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.

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.

How much is each one of your teeth worth to you? Today there are a plethora of websites which will guide you on the price of many different things – houses, cars, clothes, utilities, food, household goods. You name it, the online price comparison site or shopping experience is there for you. You can even determine the cost of frames for your spectacles. But teeth are a different matter entirely.

I was very interested when I saw that the British Endodontic Society had carried out a survey of dentists. The survey found that 98% of dentists had experienced patients opting not to undergo root canal treatment, 42% because they felt it was too expensive. The only remedy for patients in this situation would be an extraction. I know that some patients, if the tooth is a molar, they are happy to have an extraction and a gap. Others are probably thinking that they will fill the gap that’s left behind with an implant. Ironically, the cost of replacing a missing tooth with an implant can be much higher than a root canal treatment.

When a patient has a root canal treatment carried out by me for the first time they are delighted that it isn’t the terrible experience they were anticipating. I use the Wand for delivering a local anaesthetic and this makes the treatment pain free.  They are also struck by how complex the procedure is. Once they have experienced two hours of my time, my dental nurse’s time and seen the equipment I use, they have an appreciation for the value of the dentistry that has saved the tooth.

If you are still trying to answer my question about the price you would put on a tooth, feel free to check out this website: www.savingteeth.co.uk

You may not be able to put a price on your tooth, but you will understand its value!

Just how devastating it was to have dental decay before the era of modern dentistry is forcefully illustrated by an exhibition at the British Museum called Ancient Lives, new discoveries. The exhibition focuses on the lives of eight people who lived in Egypt and Sudan over several centuries prior to and spanning the start of the Christian era. The bodies have either been embalmed or mummified. Thanks to advances in CT scanning, the bodies are delivering valuable information to researchers. (It’s extraordinary to think that the mummies are being transported to a hospital for scanning and that modern technology can deliver insights into bodies which are centuries old).

The exhibition curators share the information they have gleaned from the body, the grave and any objects the person was buried with. They are unable to tell us how any of them died. What they can tell us is the pathological conditions the people were suffering from.

The most common condition to emerge is dental disease. Four of the bodies – The man embalmed for the Afterlife, Tamut, the priest’s daughter, Padiament the temple doorkeeper and an unusual mummy from the Roman period – had dental abscesses and would have been in considerable discomfort. It’s possible that at least one of the people  - The man embalmed for the Afterlife – might have died as a result of the infection entering the bloodstream.

Why was decay a problem? They probably ate a lot of sugar and their molar teeth appear to have been worn down by a fibrous or gritty diet. All aspects of the exhibition are fascinating, especially the way the people worshipped and lived, but undoubtedly to me the most interesting aspect was the insight I got into the appalling burden of dental disease in Ancient civilisations. The exhibition is on until April 19^th . http://www.britishmuseum.org/whats_on/exhibitions/ancient_lives.aspx

© Trustees of the British Museum The image above is the skull of the British Museum’s Man embalmed for the Afterlife;  look carefully and below his lower front teeth you will see the hole in the jaw caused by dental abscesses

When I first started on the digital route, I had three aims. The first was to have a website, the second to achieve a paperless practice and the third was to support Gary Carr’s company, The Digital Office. It seemed simple, especially as The Digital Office – or TDO – provides a route to a paperless practice.

I don’t think I had a clear idea of what my practice would look like or the extent to which my website would be so important to my practice marketing. Or that I could be giving a lecture in Belgrade or in Berne or in Bonn and be able to use the TDO app on my iPhone to to call up a patient record and look at their notes and speak to their dentist. For someone who travels a lot, this is hugely reassuring.

At the end of 2014 we launched Rootipedia on this website  http://www.roottreatmentuk.com/html/rootipedia. A glossary of common endodontic and dental terminology, it was compiled as an online resource for patients but also intended to have an impact on website optimisation. Hundreds of people visited the website in response to the launch and I can tell which country they were in and exactly when they visited and which of the different communication platforms prompted their visit. This is so different to sending out a brochure!

Dentists who refer to the Harley Street Centre for Endodontics are given a log-in so they can access the records and images of their patients which can be viewed within 15 minutes of the patient’s appointment. The virtue of this is that my referring dentists are always in the picture and I like the respect that this demonstrates. Embracing the digital age has certainly brought some unexpected benefits.

The radiograph pictured here tells a painful story and could so easily have been avoided. The patient self referred to me because she was in much pain after a root canal treatment by her dentist. Her dentist initially advised extraction the tooth but, rightfully, she wanted it saved.

If you look at the radiograph you will see that two roots have been over-filled with the root canal filling material extruded from the end of the tooth. No surprise the patient was in pain. Each time she went back to her dentist, the pain level increased and she was put on another course of antibiotics – 4 course of antibiotics in total. I must stress that this is unusual and the dentists we work with are skilled clinicians who know when to treat and when to refer.
Sadly the tooth had a poor prognosis and the only solution was to extract it. What a shame and a waste. This tooth would have had an excellent prognosis if treated by the correct hands.
My advice to all patients offered a root canal treatment by their dentist – “Should I be referred to a Specialist Endodontist to do the root canal treatment?”. It may not always be practical, but at least you know that all avenues were explored before you said yes to the treatment.
In this instance, the dentist should definitely have referred the treatment rather than attempting it.
Not for the squeamish

The radiograph pictured here tells a painful story and could so easily have been avoided. The patient self referred to me because she was in much pain after a root canal treatment by her dentist. Her dentist initially advised extraction the tooth but, rightfully, she wanted it saved.

If you look at the radiograph you will see that two roots have been over-filled with the root canal filling material extruded from the end of the tooth. No surprise the patient was in pain. Each time she went back to her dentist, the pain level increased and she was put on another course of antibiotics – 4 course of antibiotics in total. I must stress that this is unusual and the dentists we work with are skilled clinicians who know when to treat and when to refer.
Sadly the tooth had a poor prognosis and the only solution was to extract it. What a shame and a waste. This tooth would have had an excellent prognosis if treated by the correct hands.
My advice to all patients offered a root canal treatment by their dentist – “Should I be referred to a Specialist Endodontist to do the root canal treatment?”. It may not always be practical, but at least you know that all avenues were explored before you said yes to the treatment.
In this instance, the dentist should definitely have referred the treatment rather than attempting it.

Imagine a time when it was considered revolutionary to hear a concert down a telephone line! This occurred in 1892 at the 13^th British Dental Association (BDA) conference in Manchester, courtesy of the National Telephone Company.

I have this information on good authority from the BDA Museum which had a stand at the 2014 BDA conference, also in Manchester. Some 200 delegates went to the 1892 meeting. Apparently one of the highlights was a discussion about the extraction of first permanent molars. The majority of delegates  concluded that “extraction should be avoided if possible unless the teeth were unsaveable.”

How interesting that 122 years later there is a Saving Teeth Awareness Campaign which highlights how important it is for teeth to be saved: www.savingteeth.co.uk

When it comes to technology, however, times have certainly changed. At the 2014 meeting the range of equipment and technology was staggering. Meanwhile, one of the highlights of the 1892 BDA meeting was the application of electricity to dentistry!

Not so long ago, it was predicted that with the advent of fluoride toothpaste and improved care of our teeth, dentists would become redundant.  But those predictions proved wrong, very wrong. Not only do we have more dentists in the UK than 20 years ago, but there are new conditions emerging for the profession to contend with.

One of those conditions is tooth wear. The causes are multi-factorial. Teeth can be worn down by grinding or clenching, known as bruxism, a feature of stress; or by acids in the diet or from acid reflux due to a health problem or bulimia; or thirdly, through abrasion from a coarse diet or vigorous tooth-brushing. More often than not, it’s from a combination of two or even three of those factors.

My colleague Professor Andrew Eder is an authority on tooth wear and I’m full of admiration for the work he is doing to raise awareness of the condition.

I ask him if it’s possible that the increase in tooth wear can be reversed?   He tells me it’s unlikely, since stress is almost unavoidable. Furthermore, erosion is also associated with modern lifestyles and high standards of living and is seen in people who drink a lot of wine, have unusual diets or are dedicated athletes.

All we can do is make sure our patients understand how they can keep the impact of tooth wear to a minimum, which is exactly what Professor Eder and the London Tooth Wear Centre^® are doing.

In the world of medicine, a specialist appointment for a complex medical problem is a regular part of the treatment pathway. As patients, we positively welcome the moment the GP says he or she thinks we should be referred to see a specialist to help diagnose and treat the condition that cannot be resolved in primary care. At no time is there any charge for these appointments – unless you choose to see a specialist privately.

In dentistry, also available as an NHS treatment, but for which the majority of patients pay a fee, the boundaries between general practice and specialist practice are not so clear. Nor is there the same level of specialist care available to NHS dental patients. If you are an adult patient who needs endodontic treatment, for instance, and your dentist says you need to see a specialist, it’s difficult to find a specialist who will treat you as an NHS patient. You might find an endodontist in a hospital to whom you can be referred, but the risk is that you won’t reach the top of the waiting list in time for your tooth to be saved. Medicine and dentistry overlap, but they are still worlds apart.

In the world of audiology, an entirely different system prevails. If you are hard of hearing, it’s possible to be referred to a hospital specialist and then supplied with a hearing aid and batteries, all courtesy of the NHS, with no charge at all.

How has it arisen that we must pay a fee for a crown, for instance, which will save our tooth, but not for a hearing aid? It’s often said that we are more likely to value what we pay for, but many British people are still indifferent to the value of their teeth, despite having to pay for treatment.

Having said all of this, I do notice a sea change. More patients are coming to see me saying they have put their endodontic treatment before a holiday or other indulgence. The heavy metal generation, those whose teeth will need life long maintenance, don’t want to be like their parents, with the glass beside the bed to hold their dentures overnight.

This is very welcome. But I would still like to see all the different health arenas dealt with more equitably – wouldn’t you?