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.

“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.