Vol. 112 No. 1 July 2011

EDITORIAL

Are we doing enough?

This will be my last editorial in this journal, because Irecently relinquished my role as the Endodontologysection editor. I have enjoyed this role immensely, andI have seen the growth of the endodontology knowl-edge base at first hand. During the �10 years I haveserved in this role I have experienced an astonishingincrease of manuscript submissions. Endodontology re-search is no longer limited to a few countries but isbecoming increasingly spread to all corners of theworld. However, as the research interest in endodon-tology is increasing, endodontic preservation of teeth indental practice is under increased scrutiny and ques-tioning by many interests but especially those of themore lucrative dental implant craze. I believe we are ata crossroads and that we need to carefully evaluatewhere we have been and where we are heading. Criticalanalysis is now important, so that we can together forma successful plan for the future.

I regularly receive manuscripts on cross-sectionaloutcome studies of endodontic treatment from variouscountries or population groups. These studies reportresults which are, in most cases, depressingly similar.They show that residual disease after endodontic treat-ment, in general population groups, is high. Any waythat we look at these results, the numbers of untowardoutcome in general practice is unacceptable if we com-pare the frequency with results from controlled out-come studies. A year after treatment of endodonticcases with uncomplicated pulpal diseases, the resultshould be highly predictable and successful. Some en-dodontists like to put forward insurance data to showhow rosy the endodontic picture is. Unfortunately, in-surance data tells nothing about residual disease, onlyretention. In addition, there are many reliability ques-tions involved with insurance data mining. Therefore, itdoes not change the disease information obtained frommore detailed studies.

Why are we in this embarrassing situation in a dis-cipline that in scientific journals normally reports a high

rate of healing (success)? Advances in recent years

have mostly been associated with instrument designand materials, which has resulted in improvementswhere the treatment can be delivered with less patientsuffering in a shorter time period. There is little evi-dence, however, that the treatment outcome is signifi-cantly enhanced.

We have through objective research assembled es-sential factors for a successful endodontic treatment.However, all this essential information has been lost inthe transfer to the treatment room where our entireendodontic knowledge base has been brutally collapsedinto an expedient process, all too often, called “doing aroot canal.” The literature tells us that the treatment ofa tooth diagnosed with a vital and inflamed pulp (pul-pitis) has a significantly higher rate of success com-pared with teeth with pulp space infection and periapi-cal disease. In the first case the treatment should focuson asepsis, whereas the latter diagnosis requires a focuson antisepsis. Real life is not that clear-cut, and allkinds of variations exist in between. Despite thisknowledge, most dentists use only 1 treatment modalityor diagnosis, superficially known as “doing a root ca-nal.” This is not surprising, because most pre- andpostdoctoral teaching programs fail to make a distinc-tion between the various pulpal diseases and their op-timal treatment. This is a practice which is also fur-thered by the American Dental Association/AmericanAssociation of Endodontists (AAE) insurance codes,which make no distinction for treatments of various teethwith simple or complex pathology. It is a travesty thatgraduates of higher education, dentists/endodontists, areunable or unwilling to differentiate between the 2 treat-ment concepts limited to just 2 fundamentally differentdiseases. This result provides an environment where thescience-based treatment of a disease takes a back seat toa mechanical procedure (“doing a root canal”).

Is there a fix to this very severe problem of poorendodontic treatments in dental practice resulting in ahigh number of unfavorable treatment outcomes? Yes,

but not until the specialists (and their organizations)

1

OOOOE2 July 2011

and educators of the endodontology field seriouslychange their approach to endodontic education, at bothpre- and postdoctoral levels. The trend has too longbeen downward to mediocrity. We must therefore takecharge and first accept that at most dental schools in theUSA (and probably the world), the dental graduate hasinsufficient endodontic case experience to be a safeindependent beginner. The experience required to grad-uate has continually been lowered to a level where eventhe best student lacks minimal competency, any waythat we define it. Although a poor excuse, lack ofsuitable patient material is often used by administratorsas an explanation to this phenomenon. Thus, the classicclinical teaching model is no longer working and mustbe modified to allow for a higher patient throughputsatisfying the needed flow of cases. An endodonticprocedure is irreversible and more complex than arestoration with amalgam or resin composite. Still, theendodontic educator appears satisfied with a graduate’ssingle-digit case experience when the restorative den-tistry educator often requires triple-digit case experi-ence for graduation. The schools’ curricula also oftenseverely limit the didactic time to a level where tech-nique gets the majority of time and the understanding ofpathology, microbiology, and treatment objectives areminimized.

These topics are also often missing in postgraduateteaching programs, especially in large 2-year programs.The subjects are taught, but the facts are rarely prac-ticed. Is the treatment protocol regularly modified ow-ing to pulp or periradicular diagnosis? Is biopsy mate-rial regularly discussed at light-microscopic levels? Isasepsis systematically taught by using microbiologictechniques? Is antiseptic success regularly tested by asimple culturing technique or systematic multiyear fol-low-ups? These are simple teaching techniques thathelp the student’s understanding and demonstrate facts.Instead the specialist-to-be reads endless number ofpapers on these subjects, and the facts often enter oneear and leave the other without much mental retention.In microbiology, the postgraduate student reads andlearns to regurgitate hundreds of bacterial strains andmolecular mediators without much understanding of

what it means clinically, if anything. We seem to be

mostly infatuated with high-tech toys and tissue-engi-neering biology while forgetting the basics. I am old-fashioned enough to believe that it is now time to returnto a solid teaching base and by rigorous follow-upsmake sure that the graduates have a good intellectualunderstanding of the objectives of endodontic treat-ment. That requires hard-working dental school teach-ers and program directors, solidly supported by thelocal community of endodontic specialists and theirnational organizations (AAE). The quality of endodon-tic treatment in general practice must improve, or thescope of cases should be restricted to simple vital pulptreatment. These changes are necessary to enhance thestanding of endodontic treatment as a valuable therapyoption. Endodontic treatment is highly successful ifexecuted in the right way. Only by solid efforts by allof us and by abandoning “social promotion” of stu-dents/trainees can the trend be changed and lead to anacceptable competency.

I hear much too often from my specialist friends howgeneral dentists do unsatisfactory endodontic treat-ments requiring retreatments or repairs by specialists.However, we have ourselves created this situation byignoring the predoctoral programs and focusing all ourefforts on postdoctoral education. To remedy this seri-ous deficiency is everyone’s responsibility and must beshared by “town and gown.” Therefore, the specialistorganizations, such as AAE, must look beyond theirparochial interest and politics and truly get engaged inthe process of high-quality endodontic education at alllevels. This will be a very heavy chore and may requireorganizational changes. Not until basic endodontictreatment of the general public is performed at anoptimal level, and therefore highly successfully, willthe speciality flourish again.

Thank you for listening to me a last time. As always,I have enjoyed the opportunity to share my thoughtswith you.

Larz S.W. Spångberg, DDS, PhDSection Editor, Endodontology

doi:10.1016/j.tripleo.2011.04.002