CBCT and Other Advances Are Improving Endodontic Success

Brooke Blicher, DMD, is a board-certified endodontist who is deeply involved in teaching, research, and mentorship. She holds positions as an assistant clinical professor in the department of endodontics at the Tufts University School of Dental Medicine and a clinical instructor in the department of restorative dentistry and biomaterials science at the Harvard School of Dental Medicine. In addition to teaching and lecturing, Blicher has published extensively on endodontics, particularly in the area of diagnosing and treating painful conditions and root resorption. She recently took a break from providing care at her practice, Upper Valley Endodontics, in White River Junction, Vermont, to speak with Inside Dentistry about various aspects of endodontic care.

Inside Dentistry (ID): With research providing a better understanding of the limitations of implants and the current trend toward minimally invasive treatment, is saving teeth with endodontics seeing a resurgence in the profession?

Brooke Blicher, DMD (BB): In my practice and community, I have seen the pendulum shift back toward saving teeth, despite the popularization of extractions and implants in recent years. Implants are not without risk, and as they exist in the mouth for many years, they require maintenance and restorative replacement-even in successful cases. As a result, many of my surgeons have become my best referrers, sending patients our way to save teeth that were initially planned for extraction.

Although it might seem like a cynical perspective, in many ways, dentistry serves to simply slow the natural deterioration of patients' dentitions as they age. Accordingly, the idea of holding on to teeth as for as long as possible and reserving extraction and implant placement as a later-stage alternative supports the natural progression of a patient's dentition, similar to the way that orthopedic surgery for diseased or injured joints is staged from repairs to replacements-and even revision replacements.

(ID): Cone-beam computed tomography (CBCT) is revolutionizing diagnostics and treatment planning across the specialties and even in restorative dentistry. How is it being used in endodontics to improve patient outcomes?

(BB): We have been using CBCT imaging in our practice for a little longer than a decade, and during this time, we have seen the technology revolutionize diagnostics and treatment delivery. We have learned that the sensitivity of these images allows us to diagnose pathoses in early, subclinical stages and that the technology picks up incidental findings so commonly that it changes diagnosis and treatment planning in the majority of cases. This improved diagnostic accuracy lets us be more selective in the cases that we take on, giving us the ability to selectively treat the cases with expected high rates of success and not treat those with factors, including subclinical resorption and fractures, that would negatively impact success.

Beyond improving our case selection, CBCT imaging impacts our ability to deliver the highest quality care by serving as a roadmap for treatment. It allows us to be more thoughtful in our treatments without subjecting patients to the invasive, exploratory procedures of years' past. There is nothing like knowing the number of canals and their locations prior to accessing a tooth, and in so doing, ensuring that we treat the anatomy completely. For previously treated teeth, utilizing CBCT results in huge benefits in our ability to correct previously missed anatomy or address surgical cases more completely.

(ID): Endodontic instrumentation has come a long way since the invention of the first manual files. What advancements are making the biggest impact on clinical endodontics, and how are clinicians and patients benefiting from these advancements?

(BB): The breadth and variety of nickel titanium rotary instruments on the market these days allows clinicians to take a really tailored approach to effectively and efficiently treating canal anatomy. I find the more modern rotary instruments to be more flexible and fracture-resistant than earlier iterations. They clean and shape the canals in a way that follows the natural anatomy, ensuring that I've removed all of or, more realistically, the majority of the problematic tissues. Newer instruments have narrower tapers, which facilitate greater conservation of cervical dentin, and early research shows that this is greatly impactful regarding improving fracture resistance. Ultrasonics also ensure that we can keep preparations conservative while accessing and cleaning all anatomy, resulting in greater symptom relief in the short term and success in the longer term.

(ID): Another key aspect of endodontic treatment is canal irrigation and disinfection. How important is disinfection, and how have approaches to disinfection changed to benefit both patients and clinicians?

(BB): Recent studies have shown that irrigation is perhaps even more important than instrumentation-our endodontic files simply help the irrigants gain access to the full extent of the canal anatomy. Because our instruments are unable to touch all of the walls of complex root canal systems, our irrigants need to do the work of debridement as well as disinfection. Although research supports that our longstanding irrigation mainstays, such as sodium hypochlorite, remain the most effective, it has also demonstrated that they are even more successful in accessing complex canal anatomy when activated. Even simple means of irrigant activation, such as ultrasonic and sonic devices, work well to bring irrigants in contact with a greater volume of tissue, and that contact is what makes the difference in their ability to dissolve and disinfect. Appropriate tissue removal and disinfection are key components in resolving the sources of endodontic infection and pain.

(ID): Once a canal has been shaped and disinfected, there are a variety of obturating and filling materials, cements, sealers, and other products available to complete the therapy. What recent advancements in endodontic materials are helping to improve outcomes?

(BB): Although I am excited by some of the advancements in sealers that show promise in biocompatibility, as of yet, none of the data indicates that these are better than other current options. But options are a good thing, and research is ongoing. That being said, some seemingly simple and obvious things, such as placing intraorifice barriers over obturation materials and ensuring that we're using the heartiest and most leak-proof temporary restorative materials, can make a big difference in fighting off perhaps the most common (and preventable!) reason for endodontic failure-coronal leakage. We incorporate several products in our practice with resin-modified glass-ionomer components for both of these purposes, with a marked difference in expected success by keeping saliva recontamination out of the picture.

(ID): What do you think the future of endodontics will look like, and what technologies or protocols currently being researched do you feel will have a significant impact on it?

(BB): As impactful as it already is, CBCT imaging also has great potential to help us develop guides for nonsurgical and surgical endodontics. I anticipate that, sometime in the near future, we'll have the technology to guide us to MB2 canals because it simply requires making the connection to the already readily available images.

I'm curious about how AI will impact endodontics. Throughout dentistry, AI has tremendous potential in helping with documentation and diagnosis, particularly when applied to radiographs. I'm not sure what this will look like on a day-to-day basis, but I do see this technology becoming a component of endodontic practice because ours is a specialty that is particularly adept at adopting new technologies.

Beyond that, I also see materials science as a place for growth in endodontics. Bioceramics have already made their mark in our field as the gold standard for perforation repair and apical surgery and will no doubt find greater applications.