|Figure 1. Dr. John West’s teaching style combines comprehensive classroom education with practical and immediate hands-on application.|
Let’s talk about some of the current trends and future issues in endodontics. John, would you like to make some opening comments to set the stage for this interview?
Dr. West: That would be great, Damon. In endodontics, we have come to a moment of reckoning in diagnosis, treatment delivery, and treatment planning. The endodontists of the future—and the future of endodontics—are at the knee of the exponential curve of change. The only constant is change, and the future belongs to those who learn from the past and adapt to change in the future. American theologian Reinhold Niebuhr once wrote about change more poignantly and eloquently: “Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” My goals in giving this interview are twofold: (1) to offer wisdom, based on 35 years of clinical experience and teaching, regarding rapidly and dramatically changing trends in endodontics, and (2) to help readers anticipate and adapt to the changing world of endodontics and therefore succeed in being the endodontic clinicians of the future.
How has endodontics changed in the past 20 years?
Dr. West: There have been 4 major influential changes. First, technology and the prompt dissemination of endodontic information have transformed endodontics forever. Endodontics is now safer, more predictable, easier, and therefore more enjoyable for the dentist and the patient. It is also more profitable for the endodontic clinician and a sound investment for the patient. Second, including endodontics in an interdisciplinary approach to dentistry has become an essential part of a comprehensive treatment planning process by facilitating the endodontist’s invaluable contribution to predictable patient outcomes. Third, increased longevity means patients are living longer, and their desire to look good, feel good, and be healthy is more essential than ever before.
Fourth, the value of predictably treating and saving endodontically diseased teeth now rivals implant placement success rates. Throughout the duration of these 4 changes, the classic Endodontic Triad of “disinfection, preparation, and obturation” currently remains the proven protocol for long-term endodontic success. In the past 20 years, many new endodontic technologies have enabled dentists, who have understood and embraced these 4 changes, to improve all 3 domains of the Endodontic Triad.
At the 2016 Dentsply Sirona event, SIROWORLD, in Orlando, you were asked to present and represent endodontics in the gala opening ceremony. Your title was “Endodontics: From Dark to Dawn.” Can you tell us why you chose this theme, and how understanding it benefits our readers?
Dr. West: When you think about it, endodontics is the only dental discipline where we “do it in the dark.” Can you imagine cutting a crown prep, placing an implant, extracting a tooth, or simply taking a dental impression with your eyes closed? Well, that’s exactly what we do in endodontics. We cannot see and do simultaneously. We must rely on different feedback to assure the predictability of our radicular endodontic preparation and obturation.
In the last 2 decades, the following 6 endodontic technologies have allowed dentists to see what we could not see before:
1. Microscopes enable us to prepare a successful access cavity and find all the canals, as well as facilitate the diagnosis, such as observing hairline vertical fractures. The microscope brings the dentist closer to reality through a combination of illumination and magnification which in turn improves treatment planning. Dr. Gary Carr is often credited with pioneering this transformational trend.
2. Tooth Atlas (ehuman.com) offers interactive 3-D visualizations of real tooth root canal systems, and we can literally practice virtual endodontics before ever treating a patient.
3. Digital imaging helps us read images more clearly and in more detail.
4. Apex locators precisely identify the physiologic terminus.
5. Nickel-titanium (NiTi) endodontic shaping instruments have made mechanical shaping more predictable, safer, more efficient, and easier than ever before. With improved designs and metallurgy, almost all endodontic companies produce a satisfactory NiTi file, although some are higher quality and higher value than others.
6. 3-D CBCT permits dentists to “see” inside the patient’s tooth. As dentists, when we can see it, we can do it.
These 6 eye-opening technologies have brought endodontics out of the dark, giving dentists a new level of competency, consistency, and confidence. Seeing yields improved results, which is important because the endodontic clinicians of the future will no longer be reimbursed by procedure, but instead, by their capacity to deliver documented endodontic quality, value, and patient outcomes. This value-added care approach will be driven by performance management systems (such as c-sats.com). New reimbursement models represent a gigantic shift in determining the value of endodontic treatment rendered, and dentists’ procedural outcomes will be evaluated through social media, data analysis, cloud computing, gap analysis, and artificial intelligence.
|Figure 2. From coast to coast, professional endodontic training centers offer high level education for both restorative dentists and endodontists. (a) Dr. John West’s model for teaching endodontic mastery skills is simple: “Hear It, See It, Do it, Measure It, and Celebrate It!” New insights keep John’s education fresh and alive (ideausa.net). (b) Dr. Tom McClammy (far background) passionately teaches nonsurgical and surgical endodontics plus implant placement (horizondentalinstitute.com). (c) This video grab shows Drs. George Bruder and Sergio Kuttler teaching their hands-on cadaver program. The cadaver programs focus on nonsurgical, surgical, endodontic restorative, and digital imaging (idifl.com). (d) Dr. Cliff Ruddle’s “One-on-One” training accelerates peak personal performance and is conducted in the energetic, comfortable, and family-enriched environment in Cliff’s private office, as shown in this video grab. Dr. Ruddle knows exactly how to guide you toward your practice vision (endoruddle.com). (e) Dr. Steve Buchanan has always been ahead of his time. In this photo, he champions 3-D treatment imagery combined with 4-handed delivery (delendo.com).|
What do you see as the major trends in endodontics today? How did we get here, and where are we going?
Dr. West: First, advanced clinical technologies in conjunction with cutting-edge clinical education have made learning the time-tested Endodontic Triad possible and are available to any dentist who wants to learn and master them. The major new technology trends in the Endodontic Triad are as follows:
• Shaping with special heat-treated files (such as ProTaper Gold and WaveOne Gold [Dentsply Sirona]) to produce appropriately sized, minimally invasive, smooth-tapered walled preparations that were previously rare and often unattainable. Only enough dentin is removed to facilitate cleaning and develop a gentle funnel shape for easy obturation hydraulics.
• Obturation is trending toward precision, injection-molded micronized nanoflow gutta-percha as well as next-generation carrier-based obturation. The interface layer of master cone and root canal sealer will be first blurred and then eventually eliminated. Bonding obturation materials and techniques look promising but are without long-term proof of success.
Now for a moment, I invite you to use your wildest imagination. Given the increasing rate of dental and endodontic technology, in 10 to 15 years, we may well have a phone app or other device, a prescription pill, a vaccine, or a medicine to treat endodontic disease or even caries, the most widely prevalent malady in humans. Trends point to medical treatment versus surgical treatment of dental caries and, therefore, endodontics. Meanwhile, future regenerative tissue-engineered endodontic materials will involve “time-release growth factors” and will have “time-controlled resorbable” material matrix designs. Armed with these trends and potential, I took out my smartphone and asked: “When will tooth regeneration occur?” And the Web responded: “It already has.” We already have the science to grow teeth. Stay tuned! Meanwhile, back to the present…we have the tools to see and do endodontics with exceptional predictability, high profitability, and a sense of fulfillment that is the aspiration of all dentists. Are we fully taking advantage of this?
Second, mergers such as Dentsply and Sirona will ultimately benefit all of dentistry. Combining these 2 companies’ research and development has the capacity to support end-to-end clinical same-day solutions that advance patient care.
Third, acquisitions such as Sonendo acquiring the Pipstek laser company are defining the cutting edge of endodontic trends. The GentleWave System by Sonendo is a product of considerable research and development. Innovative companies and talent, in collaboration, will push technology even further, which will benefit all patients, endodontics, and dentistry itself.
The fourth trend in endodontics is how we market our practice. I define marketing simply as an “exchange of values,” as in dentists’ skills and education in exchange for the patient’s investment fee. Increase skills and you increase value.
What are the major challenges facing endodontics today?
Dr. West: “Shift happens!” Whenever there is change, there are challenges and opportunities. To me, change is either feared or adapted to and embraced. Again, change is the only constant. There are 3 major challenges facing endodontic change today: trivialization, endo versus implants, and group/corporate versus solo practice.
First, on trivialization, one endodontic company suggests you can retire early if you purchase their endodontic file, while another relentlessly suggests their file is twice as good as the competition for half the price. The next time an endodontic rep says this to you, ask that person to prove it! Endodontics is much more than a file—it is diagnosis; proper emergency care; interdisciplinary treatment planning; and finding, following, and finishing canals; as well as the restorative considerations of structure, function, biology, and aesthetics.
The second challenge is to answer the question of endo versus implants. The answer is simple. Dentists have discovered that if the root canal system can be predictably treated, which it can, and if the tooth has sufficient ferrule, dentists worldwide tell me that saving the tooth is desirable for the patient and the dentist, rather than removal and implant. We still love teeth!
The third challenge in endodontics is a broader challenge than how we do endodontics. It is a challenge of practice structure and infrastructure. Managed group practices continue to expand at a rate of 20% per year and solo practices contract at 7% per year. How endodontics and endodontists will fit into group and corporate practices is unknown.
What we know for sure is that all 3 challenging elements will have an impact. The old days of doing endodontic business are over.
What do you see as dentists’ greatest opportunity for the endodontic part of their practice in the next 5 to 10 years?
Dr. West: Restorative dentists perform 70% to 90% of endodontic treatment in the United States. Learning new endodontic skills, technologies, and techniques is the fastest way for dentists to further increase their predictability and productivity. With no lab costs, endodontics can be highly productive as well as highly satisfying.
Dentists who want to look professional and build the confidence of their patients always put their patients’ needs and interests first. The successful interdisciplinary dentists have learned, for example, to call in their endodontist for nonsurgical and surgical endodontic retreatments, challenging diagnoses, and/or patient pain, before it is too late. Creating iatrogenic blocks in endodontic preparations, ledges, transportations, perforations, and broken files is also too late. Our patients have granted us trust, and we must earn it one procedure at a time.
Are dentists evolving with endodontic technologies, techniques, and tools?
Dr. West: Dentists by nature are gadget people. For endodontics, the microscope was a breakthrough technology. It gave us a head start on dental technology before the word technology ever became popular. The new dentist and the dentist of the future are especially tuned into change. In fact, millennial dentists only know change, and that change is changing exponentially. Think about it. Humans and machines are evolving together. It is not humans versus machines; it is humans and machines.
Could you describe how you envision the evolving role of endodontics in interdisciplinary diagnosis and treatment planning?
Dr. West: The role of endodontics will expand and will be viewed with a confidence in endodontic predictability that has been proven. And we are getting even better! Instead of endodontics being considered the weakest or missing link in interdisciplinary treatment planning, it will be recognized as one of the strongest links. This endodontic optimism is the result of greater knowledge, mastered skills, and breakthrough technologies that make saving endodontic teeth more predictable, safer, and more cost-effective. The determinants of predictably successful endodontics have been demystified!
How does what you refer to as “the new endodontics” help the GP decide between endo treatment and an implant?
Dr. West: That’s simple! We are now able to predictably save endodontically diseased teeth that seemed previously hopeless. Complex and calcified anatomy or an underfilled root canal system used to be hopeless causes. If a dentist is willing to learn advanced technologies or has an endodontist as part of his/her interdisciplinary team, any endodontically diseased tooth has the capacity to be saved if the endodontic biology can be treated and the tooth is structurally restorable. Period. The question now is not endo versus implant; it is endo and implant. Both treatments have the same predictability. The question for the dentist to answer is which treatment option is more aesthetic, which is easier to restore, which is structurally more predictable, and which one makes the most economic sense for the patient.
Please update us on what’s new for dentists who want to learn the latest and most predictable endodontic concepts, technologies, and techniques. Short of a 2- or 3-year postgraduate endodontic program, what noteworthy educational sources are available?
Dr. West: Formal teaching centers, new media, and digital technology will transform and transcend endodontic education as we know it. Cohorts of newly and properly trained dentists, as well as endodontists, will receive training in leading-edge technologies and treatment planning (Figure 1). Dental school preparation, while providing information about less complex endodontic patients, simply cannot teach the level of education and training required by today’s aging and more technically challenging endodontic patients.
There are currently 5 significant endodontic training centers that are available for dentists and endodontists who desire to improve their endodontic skills: (1) Dr. John West, Interdisciplinary Dental Education Academy, San Francisco; (2) Dr. Tom McClammy, Horizon Dental Institute, Scottsdale, Ariz; (3) Drs. George Bruder and Sergio Kuttler, International Dental Institute, Palm Beach Gardens, Fla; (4) Dr. Cliff Ruddle, “One-on-One,” Santa Barbara, Calif; and (5) Dr. Steve Buchanan, Dental Education Laboratories, Santa Barbara, Calif (Figure 2). While training centers will surely continue to be relevant in the future, travel and ability to meet individual and global needs has logistic limitations.
You have achieved the pinnacle of success in endodontics as a clinician, leader, teacher, and inventor. What’s next for you?
Dr. West: I have always considered myself as a clinician whose value is measured by my level of performance, one patient at a time. Producing successful endodontic results has been a source of endless pleasure. And I am still learning! It has also been satisfying mentoring clinicians who yearn to personally achieve what’s possible for them and calls them to action. Like measuring endodontic performance one patient at a time, teaching both mechanical and thinking skills has been similarly accomplished one student and one audience at a time. This dissemination process, however, is too slow to keep up with change. Endodontic global learning and teaching, for the first time, will soon be instantaneously possible due to epic changes in multimedia platform.
There is a huge opportunity ahead that will change how we learn endodontics, do endodontics, implement endodontics, and how we have fun in the process. I am referring to my upcoming participation in a weekly webcast production called the EndoShow, soon to be launched. We believe it will change everything.
The EndoShow is the longtime aspiration of the quintessential endodontic teacher, Dr. Cliff Ruddle, who is respected and revered throughout the world. The show teaches the dentists, endodontic specialists, educators, and industry leaders worldwide how to master endodontics by offering insights that drive continuous improvement as well as teaching technical skills that impact outcomes. The show is about the endodontic clinician of the future and the future of endodontics. And the ultimate beneficiaries are the people who are not reading this article: our patients!
How is the EndoShow different from other endodontic education for dentists?
Dr. West: The EndoShow is now—present tense. It is relevant and unbiased. It makes the endodontic world better as it becomes better. Its purpose is to improve and raise the global endodontic standard. No red tape, no print delays, no outdated information. New dentists, seasoned dentists, and specialists will learn what works from the collaboration of not just the world’s leading endodontists, but also from industry, research, engineers, and endodontic visionaries worldwide.
How do you see the EndoShow being used by dentists in practice worldwide?
Dr. West: The show will serve as a reference, a source, and a forum for controversies and the pressing issues of our time, shaping the narrative of a constantly unfolding future, and a roadmap for not only endodontic success for their patients, but also success for themselves. The EndoShow will be a library that is a current and freshly updated endodontic resource founded on timeless endodontic principles as well as current and future trends and techniques. Specifically, the show will consist of interviews, controversies, forums, study clubs, hands-on demonstrations, dental assisting, all things interdisciplinary, and the business of endodontics. The show will be hearing and sharing what matters to you. It is a show that belongs to us all. You are invited to join us in the conversation and to celebrate what makes endodontics different. We are listening, and we need your voice.
In closing, thanks so much for your time and vast experience and expertise! Before we wrap this up, if you were to offer one piece of advice to dentists who want to know how learning about new endodontic trends could benefit their endodontics, what would it be?
Dr. West: Adapt to the changing trends, embrace the changing trends, and take action. Remember, a goal without a plan is only a wish!
Disclosure: Dr. West is co-inventor of ProTaper, Wave One, ProGlider, GoldGlider, and Calamus Technology (Dentsply Sirona).
Also By Dr. West