveraged, mesialized access. One-year (Venuti) and 2-year (Apelian) follow-ups.

a

b


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Image-Guided Endodontics: The Role of the Endodontic Triad8. Trope M, Bergenholtz G. Microbiological basis for endodontic treat-

ment: can a maximal outcome be achieved in one visit? Endod Topics. 2002;1:40-53.

9. McGurkin-Smith R, Trope M, Caplan D, et al. Reduction of intracanal bac-teria using GT rotary instrumentation, 5.25% NaOCl, EDTA, and Ca(OH)2. J Endod. 2005;31:359-363.

10. Boring EG. Cognitive dissonance: its use in science. Science. 1964;145:680-685.

11. Seltzer S, Bender IB. Cognitive dissonance in endo dontics. J Endod. 2003;29:714-719.

12. Khademi J. Endodontic access. In: Johnson WP, ed. Color Atlas of End-odontics. Philadelphia, PA: Saunders; 2002.

13. Gutmann JL. Endodontic access. In: Cohen S, Hargreaves KM, eds. Path-ways of the Pulp. 11th ed. St. Louis, MO: Mosby; 2016;5:391.

14. Carrotte P. Endodontics: part 8. Filling the root canal system. Br Dent J. 2004;197:667-672.

15. National Research Council of the National Academies. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease. Washington, DC: National Academy of Sci-ences; 2011.

16. Herold CJ, Lewin JS, Wibmer AG, et al. Imaging in the age of precision medicine: summary of the proceedings of the 10th biannual symposium of the International Society for Strategic Studies in Radiology. Radiology. 2016;279:226-238.

17. Clark D, Khademi J. Modern molar endodontic access and directed den-tin conservation. Dent Clin North Am. 2010;54:249-273.

18. Khademi J, Clark D. Incommensurability in Endo dontics: the role of the endodontic triad. Dent Today. 2016;35:8-10.

19. Debelian G, Trope M. BT-Race—Biologic and conservative root canal instrumentation with the final restoration in mind. Endodontic Practice US. February 17, 2014. endopracticeus.com/clinical-articles/bt-race-bi-ologic-and-conservative-root-canal-instrumentation-with-the-final-resto-ration-in-mind. Accessed on June 1, 2016.

20. Ayrapetyan M, Williams TC, Oliver JD. Bridging the gap between viable but non-culturable and antibiotic persistent bacteria. Trends Microbiol. 2015;23:7-13.

21. Casadevall A, Pirofski LA. Microbiology: ditch the term pathogen. Nature. 2014;516:165-166.

22. Medzhitov R, Schneider DS, Soares MP. Disease tolerance as a defense strategy. Science. 2012;335:936-941.

23. Buerger S, Spoering A, Gavrish E, et al. Microbial scout hypothesis and microbial discovery. Appl Environ Microbiol. 2012;78:3229-3233.

24. Pirofski LA, Casadevall A. The meaning of microbial exposure, infec-tion, colonisation, and disease in clinical practice. Lancet Infect Dis. 2002;2:628-635.

25. Casadevall A, Pirofski LA. The damage-response framework of microbial pathogenesis. Nat Rev Microbiol. 2003;1:17-24.

26. Schwartz RS, Canakapalli V. Best Practices in Endo dontics: A Desk Refer-ence. Chicago, IL: Quintessence Publishing; 2015.

27. Kois JC. Potential failures with teeth and restorations. Inside Dentistry. 2014;10:104.

28. Krishan R, Paqué F, Ossareh A, et al. Impacts of conservative end-odontic cavity on root canal instrumentation efficacy and resistance to fracture assessed in incisors, premolars, and molars. J Endod. 2014;40:1160-1166.


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1. Endodontic treatment protocols have been based on the tooth type, not specifically tailored, nor executed in appreciation of the morphologic and anatomic uniqueness routinely encountered.

a. True b. False

2. Precision medicine refers to the tailoring of medical treatment to the scientifically averaged characteristics of all patients.

a. True b. False

3. Traditional endodontic treatment has been convenience-driven and endodontic-centric, primarily focused on operator needs, and has been decoupled from the restorative needs and tooth needs.

a. True b. False

4. Smaller access (openings) might hinder the clinician’s ability to locate clinically relevant anatomy, and has been a primary objection to the minimally invasive strategy.

a. True b. False

5. The CBCT imaging guides treatment in a way that complements the microscope; access can be precisely extended if needed to address the additional anatomy.

a. True b. False

6. Regarding the concerns with conservative canal preparation and clinician’s need to “cleanse and shape the canal properly,” it is imperative to remember that these are the tooth’s needs.

a. True b. False

7. To practice endodontics at the highest level (possible; and as limited by current technology) only a microscope is needed.

a. True b. False

8. As Dr. John Kois has said: “Significant problems are more related to the loss of tooth structure more than the endodontic procedures themselves.”

a. True b. False

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