Introducing a new treatment planning internship at the Academy of Advanced Endodontics

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Complex endodontics versus extraction – when a PA radiograph is simply not good enough.

In my recent FMC debate with Michael Norton entitled Endodontics versus Implants, I tried to highlight our inadequacy in decision-making and reaching what one would like to think would be a correct treatment plan, whether to root treat or extract a tooth. 

In Daniel Kahneman‘s new book Noise, the human frailty in decision-making is exposed. He draws attention to numerous examples of serious life-threatening flaws in this process. 

In this exploration of why people make bad judgements, Kahneman et al define two equivalent types of error. 

The average of error is bias, and the variability of error is noise. Bias can be understood, predicted and therefore reduced, or even eliminated from the system.  

Noise, however, is entirely random. It is far more difficult to deal with. It can be for example the reason why parole boards are more favourable to prisoners at hearings before lunch than after.  

Now we could dig deeper into how the authors suggest we should carry out decision-making using decision hygiene audits, algorithms and checklists to try and eliminate as much noise as possible.

We are working on defining this process as part of a future campaign to ‘save my tooth’. But at this point, I would like to focus on the very first stage of decision-making. And the fundamental step of objective data gathering.

Periapical radiographs

Unfortunately, in health diagnostics (and maybe particularly dentistry, the very poor cousin when it comes to medical technology), we are plagued with clinical tests that are subjective with relatively poor sensitivity and specificity.

It never fails to get a self-deprecating laugh from a knowing lecture audience when I compare the tests available to the high street optician to detect eye disease, with that used by general dentists (and specialist endodontists, for that matter) to detect pulp disease. 

We examine the surfaces of the tooth. We tap them, we freeze them. And some of us will electrocute them.

We also place a huge amount of faith and emphasis on a technology now over 120 years old – the periapical radiograph. 

I’ve lost count of the number of times patients will tell me their dentist took an X-ray. And then told them that there is nothing wrong. 

Simply stated, the sensitivity and specificity of two-dimensional intraoral radiography, the ability to detect the presence and absence of pulp and periapical disease, is severely limited. 

In some areas of the mouth, it is no more accurate than flipping a coin. 

And if we cannot see the disease to start with, how can we possibly evaluate the efficacy of our treatment?  

Ultra-low dose review

I am not saying that we cannot make a diagnosis with a periapical X-ray. But disease can be missed and importantly the aetiology of the disease is difficult to ascertain and can often only be guessed at.

Without discovering the cause-and-effect relationship to the disease process, treatment planning and prognosis is often hit and miss.  

Fortunately, things have moved on with the introduction of three-dimensional imaging.

Not only can we properly visualise the complexities of the root canal system, and render the pathology obvious, we can also calculate why it happens.

With this information treatment planning comes with a degree of accuracy in the prognosis. And where questions are still present it is possible to attempt the first stages of treatment and accurately check whether healing is taking place over a relatively short period of time.

This form of treatment we call the ultra-low dose review protocol (Figure 1). It requires skills in both reading and aligning CBCT scans.

Treatment planning internship

However, much of the profession seems trapped in a time warp. We’re still dependent on the two dimensional periapical to make important treatment planning decisions.

A decision to extract an ingenuously designed piece of chewing technology with internal and external biofeedback sensors and its own defence system; removed and replaced by a metal bollard screwed into the jaw on limited evidence. This is simply not in the best interests of our patients.  

We are only in the infancy of digital endodontics. New protocols, advances in treatment and improvements in the technology are introduced all the time. There are significant rewards for both practitioners and in particular patients who want to save their natural teeth. 

In the Academy of Advanced Endodontics, diagnosing and treatment planning complex endodontic problems is the cornerstone of our practice. It’s at the heart of everything we do.

Our Treatment Planning Internships help general dental practitioners, GDPs with a special interest in endodontics. We also train endodontists to learn and refine their skills in assessment and treatment planning in complex endodontics using three-dimensional imaging. 

The intern will attend 12 days of new patient and review clinics at the Academy over one year. They will work with us (me in particular), examining patients, taking scans, assessing and then treatment planning our referred patients.

This is a unique opportunity to understand and take part in the future of endodontic treatment and high-powered tooth saving.  

If you require any further information please email our practice manager, Joanne at joanne@endodontics.co.uk.

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