Welcome to Julian Webber's blog where he muses on a range of topics including some of his most interesting cases,
stories from his travels, the latest from the clinic and news on our Saving Teeth Awareness Campaign.

Good treatment is the solution to dental pain, not antibiotics

I don’t often comment on the provision of root canal treatment as part of the National Health Service. But I am drawn to do so following a critical article in The Times on this topic.

First, I should draw your attention to the excellent response from the British Endodontic Society’s President, Mike Waplington. I completely agree that the importance of endodontic treatment to overall dental health is not adequately recognised by the NHS dental contract, nor the complexity. Units of Dental Activity, the NHS payment system, do not adequately reward dentists. Perhaps it’s time to recognise that not all dentists working in the NHS should be expected to carry out root canal treatments without additional funding. After all, even for the best of us a complex endodontic case can take well over an hour to complete. There are many committed dentists who excel at root canal treatment and some of them have invested in technology to help improve outcomes. These dentists with a special interest should be adequately recompensed for providing endodontic treatments.

This brings me to another point. I would like to highlight publication of a study from earlier this year which showed the high numbers of unnecessary prescriptions for antibiotics made by medical doctors. This carries a double cost – the first is the prescription itself and the second that unnecessary antibiotics are contributing to the threat of antimicrobial resistance. The argument goes that if too many of us consume antibiotics anti-microbial resistance will develop and we will have no protection against superbugs. Prescriptions for antibiotics are still handed out too routinely and too many dentists are as much to blame as our medical colleagues when it comes to the issue of over-prescribing.

The American Association of Endodontists (AAE) of which I am a member has recently added an interesting article to its website which shows there is no evidence that antibiotics are effective for the control or prevention of endodontic infection. There are times when they are called for but these are limited. A painful irreversible pulpits or an endodontic abscess require treatment and not antibiotics. Gaining access and then shaping and cleaning the canals will ensure symptoms are eliminated.

Treatment is what’s required when you have pulpits, not antibiotics and the more dentists capable of undertaking quality endodontics the more teeth will be saved.

 

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CBCT and finding the evidence

 

Radiography, or the taking of X-rays, is probably more critical to dentists in the diagnosis of endodontic disease than any other dental procedure. In fact, diagnosing endodontic disease probably accounts for a significant percentage of the x-rays taken on a non-routine basis in general dental practice.

But for those of us in specialist practice, the routine x-ray sometimes isn’t enough. It only delivers a two-dimensional image of the roots of a single tooth. Which means we can’t see the whole tooth, the adjacent teeth or the surrounding structures. The solution is cone beam computed tomography (CBCT) which provides a 3-D image of the problem area, providing a comprehensive picture from every possible aspect.

We use small volume CBCT on many of our patients. Its invaluable imagery helps us accurately assess or identify the following:

  • the presence of endodontic disease (apical periodontitis)
  • bone defects
  • complex anatomy
  • a concealed root canal
  • Resorption and perforations
  • the impact of trauma

If it’s straightforward endodontic disease, we have a good chance of saving the tooth, if there is a vertical crack, there is little chance.

For our patients, the small additional costs of a referral for a CBCT image are well worth the investment. We send the patient to Cavendish Imaging, which is just down the road in Harley Street and we prescribe which area of the mouth should be scanned – for instance, a small volume image of the lower right first molar and surrounding teeth. No more than 20 minutes after the scan has been taken, it’s on the Cavendish Imaging website for us to assess. If we see there is a vertical crack in an ailing tooth, we don’t end up wasting the time and money of the patient. But the patient is reassured because they know we have done everything we can to save the tooth.

Of course, radiography should be kept to a minimum and CBCT uses ionizing radiation. We have to remember ALARA, the principle of “as low as reasonably achievable” when using the technique. However, the dose is lower than a conventional CT scan and a similar one to a pan-oral which is usually taken for orthodontic purposes.

In root canal therapy, getting the right diagnosis is all important. An accurate appraisal of the cause of the patient’s problem allows me to save a tooth which might otherwise be lost or conversely, confidently abandon a tooth that has no hope of being saved. I predict that because it’s invaluable for diagnosis and this is so critical to endodontics, CBCT will become more widely used as costs of the equipment go down.

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From frazzle to dazzle: lasers for root canal therapy

Lasers have been successfully applied in dentistry for several decades. Although reportedly available as early as the 1960s, it wasn’t until the early 1990s that they were first approved by the US Food and Drug Administration for the treatment of gum conditions. In 1996 they were approved for hard tissue treatments but their use in the specialty of endodontics has been limited.

An article in the BDJ in 2007 outlined why the use of lasers was considered controversial at that time. In essence, this was due to the photothermal action – generating a lot of heat –  of high-powered lasers with potential for collateral damage. There were also risks associated with operating ‘blind’ in the tiny internal space of a tooth.

But nearly ten years on, the picture is changing.  This is partly due to the advent of a new design of tip attachment for the erbium:YAG laser.

This has given rise to the concept of PIPS, Photon Induced Photoacoustic Streaming. Pulses of laser energy are directed into a bath of hypochlorite inside the tooth. These extremely short bursts of energy pump debris out of the canals and debride, disinfect and sterilize each canal down to the tip and then out into additional lateral canals.

It’s well documented that decontamination of the root canal is one of the major challenges in endodontic therapy. In specialist practice we have developed a robust approach combining mechanical measures supplemented by antimicrobial solutions.

But my mind is always open to new and improved methods of cleansing the canals to eradicate the potential for the regrowth of micro-organisms. Where there is good research, I will listen. I am impressed by the work carried out in the US by Enrico DiVito and others which demonstrates that PIPS achieves high efficacy and can be used as an additional tool in the decontamination of infected root canals.

It’s not just the efficacy of PIPS that has excited me, however, but the potential for bringing endodontic therapy into the fold of Minimally Invasive Biomimetic Dentistry (MIBD).

Until recently, it wasn’t possible to describe endodontics as minimally invasive. I grateful to Mark Malterud for his inspiring article on this topic in the publication of the Association of General Dentistry. Rigorous instrumentation is needed to give the clinician access to root canals for thorough cleansing prior to obturation (filling). This has led to canals being over-shaped and enlarged, losing precious tooth structure and potentially making the tooth vulnerable to fracture in the future.

By contrast PIPS technology allows for the clinician to place the tip  into the coronal aspect of the preparation without penetrating into the canal system, reducing the need for instrumentation. The end result is a tooth with more of its structure retained.

Given that thorough eradication of micro-organisms from the root canal system is a major predictor for endodontic success I believe that if the price of lasers continues to decline, all dentists and endodontists will want one, me included.

 

 

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When diabetes and dentistry meet

The world’s first diabetes prevention programme has just been launched by NHS England  with the aim of identifying patients who are most at risk of Type 2 diabetes. This is welcome news. Within the dental profession there has been growing evidence of links between diabetes and dental health and this is now being communicated directly to patients. A major online diabetes forum in the UK tells visitors that problems with teeth and gums can be more common and more serious in people with diabetes.

While periodontists treat gum disease, it falls to endodontists to treat apical periodontitis. This is disease in the bone area mainly  around the tip of the tooth (periapical lesions) caused by bacteria in the dental pulp.  The disease process can lead to considerable pain and  and swelling requiring root canal treatment. A possible connection between diabetes and endodontics makes sense. There have already been some studies which indicate that in diabetic patients there is a higher prevalence of Endodontic disease with associated apical periodontitis.

Studies also show that these areas of infection – lesions – may be bigger and take longer to treat or may even be more difficult to treat in diabetics. Slow healing of wounds can be a feature of diabetes. Certainly, among my diabetic patients, post endodontic healing is likely to take marginally longer than healing in other patients.

What does this mean for people with diabetes? Well, it’s worth bearing in mind that there are around 4 million people in the UK with diabetes and about 500,000 of those have the condition and aren’t aware of it. The vast majority of diabetic patients – around 90% – have Type 2 diabetes. They are more likely to be over 40 and may have heavily filled teeth. Endodontic infection can begin when an old filling fails and decay penetrates into the dental pulp.

So, what I’m suggesting is that the 500 people every day being diagnosed with Type 2 diabetes may well include a cohort prone to endodontic infection and they will need extra care taken in their management. The medical history form that dental patients are asked to fill in and then keep up to date has never seemed so important.

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The dental implant revisited

It doesn’t seem so long ago that dental implants appeared to be a threat to the future of specialist endodontic practice. Some 15 years ago, instead of being offered root canal treatment, patients with problematic molars were being offered a dental implant to replace the compromised tooth. A dental implant, so patients were told, operated just like a natural tooth. For not much more money, the filled and damaged molar which had caused the patient pain and discomfort could be replaced by an artificial tooth which offered a long-term solution. What was not to like?

It was to challenge this orthodoxy prevalent in the early part of this century,  I spear-headed the Saving Teeth Awareness Campaign. My aim was to highlight that if the biological tooth can be saved, it should be. A dental implant can never be justified for a tooth which has not previously undergone root canal treatment and which is restorable.

A lot of colleagues felt the same way as I did and the campaign garnered considerable support. Not long after this, implant surgeon Michael Norton and myself undertook some public debates.

I would make the case for endodontics and he would make the case for dental implants. The key to the success of these presentations was the clinical consensus on the most critical issues. Instead of descending into an embarrassing disagreement, Michael and I could shake hands in the safe knowledge that we would both put the interests of patients first -  if a tooth can be saved, it should be. We communicated the positive message that implants and endodontics can work in harmony to the benefit of patients. We argued that researchers should use the same criteria when studying the outcomes of both modalities. Implants tend to be measured according to their survival rate whereas endo studies measure the re-occurrence of disease.

The tables were already turning a little. Since then, they have turned even further. What were promised as long-term solutions for patients are failing in about 20% of patients.  This is partly the result of emerging research in the field of periodontology – the specialist area dedicated to gums – which shows there is a worrying increase in peri-implantitis, a condition which can cause an implant to fail. A recent study shows that maintaining a periodontally compromised furcation involved  molar is less costly than its extraction and replacement with an implant supported crown and is likely to be  retained for a longer  time period,  irrespective of the degree of furcation involvement.  For those of you who aren’t au fait with dental terminology, the furcation is where the roots divide; a furcation-involved molar suffers bone loss caused by periodontal disease. Treating disease in this hard-to-reach location is extremely challenging and needs the intervention of a gum specialist and the long-term support of a hygienist.  Who could have predicted 20 years ago that we would be reappraising the dental implant so radically?

As we start 2016, hopefully everyone in the dental profession would agree that whilst dental implants are a good option for the right patient they may be ill-advised for patients with a history of periodontal disease. To quote the American endodontist and colleague Cliff Ruddle, the natural tooth is the ultimate dental implant.

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The antibiotic revolution

1928 was an important year. Penicillin was first discovered and it revolutionised healthcare at the time, curing or controlling severe diseases such as tuberculosis, syphilis, pneumonia and other bacterial infections. What followed was a huge wave of optimism, as people believed the war on bacteria was over. In 1969, the Surgeon General of the United States even stated it was time to “close the book on infectious diseases.” Little did he know that several decades later bacteria would be fighting back.

 

Winning the battle against one of the most powerful organisms in the world isn’t that simple. One of their characteristics is that they reproduce exponentially and can tackle challenging conditions – such as the emergence of penicillin. This means that they can adapt to new circumstances and the longer they are subjected to an antibiotic, the more resistant they become. Weaker microorganisms will still be defeated by antibiotics, but the stronger ones survive, making each following generation of bacteria better armed to tackle future antibiotic challenges.

 

Infections in the pulp of the root canal are the most likely cause for dental patients to be prescribed antibiotics. Because patients come into my clinic for diagnosis and specialist treatment, I’m unlikely to find myself  under pressure to prescribe. On the contrary, I am able to tell the patient that a properly carried out root canal treatment will resolve an endodontic infection without the need for antibiotics. For general dentists however, it’s more difficult. Patients in pain will sometimes push for a prescription, believing this is the way to get rid of their symptoms.

 

In order to solve this problem, we need to make patients aware that antibiotics are not always required for managing an infection and removing the source of infection is a far better option. The Faculty of General Dental Practice in the UK has started a campaign, called Thunderclap, in which they ask dentists to pledge that they will “make more time to manage infection and only prescribe antibiotics in line with published guidelines”. (http://www.fgdp.org.uk/content/press-release/fgdpuk-urges-responsible-approach-to-antimicrobial.ashx)

 

A good start. As the American Association of Endodontists, of which I am a member, points out, Norway does not have killer bugs yet thousands of people in sophisticated hospitals in North America, other parts of Europe and Asia are dying from contagious infections. The reason is that in Norway, the number of antiobiotic presecriptions has been dramatically scaled down.

 

All healthcare professionals need to resist the temptation to hand out a prescription for antibiotics because that’s what the patient wants. And we all need to be signed up to it. Otherwise, as the World Health Organisation points out, we are heading for a post-antibiotic era in which common infections and minor injuries can kill.

 

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Training trip in Asia – high standards & huge commitment

Endodontic treatment will always be one of dentistry’s most challenging procedures. But my mission, with cases that aren’t too complex, is to help colleagues feel confident to carry out root canal treatment themselves. With this in mind, I helped develop Dentsply’s WaveOne and more recently WaveOne Gold single file systems for use in reciprocation. The file system allows nearly 80% of cases to be treated with just one shaping file. That’s real simplicity and I am proud to say that my goal has been achieved.

Now all that’s needed is to train potential users.

One of the benefits of being a developer is that to promote a new file system like WaveOne Gold, I get to travel around the world. For instance, I recently had the pleasure of travelling through Asia to give lectures and hands-on demonstrations at universities and conferences in Taiwan, South Korea and Thailand. It was an amazing trip.

Over the course of 10 days, I gave 9 lectures and 9 hands-on sessions, including sessions called ‘Train the Trainers’. The aim of these sessions was to pass the baton onto leading professionals in each country, so that they could then provide WaveOne Gold training to their colleagues. It was an honour to work with some highly competent dentists and endodontists, and  I was most humbled by  the fact that there wasn’t a single occasion where a translator was needed or provided. I could deliver every single lecture and training session in English. What a way to make me feel welcome!

Another thing I found incredibly striking was the delegates’ desire for learning and their keen interest in everything I had to tell them about the development of endodontic technology. The standard of endodontics in Thailand, Taiwan and South Korea is of a very high standard and none of the students, dentists or endodontists I met during my trip, failed to impress me. Speaking of high standards, the film crew that was with me throughout my tour caught a brilliant scene on camera – a little girl in Taiwan being taught by her endodontist mother how to use WaveOne Gold. It really was video gold!

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Fatal flaws in our jaws – article in Jewish Chronicle

“Patients should consider investing in endodontists with the best equipment as it saves money as well as teeth in the end.”

This advice from the journalist Anthea Gerrie in a health supplement of the Jewish Chronicle is a very welcome validation of an endodontist’s investment.

In her article, Anthea describes how she came to see me with her three problem teeth.  Unfortunately,  her treatment didn’t have a fairytale ending. The teeth were cracked and beyond repair.

But her experience led to the thoughtful article with the headline: Fatal flaws in our jaws. She was interested that I had to open up the tooth before I could provide a diagnosis and opinion. The reason, I explained, is that fillings obscure the tiny cracks that can form down the inside of a tooth or on the floor of the pulp chamber.

It’s only by removing the filling and using an operating microscope that you can see what’s really going on. Although it’s frustrating to initiate the procedure and then abandon it when a tooth is beyond repair, she at least knew we had both done all we could to save the tooth. As she observed, the high cost of a crown is worth it only if the root canal work has been properly executed. Otherwise the tooth will ultimately fail. She also endorsed the Wand, the device I use for delivering a local anaesthetic – “at least I can confirm root canal is painless”.

Treating Anthea highlighted to me how important communication is around cracked teeth. At the Harley Street Centre for Endodontics we see several a week because they are the most complex cases and belong in specialist practice.

Teeth may be the strongest parts of the body but unlike bone, they don’t heal when fractured. Returning to the fairytale theme, as Anthea rightly states, endodontics is the Cinderella of dental practice. If that makes me a prince, my shining armour is my superb technology and it’s great to have had recognition from a high quality publication like The Jewish Chronicle.

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Root canals, dental implants and saving teeth

Dentists warn of risks of not looking after implants”  was a headline that caught my eye recently when checking the BBC news app. According to the article, there is an epidemic of peri-implantitis. This condition is an infection of the gum and bone around an implant, leading to bone loss and potentially the loss of the implant if the inflammation cannot be controlled.

The story is  worrying because it risks causing panic among patients. Many patients consider implants to be indestructible  – but they are no different from natural teeth and roots. They must be kept clean and maintained regularly. And smoking is ill-advised.

Disagreement

To my mind, over enthusiastic marketing has had a role to play. Dental implants have been marketed as replacement teeth. It has sometimes been implied that having a dental implant is preferable to saving a tooth which is already causing problems. I don’t agree. Obviously.

An implant is not a replacement tooth, it fills a gap left by a tooth which could not be saved by root canal treatment. This was well expressed in a guide for young dentists produced by the British Society of Periodontology: An implant is not a substitute for a tooth, it’s a substitute for NO tooth.

Saving teeth with root canal treatment

I have spoken publicly several times on the topic of endodontics versus implants, sharing the stage with dentist and implant surgeon Michael Norton. Our presentation was structured as a debate but we always ended up in furious agreement. When a tooth can be saved, it should be. The reasons are clearly set out on this website: www.savingteeth.co.uk

Moving forward, we need clear and responsible marketing of dental implants, we need improved education of patients who have dental implants and more teeth being saved whenever it’s possible. And let’s avoid scare-mongering. A well made dental implant placed by an experienced dentist or specialist in a healthy mouth is an important option for patients and long may it remain so.

 

 

 

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The disease and the dilemma

Around one in two adult patients in the UK may have infection beneath their teeth which they are unaware of. This is based on a study at a London teaching hospital  which found that 49% of the group had apical periodontitis (AP), the dental name for this kind of oral disease.

 

Sometimes AP causes the tooth to flare up and sometimes it won’t.  Only visible on an X-ray, the chronic disease can remain dormant and painless for years. The dilemma for the dentist is to know whether to intervene and treat the disease when it’s not causing a problem to the patient. Research shows that specialists like myself are more likely to want to treat a tooth when we identify AP from an X-ray, possibly reflecting the confidence that comes from both experience and having a specialist practice fully equipped with specialist technology. This study showed that high quality root canal treatment is crucial to ensure a favourable outcome.

 

The aim of root canal treatment is to remove all infection from the pulp and root canal system and leave the tooth healthy and functioning in the jaw. Sometimes the attempts to clean out all infection fail. Clearly, the ideal solution would be to improve standards in root canal treatment, reducing the number of people who live with the silent disease.

 

This bacterial infection spreads from the pulp and into the root canal system.  It moves into the bone below the tooth tip where the surrounding tissues respond to the bacteria. This can lead to the bone beneath the tooth reformatting and retreating, leaving a small vacuum. It is this vacuum which can be picked up on an X-ray. The advent of advanced X-ray systems (cone beam computed tomography) makes it easier for dentists to spot the signs of infection.

 

But there are other reasons why the issue of untreated AP is topical and needs to be resolved. Firstly dental implants are more prevalent and should be placed in strong and healthy bone. Patients who might need and want dental implants shouldn’t be vulnerable to AP.

 

Furthermore, a link between gum disease and other health issues has been established – http://www.nhs.uk/Livewell/dentalhealth/Pages/gum-disease-and-overall-health.aspx – which suggests that the potential for a link between AP and overall health should either be investigated and proved or, ideally definitively eliminated.

 

A recent opinion paper in the British Dental Journal sets out the need for such a study. The authors of the paper have helpfully provided a model to help researchers measure the effect of both leaving the disease and treating it.

 

I believe that as a result of the proposed study, clear guidelines for the benefit of both patients and the profession are almost within our grasp. The debate over whether to intervene when AP is spotted has been simmering for years and needs to be resolved soon.

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