Changing Views on the Restorability of Teeth

Digital in-roads

The digitisation of endodontics has been a relatively slow process compared to other restorative specialties and the initial focus has been very much on advanced radiography techniques. One area of focus has been the utilisation of CBCT imaging in the diagnosis of periapical lesions. Numerous studies have shown CBCT to successfully detect lesions that cannot be seen on a periapical radiograph.[i] CBCT facilitates a more accurate assessment of any lesions present, as well as their relationships with surrounding anatomical structures. This is clearly beneficial for treatment planning and can lower the risks of lesion excavations and/or surgery.[ii] The use of artificial intelligence (AI) to support assessment of more complex radiographs is also a developing area – automatic assessment and reporting on a CBCT is the ultimate goal here and a number of researchers and commercial organisations are working on this technology.

With regards to pre-operative endodontic treatment assessment and planning, there is also evidence to show that CBCT imaging is more effective at identifying low-quality root fillings than a periapical radiograph. Research has shown that CBCT images made it possible to detect voids in root fillings in 46% of endodontically treated teeth with vital pulps, while periapical radiographs identified voids in only 16%.[iii] With technologies using more sophisticated software that is easier to use and requires lower radiation dosages than ever before, CBCT is becoming a common step in the endodontic workflow.

The concept of guided endodontic access is also growing in popularity, thanks to the claimed benefits of increased accuracy, lower cost and greater accessibility for a range of clinicians.[iv] It has been suggested as a useful tool for non-surgical access and canal location in sclerosed cases, as well as apical surgery, the removal of fiberglass posts and treating teeth with morphological asymmetries.[v] Limitations do, however, remain and the technology will require further development and refinement to allow it to reach its full potential.

There is also scope for digital solutions to support and enhance treatment and referral pathways. A new Endodontic Complexity Assessment Tool (E-CAT) has been tested to see how effectively it can evaluate the difficulty of a specific case and help GDPs evaluate whether treatment is within their remit or if referral to a specialist is required. Early results have been promising in risk calculation, though again further testing and development is needed to determine its reliability in practice.[vi]

What does all of this mean for patients? Essentially, if digital workflows help clinicians to achieve better outcomes in endodontic treatment, more teeth can be saved and patients will retain their natural dentition in situations where they might previously have needed extractions.

Restorative digital benefits

Digital workflows in prosthodontics are also helping clinicians to retain more teeth. As diagnosis and treatment planning capabilities advance, so too does our ability to restore teeth that might once have been considered unrestorable. Indeed, digital technologies have been shown to facilitate minimally invasive patient care, making smile rehabilitation more predictable and leading to impressive aesthetic outcomes.[vii] The accessibility of various solutions from imaging and scanning to milling and 3D printing also mean that clinicians have more options to support a conservative treatment approach. It has been shown in some circumstances that CAD/CAM technologies, for example, enable the dentist to plan and execute restorative dentistry easier and with fewer errors than when using conventional techniques.[viii]

The restorability of a tooth post-endodontic treatment must be considered from the beginning of the procedure in order to ensure that the root canal is well-sealed and the tooth protected from fracture, while also meeting the patient’s aesthetic expectations. The definitive restoration will influence the tooth’s long-term prognosis, so careful thought must be given to the biological and functional needs of the dentition and to the restorative materials employed.[ix] Given the increasing complexity encountered in dental practices today – especially with an ageing population often with significant tooth surface loss and ever-higher patient expectations – the flexibility and innovation that digital solutions bring to the field may well prove pivotal in how endodontic procedures are provided, as well as how root-treated teeth are restored.

Opportunities for the future

Given how the digital revolution has impacted so many areas of dentistry, it follows that similar technologies could enhance and diversify endodontics as well. With a little further development, there is potential for a digital workflow that optimises every stage of the journey, from diagnosis and planning, to root filling and restoration. This was a key theme of the recent BES Spring Scientific Meeting 2023, during which speakers explored some of the trends, opportunities and remaining challenges in the field. Could digital be the answer? Yes – we’re just not there yet. However, there is real promise in the advancements so far and it is exciting to consider what may be possible in the next year or two.

Author: Dr Alyn Morgan, President of the BES.

Alyn Morgan graduated from Leeds Dental School in 1995 and worked in general dental practice for 12 years. He undertook an MSc in Endodontics at the Eastman Dental Institute which was awarded with Distinction in 2009. He has worked as a specialist in endodontic practice for 10 years at U Dentistry in Ilkley and has been a Senior Clinical Teaching Fellow in Endodontics at both the Eastman and Leeds Dental Institutes. He is currently Head of Endodontic Teaching at Leeds where he teaches undergraduates, postgraduates and hands-on courses for GDPs. He is President of the British Endodontic Society

[i] Uraba S, Ebihara A, Komatsu K, Ohbayashi N, Okiji T. Ability of Cone-beam Computed Tomography to Detect Periapical Lesions That Were Not Detected by Periapical Radiography: A Retrospective Assessment According to Tooth Group. J Endod. 2016 Aug;42(8):1186-90. doi: 10.1016/j.joen.2016.04.026. Epub 2016 Jun 29. PMID: 27372162.

[ii] Patel S, Brown J, Kelly RD, Abella F, Durack C. Cone beam computed tomography in endodontics – a review of the literature. International Endodontic Journal. August 2019; 52 (8): 1138-1152

[iii] Liang YH, Li G, Wesselink PR, Wu MK. Endodontic outcome predictors identified with periapical radiographs and cone-beam computed tomography scans. J Endod. 2011 Mar;37(3):326-31. doi: 10.1016/j.joen.2010.11.032. PMID: 21329816.

[iv] Decurcio DA, Bueno MR, Silva JA, Loureiro MAZ, Sousa-Neto MD, Estrela C. Digital planning on guided endodontics technology. Braz. Dent. J. September-December 2021; 32(5) https://doi.org/10.1590/0103-6440202104740

[v] Kulinkovych-Levchuk K, Pecci-Lloret MP, Castelo-Baz P, Pecci-Lloret MR, Oñate-Sánchez RE. Guided Endodontics: A Literature Review. Int J Environ Res Public Health. 2022 Oct 26;19(21):13900. doi: 10.3390/ijerph192113900. PMID: 36360780; PMCID: PMC9657991.

[vi] Essam O, Boyle AL, Whitworth JM, Jarad FD. The endodontic complexity assessment tool (E-CAT): a digital form of assessing root canal treatment case difficulty. International Endodontic Journal. July 2021; 54(7); 1189-1199.

[vii] Li Y. Yu Y. Feng Y. Liu W. Predictable digital restorative workflow for minimally invasive esthetic rehabilitation utilizing a virtual patient model with global diagnosis principle. JERD. July 2022. 34(5);769-775 https://doi.org/10.1111/jerd.12894

[viii] Kongkiatkamon S, Rokaya D. Full Digital Workflow in the Esthetic Dental Restoration. Case Rep Dent. 2022 Jun 18;2022:8836068. doi: 10.1155/2022/8836068. PMID: 35762014; PMCID: PMC9233610.

[ix] Eliyas, S., Jalili, J. & Martin, N. Restoration of the root canal treated tooth. Br Dent J 218, 53–62 (2015). https://doi.org/10.1038/sj.bdj.2015.27