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.

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.

“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.

I am grateful to Alpha Omega http://alphaomegauk.co.uk for asking me to carry out a live treatment recently. The picture above shows the treatment underway with myself and my nurse Paulette using the operating microscope. Watched by a handful of dentists, I explained what I do and answered questions; the experience prompted some helpful reflections. The patient in the chair had been referred to me by his dentist to treat infection and pain in an upper right molar. The referring dentist had opened the tooth up but decided that it was best treated by a specialist. What was I going to do? It wasn’t just me asking this question; a group of 7 observers were watching the procedure on a 50 inch plasma screen courtesy of my microscope which recorded the live action!

Numerous craze lines and a superficial fracture running from the front (mesial) to the back (distal) were visible on the surface of the tooth. This alerted me to the possibility that the tooth could be badly cracked or split and this could be the cause of the bone loss between the roots (furcation involvement) seen on the X-ray, leading to swelling in the cheek (buccal swelling)? After I cleaned out the root canals I spotted a fracture running from the mesial marginal ridge to the distal marginal ridge through the floor of the pulp chamber. This was clearly the root of the problem.

Could the patient’s dentist have diagnosed the fracture? The answer is no; only a clinician with an operating microscope could have seen this fracture. The limit of human vision is 0.2mm and anything less than this cannot be seen with a naked eye. I probably see a fracture across the of the  pulp chamber floor twice a month. It’s a sobering thought that outside of specialist practice, cases like this would be treated and fail. Thanks to the magnification, we avoid spending time and cost on a hopeless case.

Sadly this particular patient lost his tooth because it tooth was terminally fractured. But at least by cleaning out the canals and dressing the tooth I removed the discomfort and swelling, buying him time to talk to his dentist about the next step – a bridge or an implant.

The moral of my story is that without the correct imaging equipment problems can go undiagnosed. As clinicians we need to have an open mind and remember that the problem inside a tooth may not be visible to the human eye.And as a secondary thought, it’s always beneficial to open yourself up to the scrutiny of your colleagues. It really makes you think about what you do and why.