Endodontic Treatment Past and Present

Alan Halls

“Are there any other options?” It is a common phrase in the dental office, one that asks the practitioner to not
only evaluate the clinical implications of treatment, but to actually place themselves in the place of the patient
asking them to make the best choice in an area of their expertise. Taking into account the full extent of the
patients situation, it is up to the dentist to make the best recommendation they are able to provide.

Having been the happy recipient of 6 root canals one of them twice as I am one of the lucky 70% of the
population with 4 canals in the maxillary first molari, I confess to being that patient asking if I really needed it,
not because of a lack of desire for the pain to go away, but more than that, I was poor, living on my own
without the ability to afford the true cost of the root canal. Luckily the dentist with whom I was with knew the
value of a tooth and was able to save each tooth for me. The experience of having someone treat me in such a
way was one of the motivating factors for my desire to go into dentistry and I will always have a soft spot in
my heart for the patient who is in pain, low on funds and would like to save their teeth. Luckily many patients
are also seeing the importance of maintaining the esthetics of a healthy smile and wish to save it either through
endodontic therapy or implants.ii

In the past, endodontic therapy was performed using K-files modeled after the Kerr brand, unfortunately the
files were being produced by many manufactures without a strict standard by which they were produced.1
Thankfully this has been resolved as manufactures have standardized the tapers and lengths. In addition to
standardizing, they have also released many improvements to the materials the files are made from as they have
also advanced from hand instrumentation to powered rotary tools.

One of the major advancements is in the usage of NiTi alloys in the production of the files. The advantages of
NiTi alloy are twofold, number one is super elasticity and resistance to fatigue which make them ideal for
curved root canals where stainless which have also reduced problems such as blockages, ledges, perforations.iii
EDTA and Sodium Hypochlorite used as lubricants also act as chelating agents which assist the practitioner in
removing the smear layer, and removing obstructionsiv. Also it makes an ideal material to be used with
powered instruments which has reduced the patients time in the chair. It has also changed the procedure from a
step back approach where the tooth was first instrumented to the apex and slowly enlarged from the apex
towards the occlusal to a top down approach which is done the other way.

As the understanding of the pathology of the disease also became better known, it has changed the way in
which teeth were cared for going from extractions in the past to endodontic therapy or implants today. It has
also led to usage of a rubber dam to be the standard of care to assure isolation. Unfortunately even though the
importance of a rubber dam is known, it is much more common for an endodontist (92%) to utilize one than a
general dentist (59%). v. There are many new tools being created for those in the field but it is up to the dentist /
endodontist to do the research to be sure that they are truly acting in the interests of the patient and not simply
accelerating the procedure and to also keep up on the advantages of new techniques such as the rubber dam to
provide excellent service.

While working in a sterile manner is ideal, you also have to deal with the bacteria that are already present in the
canal and work to get rid of them. The current mainstream method is through instrumentation irrigation with an
antimicrobial solution with also acts as a lubricant for the files. Recent research however has shown that
bacteria are found to penetrate up to 1mm into dentin which poses a problem as the antimicrobial rinses only
penetrate 0.1mm, this results in a need to remove more tooth structure or find alternate technologies such as
lasers to fully eliminate the microbes.vi Lasers offer the combined advantage of removing the smear layer and
also killing microbes other methods are unable to achieve.
Silver is known to have antibacterial effects and it was to this end that endodontically treated teeth had silver
points placed in the canal which had been prepared. This treatment later was replaced by using a rubber called
Gutta Percha which was inserted, then heated to cause it to fill the canal completely in an effort to seal off the
apex from the flora of the oral cavity. This is the most common filling material used todayvii. Because teeth that
have had endodontic treatment performed become brittle with time, the next phase of treatment options include
glass ionomerviii, and resin based composites with the goal of adding structural support to the tooth from the
inside thereby increasing the long term survival of the tooth.

In answer to the question “Are there any other options?” I for one am very grateful for a caring dentist that
knew that once treated properly I would have many years of trouble free use out of my own teeth and that
choosing endodontic treatment saved me almost 50% the cost of an implant.ix A study of 1.4 million
endodontic procedures revealed that 97 percent were successful after eight years.x While it isn’t exactly
cosmetic dentistry to the patient it will seem that way if they can keep their teeth in function and the dentist can
not only resolve the pain, but be a hero with successful therapy. There are other options available, but it would
be advantageous to the patient to not simply push them into implants but to offer this as a first option if
appropriate.
i
Hartwell G, Appelstein C, Lyons W, Guzek M. The incidence of four canals in maxillary first molars A clinical
determination. J Am Dent Assoc 2007;138;1344-134
ii
Ingle J. Ingle's Endodontics - 6th Ed. (2008)

iii
Hargreaves K, Cohen S. Pathways of the Pulp p295
iv

O’Brian W. Dental Materials and Their Selection - 4th Ed. (2008) Chapter 22
v

WHITTEN B, GARDINER D, JEANSONNE G, LEMON R. CURRENT TRENDS IN

ENDODONTICTREATMENT: REPORT OF A NATIONAL SURVEY. J Am Dent Assoc 1996;127;1333-1341
vi

Schoop U, Goharkhay K, Klimscha J, Zagler M, Wernisch J, Georgopoulos A, Sperr W, Moritz A. The use of
the erbium, chromium:yttrium-scandium-gallium-garnet laser in endodontic treatment The results of an in vitro
study. J Am Dent Assoc 2007 138(7): 949-955
vii
Keles A, Köseoglu M. Dissolution of root canal sealers in EDTA and NaOCl solutions. J Am Dent Assoc
2009;140;74-79
viii
Torabinejad M. Endodontics Principals and Practice. 4th edition p307
ix

Christensen G. Implant therapy versus endodontic therapy. J Am Dent Assoc 2006 137(10): 1440-1443.
x
Ring J, Murray P, Namerow K, Moldauer I, Garcia-Godoy F. Removing root canal obturation materials A
comparison of rotary file systems and re-treatment agents. J Am Dent Assoc 2009;140;680-688