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.

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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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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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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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.


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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If an endodontic problem is invisible to the human eye, as many are, the case is doomed to failure


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.

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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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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.”



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