Some Thoughts on Endodontics and Restorative Dentistry

Endodontics is without question intimately connected to full coverage restorative dentistry.  All practitioners know that endodontics is required for irreversible pulpitis or when teeth ae nonvital.  However, prophylactic endodontics is required to change the inclination of teeth in the arch or to completely alter the architecture of teeth.  When the pulp is not present, it is possible to create teeth that are ideal shape and form.  Nothing stands in the way of creating that ideal result.

When I started in practice, it became evident that doing in-house endodontics would save both the patient and the practitioner time and money. My techniques were rudimentary and I developed some experience in perforating root canals, breaking files and transporting portals of exit.  My father (my mentor for 23 years) saw tremendous value in educating me to do in-house endodontics for both my patients and his, so he sent me to take the series of endodontics courses with Dr. Herb Schilder at Boston University.  Dr. Schilder was truly one of the great pioneers in modern endodontics and I learned a great deal from him.  He was an amazing teacher.  From him I learned about the strange anatomy inside teeth—that root canals are “systems” with flutes and unseen portals of exit where tissue can hide rather than simple “canals” connected to a central pulp chamber.  I did many root canals in those days and most of them were successful, or seemed successful judging by the X-Rays.  However, some of these teeth actually blew up after 20 years of being asymptomatic.  As I discovered later, the unseen flutes and accessory canals harbored untreated tissue that lay dormant for many years before causing infection and failure of the root canal treatment.  Who knows what stimulated this tissue to suddenly cause trouble after so many years!

Not only was physical instrumentation of the unseen root canal system impossible, but irrigation with sodium hypochlorite of those areas also proved impossible.  In an attempt to  reach some of that anatomy, endodontists of the twentieth century believed that the canals should be widened except at their termini.

Naturally, these teeth were restored with posts because the canals were actually prepared for them!    However, the teeth were considerably weakened by the widening and the use of posts.  Many of these teeth eventually fractured under the forces they had to withstand.  Watching the loss of teeth that had undergone so much treatment in order to save them was truly heart-breaking.  During this era, implants were not widely used, so the loss of teeth was doubly heart-breaking.

In the early days of my career, I developed great skill making direct cast posts and placing prefabricated posts to restore nonvital teeth.  Both types of posts resulted in the same outcome, with many fracturing. Whenever bridgework failed, you could bet your bottom dollar that the posts came out with the restoration.  As a result, the ability of posts to “strengthen” roots and retain restorations was highly questionable.

My father and I treated some abutment teeth that supported bridgework where it was impossible to use buildups or posts to retain the restoration.  These cases worked!  The reason they worked is that all that is necessary to retain crowns and bridgework is the full shoulder, a good grip on the root (ferrule) and snug fit of the restoration on the preparation.  I soon realized that restoring teeth with posts and buildups was not only harmful to the abutment teeth, but a complete waste of time.  I have restored thousands of teeth flush with the gingiva that I did not buildup with posts or core materials.  These teeth can be restored with a high percentage of success without any type of buildup.  I have boxes of dies of teeth that I restored this way.  The ONWARD program is dedicated to teaching dentists these techniques.

Indeed, one of the saddest things to see in restorative dentistry is oversized crowns and bridges made on nonvital teeth.  With no pulp, nothing stands in the way of fabricating teeth to ideal shape and form; to make them smaller than the original teeth in order to apply less stress on the supporting structures.  It is my observation that oversized posts are quite common and the patient gets oversized dentistry in spite of root canal therapy. 

Endodontics is one area of dentistry that has made tremendous strides in addressing the strange anatomy inside teeth.  Almost all good endodontists have the microscope to see some of this anatomy.  There are also new techniques of addressing the unseen anatomy where tissue can hide.  These techniques require sophisticated and expensive equipment that is not cost effective for general practitioners who are not doing a lot of endodontic procedures.  I realized that I could never do endodontics to the new standard of care, so I stopped doing in-house endodontics. Because I only care about giving the best treatment to my patients, I was happy to refer the patients to endodontists who could treat them better than I ever could.

When I practiced dentistry in Scarsdale, NY, it was my great pleasure to send patients to Dr. Justin Kolnick and his associates in White Plains, NY.  Dr. Kolnick is one of the finest endodontists I have ever met and worked with. I am a huge fan of his!

I still wanted to learn as much as possible about endodontics even though I was no longer doing endodontic procedures.  The more you know, the more you can help your patients—even if only to get them into the right hands.   I signed up for Dr. Kolnick’s study groups in endodontics and in laser therapy.  Such great courses!  Dr. Kolnick is truly on the cutting edge with lasers in endodontics and pain management.

Laser Assisted endodontics involves the use of lasers to address the unseen anatomy in the root canal system.  Dr. Kolnick was able to retreat teeth that most practitioners would consider “hopeless” with amazing success.  He also found answers for patients who continued to experience endodontic pain for inexplicable reasons.  I watched Dr. Kolnick at work in his office on several occasions.  He is a true master.

From Dr. Kolnick I learned that the prevailing opinion in endodontics was to make the endodontic preparations narrower in order to conserve tooth structure and prevent fracture.  Laser-assisted endodontics made this opinion possible.  His line of thinking was completely in sync with my avoidance of post preparations to restore teeth.

When I started to practice dentistry in Arizona, I did not think I would ever find the same excellence in endodontics as I found with Dr. Kolnick.  However, it did not take me long to find out that are actually some excellent endodontists here in Arizona.

One day, I was looking to give lectures to local study groups on full coverage restorative dentistry.  I was sending emails to the officers of these groups introducing myself.  I came across the Horizon Dental Study Club here in Scottsdale and learned that it was an endodontic study group.  I do not know what possessed me to mention that I had taken all of Dr. Schilder’s courses, but those were the magic words.  The next day I received an invitation to attend Dr. Thomas McClammy’s course at the Horizion Dental Institute.  I was the only non-endodontist in attendance.

I was totally amazed by Dr. McClammy’s skill and expertise.  His course was fantastic!  Dr. McClammy has a laboratory teaching facility attached to his office with 10 endodontic microscopes.  He is an expert in the Gentle Wave Technique—which is an entirely different approach to addressing the strange anatomy inside the root canal system that can’t be reached physically.  The Gentle Wave works like a washing machine to send irrigants into the far reaches of the root canal system through negative pressure.  Dr. McClammy thoroughly covered the theory and practice of the Gentle Wave technique and then he demonstrated the technique on a live patient in his office.  Course attendees then went into the adjacent lab and performed the Gentle Wave technique on extracted teeth.  I saw the Gentle Wave work first-hand.  I was totally amazed at how well this technique worked!  As with laser technique, the Gentle Wave technique allows for the conservation of tooth structure because excessive widening of the canals to reach the hidden anatomy is not necessary.

It is now my pleasure to work both with Dr. McClammy and one of his excellent disciples Dr. Jason Setlock.  Dr McClammy has actually treated some very famous endodontists.   I always like to work with the best practitioners—not only because of their technical excellence, but also because there is much to be learned from them.  As I pointed out, Endodontics is very closely related to Full Coverage Restorative Dentistry.  The more knowledge in one area, the more patients can be helped in the other area.

Endodontists should be enamored of the techniques taught by the ONWARD program.  These techniques minimize the loss of teeth from iatrogenic restorative procedures.  I am sure that all endodontists have personally witnessed their successfully treated teeth destroyed from the use of posts.   This sad occurrence is all too common.   It is my hope that the dental profession will one day embrace the ONWARD techniques and mainstream them.

The current philosophy of full coverage restorative dentistry—which is taught in EVERY dental institution–is to “hang” crowns on tooth structure or post/buildup structure that is above the gingiva.  This approach has not been very successful, and that is why there is an absolute epidemic of tooth extraction and implant placement for teeth with no clinical crowns.  Unfortunately, dental practitioners are so indoctrinated with this conventional approach that it is difficult for them to understand that gripping the tooth structure below the gingiva is far more important than connecting to any tooth structure that lies above the gingiva.  All retention actually derives from the shoulder and the apron (root surface)–not the axial walls.  The ONWARD techniques do not treat teeth flush with the gingiva different from any other teeth.

The ONWARD approach allows practitioners to save teeth that most dentists recommend for extraction.  Saving these teeth also provides patients with opportunities for new and unique treatment options.  These options are also covered in the ONWARD courses.