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Endodontic Advancements: How Leading Technologies Help Transform Endodontic Treatment Options by Jeffrey Krupp

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by Jeffrey Krupp

Dentistry continues to evolve as a health science, and numerous aspects of practice are not the same since we went to dental school.

Change affects our world. Change has also applied itself to endodontic therapeutics, allowing for improvements developed by the mechanism of evidence-based research. The result has been enhanced treatment outcomes for our patients.

Advancements of obturation materials, visibility, metallurgy, file design, and ultrasonic utilization, as well as our improved ability to scan—further visualizing diagnostic services—have all dramatically improved our armamentarium to render endodontic treatment. Technological progression in the field of endodontics can be labeled either incremental or exponential.

Small steps
Incremental advancements, for example, include improved NiTi file designs, which are annually introduced to the dental market.

Endodontics saw the introduction of NiTi instruments in the early 1990s. Metallurgical advances and modifications, and recommended formatting of these various NiTi instrument series will continue to develop. Instrument taper, flute design, rotation modifications, file sequencing, and most recently, heat treatments, have all affected the instrument flexibility, cyclic fatigue, and manufacturer file progression recommendations.

Endodontics continues to develop, blending the widespread integration of magnification with improved NiTi rotary instrumentation. As magnification has become more ubiquitous, an endodontic dialogue has evolved that promotes a conservative endodontic preparation, labeled by some clinicians as "minimally invasive endodontics."1

The advocates for a minimally invasive preparation have established an inquiry against a significant volume of studies. These advocates cite a need for significant canal preparation, allowing for deeper irrigation, which provides for enhanced apical canal debridement and disinfection.2, 3

Presently, there are no established protocols for the technique that constitutes a minimally invasive endodontic procedure.4

However, a number of rotary-file systems geared toward dentinal conversation are on the market today: file systems like the V-Taper (SS White), Endo-EZE AET (Ultradent), and TRUShape 3D Conforming Files (DENTSPLY International).

Giant leaps
The introduction of the dental microscope and CBCT are examples of exponential technologies that have improved the quality of treatment planning and diagnosis in endodontics.

Exponential technological improvements to enhance visualization have been afforded to endodontics with the incorporation of the surgical operating microscope. The microscope's ability to vastly improve magnification benefits from the added improvement of site-specific lighting by means of halogen, xenon, and LED illumination. LED lighting has now become standard.

The clinician's ability to pair improved magnification with superior lighting allows him or her to address many conventional endodontic challenges. With more predictability comes the higher probability to dismantle retreatment cases.

Our ability to disassemble retreatment cases, removing posts and other obstructions by means of ultrasonic instruments—partnered with magnification—has dramatically reduced the need for more invasive periradicular surgery.

More improvements
Another advancement within the field of endodontics is in obturation choices.

Bioceramic obturation materials are gaining acceptance as root-canal filling material. The term "bioceramics" describes a biocompatible ceramic material, appropriate for biomedical or dental use.

A new calcium silicate, calcium phosphate product—marketed as EndoSequence BC sealer and root repair material (Brasseler USA)—has demonstrated improved handling characteristics compared with earlier-generation materials that had already demonstrated substantial clinical success. The system involves the use of a bioceramic sealer, and chemically coated gutta percha points. The biosilicate sealer has a number of clinically valuable characteristics. Being hydrophilic, it pulls water from dentinal tubules, establishes a high antimicrobial pH, and swells slightly upon set.5

The manufacturer states that its sealer "utilizes the moisture naturally present in the dentinal tubules to initiate its setting reaction." Bioceramic sealer forms hydroxyapatite upon setting, and chemically bonds to both dentin and to the bioceramic gutta percha points. A possible explanation for the high amount of Ca+2 released by bioceramic cements could be associated with setting reactions, including hydration reactions of calcium silicates.

Another potentially exciting exponential development in the overall quality of root-canal treatments comes from Sonendo.

The GentleWave System (Fig. 1) was launched on a selective-market release. The extensive research and the outcomes of thousands of clinical cases completed to date certainly seem to qualify this technology as an exponential advancement in the field of endodontics.6



The success of root-canal treatments performed with the GentleWave System can be attributed to superior cleaning of tissue debris, bacteria, and biofilm even from complex anatomical areas, when compared to conventional treatments.7, 8

The GentleWave System incorporates a patented "Multisonic Ultracleaning" technology with advanced fluid dynamics and chemistry of the treatment fluids.9 The GentleWave System consists of a console and a sterile, single-patient-use treatment instrument. A stream of treatment fluids is delivered from the tip of the treatment instrument into the pulp chamber.

Simultaneously, excess fluid is removed from the pulp chamber by built-in vented suction, drawn through the treatment instrument, and deposited into a waste canister inside the console. Upon initiation of flow through the tip of the treatment instrument, the stream of the treatment fluid interacts with the stationary fluid inside the pulp chamber, creating a strong shear force that causes hydrodynamic cavitation in the form of a cavitation cloud.

The continuous formation and implosion of thousands of microbubbles inside the cavitation cloud generates an acoustic field with a broadband frequency spectrum that travels through the fluid into the entire root-canal system.

Also, the GentleWave System may maintain a higher degree of structural integrity than conventional endodontic devices, as it requires less root-canal shaping (Figs. 2A and 2B).

Another recent exponential endodontic development has been established by the use of cone-beam computed tomography (CBCT). This technology has migrated into the dental diagnostics environment and become commonplace in the endodontic office.

The clinician can now acquire and evaluate a case in three dimensions, revealing a tremendous amount of diagnostic information. CBCT has been specifically designed to produce undistorted three-dimensional information of the maxillofacial skeleton, including the teeth and their surrounding tissues, using a substantially lower effective radiation dose than conventional computed tomography.

CBCT does not replace conventional dental radiography.10 Yet with indicated cone-beam imaging, the clinician can offer a proven indispensable tool in a multidisciplinary approach to patient care in endodontics (Figs. 3-6).



Unchanged
Of course, many things in endodontics do not—and will not—require any changes, as they remain foundational to our profession. I will mention three cornerstone concepts, although there could undoubtedly be more. The keystone of these principles applies to the healing arts in general: First, do no harm, or primum non nocere.

Applying this principle to endodontic therapy obligates the clinician to hold off from definitive treatment until reproducible signs and symptoms can be duplicated chairside. We must be as sure as possible, clinically, that pulpal removal will enhance the oral condition of the patient. This concept blends into conservative diagnosis—a treatment concept that will not change over time.

Another endodontic concept that will not change is patient comfort. For example, has the area to be treated received adequate anesthesia? Has the apprehensive patient been adequately treated, if necessary, with anxiolytic protocols? We want to reinforce patient comfort for an overall positive treatment outcome.

A third treatment concept that also will not change over time is the trust our patients place in us to provide professional quality treatment. The patient places his or her dental treatment in our hands, which makes a strong pledge and corresponding expectation of our professionalism.

Conclusion
Dental professionals are blessed with the ability to enhance our services through innovative improvements in materials, methods, and treatment protocols. Change will naturally present us with wonderful opportunities for dental advancement. As professionals, we are obligated to integrate them into our treatment modalities. At the same time, there are also significant aspects of our profession that will never change as we move through our professional careers.

References
  1. Murdoch-Kinch C A, McLean M E. Minimally invasive dentistry. J Am Dent Assoc 2003; 134: 87–95.
  2. Weiger R, Bartha T, Kalwitzki M, Löst C. A clinical method to determine the optimal apical preparation size. Part I. Oral Surg Oral Med Oral Pathol Oral
  3. Shuping G, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel- titanium rotary instrumentation and various medications. J Endod 2000; 26: 751–755.
  4. Clark D, Khademi J A. Case studies in modern molar?endodontic access and directed dentin conservation. 49. Dent Clin North Am 2010; 54:249–273.
  5. Zhang H, et al. Antibacterial activity of endodontic sealers by modified direct contact test against enterooccus faecalis. JOE. 2009; 35(7): 1051-5
  6. Sigurdsson A, Khang TL, Woo SM, Rassoulian SA, McLachlan K, Abbassi F, Garland RW. Six-month healing success rates after endodontic treatment using the novel GentleWave™ System: the PURE prospective multi-center clinical study. J Clin Exp Dent. In Press. 2016.
  7. Molina B, Glickman GN, Vandrangi P, Khakpour M. Histological evaluation of root canal debridement of human molars using the GentleWave™ System. J Endod. 2015; 41: 1701-5.
  8. Vandrangi P and Basrani B. Multisonic ultracleaning in molars with the GentleWave System. Oral Health. 2015: 105:72-86.
  9. Charara K, Friedman S, Sherman A, Kishen A, Malkhassian G, Khakpour M, Basrani B. Assessment of apical extrusion during root canal procedure with the novel GentleWave System in a simulated apical environment. J Endod. In Press. 2016.
  10. The SEDENTEXCT project. Radiation Protection: Cone Beam CT for Dental and Maxillofacial Radiology. Provisional Guidelines (v1.1 May 2009). sedentexct.eu/system/files/sedentexct_project_provisional_guidelines.pdf. Accessed on October 26, 2010.


Dr. Jeffrey Krupp, a board-certified diplomate of the American Association of Endodontics, has been in full-time endodontic practice for more than 33 years in San Jose, California. He earned a DDS degree at UCLA dental school 1979 and received his postgraduate endodontic certificate and MS at Marquette University 1982. His passionate interest in education has been the energy behind his teaching program, Success in Endodontics.com. View Dr. Krupp's online CE course "Success in Endodontics" on Dentaltown.com.


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