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.

No rubber dam, no root canal treatment

The widely reported trauma suffered by a young woman undergoing root canal treatment this month (November 2016) was 100% preventable. The incident in Bristol led to widespread commentary in the national media after the patient told her story publicly. She said that an endodontic file went down her throat and when she choked, the file was forced downwards, piercing her stomach lining.

It seems likely that the dentist had not used a rubber dam, a stretchy sheet which both isolates the tooth and protects the patient’s airway. A hole is made in the middle of the sheet so it can be placed around the neck of the tooth, rather like a barber’s gown, so that the tooth is isolated and nothing can fall into the mouth.

The rubber dam serves several functions:

1)   It prevents anything accidentally failing into the patient’s mouth

2)    It prevents the strong chemicals that are used to clean the root canal from accidentally spilling into and burning the patient’s mouth

3)   It isolates the tooth and keeps it dry, helping to achieve a good clinical outcome.

4)    It reduces the risk of bacteria penetrating the root canals during the procedure, also improving the likelihood of healing and a long-lasting result

This is an accident that was preventable and should not have happened. Interestingly, a patient’s forum provides a section on the rubber dam which suggests that there should be no difficulty in persuading patients that placement of a rubber dam is essential. The cultural norm should be: No rubber dam, no root canal treatment.

Further reading from professional bodies and publications:










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The destructive impact of resorption

I have written before about the wonders of Cone Beam Computed Tomography (CBCT) in helping endodontic diagnosis.  Now I am going to highlight its role in helping us identify one of the more rare dental conditions – root resorption.

This is a process where the body’s cells dissolve the tooth structure. Like many of the human body’s processes, this can happen both positively and negatively. In children, for instance, resorption is the natural process  which causes primary teeth – often known as milk teeth – to fall out.

In adults it can be problematic. One respected colleague calls resorption the Silent Terminator because there are no symptoms and when it’s not picked up it can be highly destructive. If left unchecked, the teeth become loose and will ultimately be lost.

Resorption has many causes.  If you lose a tooth, the bone will gradually resorb and if a tooth is damaged, perhaps due to a fall or tripping up and banging your mouth, resorption may be triggered. What happens is that the periodontal ligaments, which hold the tooth in position, may become damaged. Over time, the roots become shorter and this puts the teeth are at risk.

Orthodontic treatment can be a potential risk factor for root resorption. It can be triggered when excessive force is applied to teeth too quickly. It’s a salutary reminder that while patients often want speedy treatment, it’s not necessarily in the long-term interests of the health of their teeth.

Orthodontic-related resorption isn’t usually the domain of an endodontist. We are more likely to see either internal or external resorption.  It has been an infrequent but recurring condition among the patients presenting at the Harley Street Centre for Endodontics.

External root resorption occurs from outside the root. It’s more likely to occur in your front teeth, top and bottom, and the small telltale lesion is often concealed beneath the gumline. It can also be detected on an X-ray, as if a chunk of a root has gone missing. Internal resorption, which is rare, occurs inside the canal or pulp chamber.  It’s like a hollow bubble which grows inside the tooth. If it’s severe, it can perforate the wall of the tooth.

Resorption can be the body’s response to inflammation as well as infection within the pulp of the tooth, where all the nerves are. When resorption starts, root canal therapy is needed to stop the process and prevent destruction of the remaining tooth structure.

If the resorptive defect is completely contained within the tooth and can be halted, there is a good chance of saving the tooth.  If the lesion breaks through the wall of the tooth, there may be no hope.

If resorption is detected, referral to an endodontist needs to be made promptly.  We can then decide if the tooth can be saved. The chief benefit of CBCT is that it gives us the fine detail we need for treatment planning.

The challenge for clinicians is in explaining to the patient what’s happened to their tooth and how the resorption has come about. In many cases we really don’t know. But we should build awareness of the condition, especially now that there is more chance of saving teeth with the assistance of CBCT.

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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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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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Why evidence matters

Since the mid 1990s, dentists have been required to base their clinical judgements on up-to-date, gold-standard research. We may take evidence-based dentistry for granted nowadays, but when it was introduced in the latter half of the 20th century, it seemed to herald a new era. Sadly, in a few areas of health, there are still small but vocal groups who prefer to peddle their own extreme theories bearing little relation to the most recent or valid research.

Take for instance the ideas of Weston A Price who lived from 1870 to 1948. His name continues to live on because it suits a very few extremists  to continue to propagate his more absurd notions.

Price was a Canadian born dentist who became very interested in nutrition and its relation to dental and physical health. A lot of us would support some of his views – that processed foods, refined sweeteners and additives are best avoided.

Where I, and the rest of the dental profession, part company with Price is on his focal infection theory. He believed that a localized site of infection could disseminate micro-organisms around the body and cause systemic disease. He believed that a tooth that had been endodontically treated would harbour bacteria that could, in time, cause serious illness. His idea of a cure?  Extraction of the tooth.

The so-called research he carried out was seriously flawed. Price may have been taken seriously in his time but he was discredited by the 1940s.  Today, we can dismiss his theory as ridiculous because it’s not based upon the kind of rigorous, scientific research expected of us.

Unfortunately, there are new generations of extremists who take ideas and attempt to breathe new validity into them. A recent online American site which a worried patient wanted my views on carried a report about Price which had more than 70,000 views and 500 plus comments.

This scare-mongering article describes a root-treated tooth as a “silent incubator “ for highly toxic anaerobic bacteria and suggests that they cause, arthritis, heart attack, kidney disease and more.

In the face of such nonsense, the dental profession needs to do its best to explain the difference between an out-of-date theory and properly conducted research.

We have support from an important quarter: the General Dental Council. I remember reading a landmark judgement dating back some seven or eight years after a dentist was found guilty of serious professional misconduct on a variety of charges relating to an alternative approach to the treatment of one patient. This is what was said to the offending dentist: “Your approach seems to have been to adopt a philosophy and then to seize on all the available evidence which appeared to support it without regard to quality. That is a highly unsatisfactory basis for treatment.”

The very clear expectation of the GDC is that registrants should know how to identify gold standard research.

Unfortunately, we can’t control what our patients find on the internet and no-one seems to have any jurisdiction over what is uploaded there. When I do have a patient who has been exposed to misleading or worrying information, I refer them to the website of the American Association of Endodontists. Their Fact Sheet on the subject is evidence-based and very reassuring: http://www.aae.org/uploadedfiles/publications_and_research/guidelines_and_position_statements/focalinfection.pdf



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Teeth repairing themselves?

It made a lovely story – the new treatment which allows teeth to repair themselves, eliminating fillings.  The Daily Mail headline alone made exciting reading – the paper excels in detecting futuristic health stories.

But futuristic is exactly what this story is. If there is a rosy cavity-free future ahead, it’s still a way off. First of all, the process of Electrically Accelerated and  Enhanced Remineralisation as the  treatment is known, is still in development. The treatment has been devised and researched at Kings College Dental Hospital, and a company has only just been formed to turn this brilliant concept into a product. The company is Reminova Ltd and is in Perth in Scotland.

My real concern  are the vast swathes of the population with heavily restored teeth. Large cavities at any age may already have allowed bacteria to enter the dental pulp leading to inflammation and subsequent disease for which the only remedy is root canal treatment.

While there is no doubt that the product is very exciting – it even whitens teeth – a lot more change and patient education needs to take place before all the UK’s population can benefit.

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Communicating confidence in 2013

Simpler and better. These two very ordinary words sum up my commitment to my speciality. I want to make it simpler for colleagues to carry out Endodontics with confidence and give patients a better experience. Each year I continue to offer courses both at home and abroad to introduce new techniques to dentists.

This year I have a few trips lined up to such places as Switzerland, Denmark, Holland, Germany, Russia and Ukraine. At home I’m looking forward to speaking to the Gloucester Independent Dentists Group with more lectures lined up as 2013 progresses.

Last year, to mark the 10th anniversary of the Harley Street Centre for Endodontics, we launched the Young Dentist Endodontic Award. We had many applicants who submitted high quality treatments. As judges we had to choose the treatment which showcased most impressively the young dentist’s aptitude, skill and understanding. As a result of looking at so many excellent entries, I know the future of Endodontics is in good hands. Rahul Bose made a worthy first winner and I was very happy to welcome him into the practice for a day so he could watch the team at work.

In 2013, we are running the award again with some wonderful prizes from my friends at Dentsply UK, QED and SybronEndo.

Dentsply Maillefer’s WaveOne reciprocating file system simplifies Endodontics greatly. It has been a huge success worldwide and I am so excited that I have been involved with this wonderful file from inception to market. If you are a dentist, watch this space as there are some new products on the horizon to cover simple to complex cases using both rotary and reciprocating files.

To all my friends, colleagues and patients, I hope you have a great year!

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