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.

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In the face of such nonsense, the dental profession needs to do its best to explain the difference between an out-of-date theory and properly conducted research.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



Read More

Listen, learn, but what next?








The slogan for the Endodontics Masterclass I chaired in 2014 was “Listen, learn and Implement”. We had a fantastic audience who definitely listened and learned. I wonder what they took back and implemented in their practices?

We had outstanding endodontists in the line-up of speakers: Ghassan Yared, Arnaldo Castelluci, Liviu Steier and Martin Trope all pictured above. Each one espoused his own technique and theories in a very detailed and well  argued presentation. All had different canal preparation systems.

Then we had question time when audience members could put their queries to the panel. One dentist confessed to being confused by the different points of view. Having listened to some of the best  known speakers in the world, it was difficult to decide which system to invest in. Another dentist asked: “Bearing in mind how long endodontics has been a field of dentistry, why isn’t there some kind of consensus for this?”

We all agreed it was a sad commentary on the state of research – the problem being that you could not get ethical approval for an RCT  which would involve treating one cohort of patients in a less than satisfactory way. What we need is for all endodontists to work together and for peer-reviewed journals to insist on research which involves hundreds of patients, not just small groups.
And my advice to the delegates at the Endo Masterclass? Read the literature and follow best advice. As dentists you have the professionalism, experience and judgement to decide which system will work best for you and your patients.one cohort of patients in a way which you thought less than satisfactory. What we need is for all endodontists to work together and for peer-reviewed journals to insist on research  which involves hundreds of patients, not just small groups.

Read More

Pulp redevelopment no longer a fiction

Regnerative endodontics has recently entered the topical mainstream. I predict that we are going to hear a lot more about this procedure which allows healthy pulp tissue to regenerate, thus avoiding definitive endodontic treatment.


In addition to the press release we have disseminated, there have been no fewer than two articles in the Daily Mail. The most recent was by David Hurst who interviewed the mother of a young patient of mine.


The previous one was much earlier in 2013 with the headline:” New op to dodge dreaded root canal treatment. I am delighted that Roger Dobson, the article’s author, picked up on the issue although for many patients, root canal treatment is no longer “dreaded” thanks to new techniques and advanced pain relief.


However, in his rush to praise regenerative endodontics, Dobson failed to emphasise it is only for young children.  But The Daily Mail at least introduced the subject of regenerative endodontics and parents  have started asking about it for their children.


It can be completed in only 2 visits, spaced 4-6 weeks apart. It stimulates root end closure over time but, more importantly, root development continues to occur which narrows down the root canal space, maintaining the natural strength of the tooth. David Hurst explained this well in his article in the Daily Mail.


The aspect of the procedure which captures the imagination, I believe,  is that regenerative endodontics harnesses the body’s natural healing mechanisms. How exciting that the re-growth of healthy pulp can lead to the normal and healthy development of the damaged teeth of our young patients without the need for root canal treatment.


Read More

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!

Read More

Shining a light on diagnosis by Trevor Lamb


I frequently find myself being asked for a second opinion. The patient comes to see me saying their dentist believes the problem with their tooth is sensitivity. But the patient suspects that the nagging discomfort is in fact a more deep-rooted problem – forgive the pun – and they wind up in my chair.

Today, dentists take a minimally invasive approach. They don’t want to open up a tooth or even carry out an x-ray unless it is necessary, which is of course correct. The trouble is, that the “minimally invasive”, “wait and see” approach does not always provide a solution.  Very often, the patient with toothache finds the absence of a clear diagnosis and a solution  frustrating because it does not signal an end to the problem.


I have several tests I undertake depending on the state of the tooth and the suspected problem. First I use the aspirator to blow cold air. This helps me zone in on a tooth or teeth that are symptom producing.  Then I percuss gently, tapping with the back of a mirror handle to see if I get a reaction. I might test all the teeth in the quadrant to make sure the patient is correctly identifying the source of the discomfort.


If the tooth has a minimum restoration and I suspect a crack, I use an LED light. Healthy teeth transmit light whereas a fracture line stops the light. For a tooth which is heavily restored, I use a bite stick or Tooth Slooth.


This is followed by cold and hot testing of the pulp of the affected tooth.  The final and definitive test is the electric pulp tester. From the above tests a preliminary  diagnosis of the pulp status can be made – reversible pulpitis or irreversible pulpitis.  Finally a radiograph is taken.


To the dentist in practice, wanting to deal with a worried and frustrated patient, I would always recommend a Tooth Slooth and/or  LED light investigation followed by an electric pulp test. By this time, the patient is reassured and happy that the cause of their toothache has been fully investigated and a solution may be on the horizon.


Read More

The comedian and the root canal treatment

Stand-up comedians would struggle to find humour in a root canal treatment. Nevertheless, my colleague Trevor Lamb got a mention on stage from one of the UK’s best known stand-ups. The comedian, who must remain nameless, came to see Trevor  needing to be got out of pain so he could perform live that very night. Trevor duly delivered and was rewarded with a mention in the comedian’s set later in the day. It’s gratifying to think that thanks to Trevor, who takes his job very seriously, and the very uncomical root canal procedure he performed, many hundreds of people were able to go out for an evening of hilarity.

Read More

Endo experience improves for patients

Endo experience improves for patients

We may talk fondly of the “good old days” but I’m not sure there ever were in endodontics. For both endodontist and patient, today’s materials and technology make treatment quicker and easier, with more reliable outcomes.

Take this patient (follow the x-ray images left to right) who presented with infection and swelling at the tip of the root of the upper right central incisor.  The most likely cause was an incomplete seal of the original root filling, hardly surprising as the apical opening was large (over ISO 150).

Twenty years ago, there were only two options for a case like this. Either an apicectomy, (root end surgery, never ideal when the root filling is so poor to start with) or removal of the root filling and then a protracted course of treatment over an 18 month period using calcium hydroxide to stimulate root end closure, followed by the final root filling. This was a complex process involving multiple visits by the patient.

Thanks to modern technology and new materials I completed the case in a single visit last year. The root filling material was removed, the entire length of the canal visualized with the operating microscope and an apical plug of MTA (mineral trioxide aggregrate) was placed precisely at the end of the canal to seal it and the rest of the canal was filled with conventional gutta percha. At the recent review appointment, I saw healing had been achieved within the  year.  All this in one visit!


Read More

The confusing nature of pain

One of the challenges we routinely face is identifying the source of  the pain or discomfort the patient is experiencing. Most patients and indeed many dentists perceive that any head and neck pain indicates the need for root treatment. Just recently, Trevor saw a patient who was convinced that she needed root canal treatment. Trevor had previously seen the patient for a root filling on the other side of her mouth so she asked her dentist to refer to Trevor again. Endodontists are trained to diagnose the cause of pain.  On this occasion the pain was not dental-related at all but caused by muscle pain which can be associated with a clenching, grinding teeth habit and sometimes is stress related. Trevor advised the patient on the steps she needed to take to eliminate the discomfort which were minimal compared to having a root treatment. The patient was so delighted she went to the website of the Saving Teeth Awareness Campaign and left the following message:

“My first visit to Trevor Lamb was one of the best things I had ever done. He saved my tooth which was badly done previously. Trevor sorted my tooth infection – he had this fantastic equipment and his micro-techniques surgery is first rated and my tooth is saved. He also diagnosed my facial stress on my left face and advised me on what to do. This has made a difference to the jaw pain which I was suffering for the last 6 months. I am so impressed with Trevor Lamb and would like to thank him for saving my tooth and the advice he gave me on my facial stress. To me he is my Hero for saving my tooth. So the campaign is very important indeed.”



Read More

Case of the Month – Extreme Decay

The extent of decay in this lower left molar makes this one of the more extreme cases dealt with here. The patient was in pain and had swelling and an extraction was a distinct possibility. Our policy is always to save teeth if we possibly can and that is what we set out to do for this patient. Follow the pictures left to right and you can chart the progress.

In the first picture, you can see the pale (radiolucent) areas around the bottom of the root and this shows that there is infection in the bone (apical periodontitis).  The old filling and all the decay were removed and the tooth was root treated in a single visit.

The tooth was rebuilt with a post and core followed by a crown by the referring dentist. The final picture shows the tooth at the 2 year review. The infection had healed. The tooth is maintained and the patient was very happy!



Read More