As the landscape of dentistry continues to change, many clinicians are reflecting on their current workflows, and the ways in which digital technology will impact their professional lives now and in the future. The field of endodontics is not untouched by the use of dental technology. As such, it is important to consider the fundamentals of diagnosis, case assessment, and treatment planning, and the ways in which digital tools may assist clinicians in these areas.
Diagnosis and case assessment
When establishing a diagnosis, it is important to use the correct clinical language. By getting the diagnostic terminology right, it is clear that a clinician has understood the aetiopathogenesis of the condition that’s present. As a consequence, the condition is far easier to treat, and you can anticipate a successful outcome as a result. This is especially important in clinical notes, as a patient’s notes must be a true and accurate reflection of the situation, and should inform any subsequent treatment. So, the use of language shows an understanding of the pathogenesis, allowing you to discuss the condition and its treatment with patients accordingly, ensuring that the diagnosis is right, and informing patient consent. In the increasingly medicolegal world in which we operate, we should record our notes using the correct terms, because it demonstrates a thorough understanding.
Clinicians should consider both the pulpal and periapical diagnosis, as some teeth will have both, whereas others may have mixed vitality – some might have apical infection without pulp necrosis. It is important to establish whether periapical disease or pulpal disease is present during the consent process as, generally, pulpal disease has a slightly better prognosis.[i] This is because, once a lesion has developed, periodontitis is a likely secondary factor.
By recording notes and discussing conditions with patients using the right terminology, it is clear to anyone reflecting on the case that you understand the disease you’re trying to treat. If the diagnosis is not properly identified to begin with, success becomes unlikely.
Case assessment and planning treatment in detail
Having arrived at a diagnosis, it’s time to move on to planning treatment in detail. Amongst other things, planning treatment involves deciding whether to treat or refer, whether to provide treatment in one or two visits, and whether to remove a restoration or not. It is encouraged to write a detailed plan, including timings to guide the entire journey. Breaking the appointment down into segments helps to use the time efficiently, allowing the clinician and the dental nurse to know when instruments and equipment are needed as treatment is sequential.
Case assessment is an essential aspect of planning treatment. Clinicians should consider the specifics of the case, including the canal curvature and techniques needed to treat it effectively, and what file system is needed. There are a number of case assessment tools available to help clinicians understand the difficulty of the situation by answering a series of questions. Medicolegally, a complexity assessment can help to support clinicians’ decisions to treat or refer.
Clinicians should not be afraid to refer cases which are outside of their expertise, or upskill to enable them to tackle more challenging cases. A large number of cases would not be expected to be undertaken in a general dental practice. Case assessments can help clinicians decide whether to refer cases which might present challenges, or be prone to complications. This can help practitioners to avoid wasting time in the practice, and depleting patients trust when preventable complications occur.
The use of digital tools in endodontics
The most impactful technological development in recent years has been CBCT imaging. Whilst it should not be used routinely, it should be employed when its findings will impact the treatment. For example, by taking a CBCT of a tooth with an unknown number of canals, you’re able to locate the canals first. As such, you don’t waste time removing dentine to try and find an additional canal which isn’t there. Additionally, the risk of missing a canal is reduced. Further to this, the canal morphology, number of canals, location, curvature, and length determination can be measured very accurately using CBCT.
Predictive AI is also a growing area of dentistry – this includes CBCT. This should be used with caution as programmes such as ‘metal artifact reduction’ technically alter the image, filling in the gaps. As such, it may not accurately represent what is really there.
Whilst it may be impossible to avoid dental AI going forward, the technology is not flawless yet. Currently, in order to get a large enough data set, clinicians must train the software. The technology is reproduceable, but it is not currently better than an experienced dentist. As such, clinicians can do better by using their skills, knowledge, and experience. However, for those who carry out very few root canal treatments, assistive technology can offer helpful guidance.
Author: Alyn Morgan
Alyn Morgan qualified from the University of Leeds School of Dentistry in 1995. He worked in general dental practice for 12 years and undertook his postgraduate training in Endodontics at the Eastman Dental Institute, where he was awarded an MSc with Distinction in 2009.
He worked as the Director of Endodontic CPD at the Eastman for several years and is currently Endodontic Teaching Lead at the Leeds Dental Institute, whilst maintaining a specialist endodontic practice at U Dentistry in Ilkley.
He has presented well over 200 hands-on courses in endodontics, lectured nationally and internationally as a keynote speaker at numerous conferences and study days and acted as a key opinion leader and adviser to several multi-national dental companies.
He is the immediate Past President of the British Endodontic Society, and the co-founder and CEO of a spin-out company from the University of Leeds, Mimetrik Solutions. The company develops innovative clinician-led solutions in the field of digital dentistry, and to date has attracted over £3.5m in grant funding and investment.
[i] Yong, D., and P. Cathro. “Conservative pulp therapy in the management of reversible and irreversible pulpitis.” Australian dental journal 66 (2021): S4-S14.
