During my short nine-year-old clinical work i came to conclusion that traditional multi-visit endodontic treatment of pulpitis is quite good in results. Radiograohically most of them are underfilled, but they often lead to root canals' obliteration. Modern single-visit concept is not so forgiving. My observations are that most of "old endo" is undrefilled. Some of them work well (in cases mentioned above), but the majority of them needs retreatment. Nowadays most of endodontic treatments are made poorly also. In Poland i think that over 50% of RCT is beeing performed badly and without standards: lack of rubber dam, no magnification, lack of proper negotiation, bad shaping, insufficient debirement, wrong irrigation and inadequate filling. It is normal, that GP is not capable to do everything well, specially difficult endo. Most of them do it and do not send patient to be treated under the microscope. Some patients, due to economical reasons, prefer cheaper and less predictable treatment.

In my opinion, I believe that insufficient knowledge on the root/root canal anatomical variations is the main reason. The prevalence of missed roots and root canals can reach over 40% as mentioned by Hoen and Pink (2002). This justifies why I usually discover a missed anatomy. in most of my retreatment cases.

In addition, many epidemiological studies show that high failure rates are observed more in old patients than adults due to the increased likelihood of calcified canals.

- I believe that if an operator is not able to configure the anatomical challenges of the root and root canal, failure may occur sooner or later, especially if the coronal seal is not adequate.

I like your positive vision related to the root canal therapy difficulties. However, i think there many aspects which could explain the bad quality of RCT. Endodontics requires a lot of time, skills and provides a weak remuneration depending on each country medical politics...

Endodontic diseases are mostly results of multifactorial insuficiencies: cmd-occlusal load, perio, decay, etc. The dental profsssion managed to expand its knowledge incredibly over the last decades. Dental education has sadly not managed zo keep the path. Clinical dentistry is of course economic and requires financing. Patient education has not kep path with the developments in dentistry as has turned very much into consumable. This discrepancies are not only mirrored in a highly sophisticated speciality like endodontics but almost in the whole of medical professions. Lack of interdisciplinary communication aggravate the condition.

High specialists have the expertise to realise and recognise the situation with deeper understanding. It is in their hands to help improve teh current situation.

Liviu steier

I think somehow it is related to ( do u believe in specialty ??).... So, if i concentrate in my study on endo ,, how can i remove impacted tooth surgically ??

I think if each one of us focus on the he study , we will give perfect service to the patient ..

So , i am an endodontist , do not give me elevator and lancet to remove impacted tooth & if i am an oral surgeon, do not ask me to find "missed" canals which i think the first reason for endo-ttt failure ... :)

endo-surgery is good example for that. Surgeon plus endodontist (both together ) could do amazing work if they co-operate ... And of-course it is all for the benefit of the patient.

Ye, this correct but you need to understand occlusion to evaluate cause of disease, treatment indication and to make ensurelong term success of your rct; you need to understand restorative to guaranteethe second 50% of the treatment (coronal seal, etc....). Yes, I highly believe in the speciality and no I do not invite you to remove wisdom teeth nore to provide a full denture!

I think lack of knowledge, lack of patient to familiarize root canal morphology, and also difficulty to ability of access in abnormal anatomy may lead to poor quality of endodontic treatment.

In my country (Romania),due to economical reasons,more pacients prefer cheaper and less predictable treatment. If I have troubles with endodontic treatment I send the pacient to be treated under the microscope. It's better for all.

Dear Dr Ionescu,

it is a very commun view among general dental practitioners that specialist endodontic treatment consists of microscopic approach exclusivly. This statement is very sad and of course disappointing. Anamnesis, differential diagnosis, diagnosis, treatment planning,treatment alternatives, execution as well prognosis and long term monitorisation are just some aspects that characterise specialist services.

Residencies in Endodontics cover so many different aspects of the specialist education...

Kind regards

Liviu Steier

Hi Liviu,

I agree with you. It is astonishing to consider the microscope as the rescuer more than the specialist !!! Basically, i think it's only a problem of communication between the patient and the general practitioner. The latter can easily refers the patient to the specialist by argueing about the specialist's modern equipments more than his real skills. Sometimes It's a little bit frustrating for the specialist...

I agree. Microscope is only an equipment. It doesn't make anything by tis own. As Frederic said: GPs mostly reffer the patients giving them information, that microscope and other gizmos will cure them. In Poland there are quite a lot of dental practises with operating microscopes (i presume that about 500 or more for 36 milion country). But really good endo is being carried out in about 100 of them.

Hi Frederic and Wojciech,

I also agree with you. Any sort of magnification is a tool, and before I use the loupes/microscope, I know where I am going to search for MB2 or any additional canals. Success in endodontics = Knowledge + Clinical experience + supporting tools.

Dear Frederik,

thank you. We are in full agreement.

Kind regards

Liviu

It should also be noted that patients, once relieved from pain, no longer provide feedback about the quality of the root canal treatment performed. Failure can occur several years later and the dentist no longer takes the blame. On the contrary, feedback concerning anything visible within the oral cavity can lead to improvement of the quality provided.

I think because teeth which undergo endodontic treatments usually have questionable or poor diagnosis by itselves , we may think that endodontic treatment is not effective enough,in addition , enough root canal debridement has a very important role in successful treatment but it may be ignored by dentists

Most treatments done by professionals undifferentiated presents a successful outcome median, while the professionals have differentiated better results. Most professionals do not use absolute isolation and aseptic care are reduced so that the results achieved are not the best. However the quality of care has improved.

Thank you for the great and valuable point.

May I kindly ask the readership

Who prescribs different irrigation protocols for different diagnosis?

Do you mind quiting in bullet points?

What is your dressing protocol?

What is your coronal seal protocol?

How do you determine the adequate restorative protocol?

I will personally not answer to avoid bias.

Yes, you are correct...sometimes this can be disappointing!

...and sometimes your students become better and better and one day

you may start and learn from them!

I'm sometimes dissapointed when i see my post-graduate-courses students don't use rubber dam, proper irrigation etc. I don't get it. They pay money for course and after that they make everything like before except few minor corrections. The quality of endodontic treatment (as well as other procedures) is in reality a state of the mind.

Even if you use all the available technics and disinfection systems and perform an excellent closure off all the canals you still never reach to eliminate the millions of bacteria hidden in the biofilm in den dentine tubules. Put together, they reach a length of various kilometers and have access to the outside through an incomplete root cement layer and along the shrinking cement and gutta-percha filling of the "Canale Grande" of the tooth. Yes, the tooth is like Venice with numerous side canals. The fact that many root canaled teeth "heel", that is, the periodontal apical destruction, visible on X-Ray, disappears, depends on the persons capability to combat the infection in the bone and reconstruct it. But the bacteria inside the tooth are still there, and, as Leslie Howard whispers out of the dark in the last scene of "Pimpernel Smith": “Yes, captain Graum, we'll be back. One day we will all be back!"

Dear Dr Beckman,

appreciate your reply, although thiit proves a non evidence based approach and as medical professionals we are bound to predicatability and guidline base.

You for sure will understand that on RESEARCH GATE the attempt should be to discuss evidence based dentistry. Afraid members of this community are investing time and resources this way.

Thank you very much for sharing your opinion and kind regards.

Salut Fred de Zurich. Are you working together with Jean Camps? Give him the best regards. Je suis un ancien de la Faculte Dentaire de Marseille. So, to reply in your question, everything is going to work better in the future, mostly because of the new technological developments (sophisticated cameras allowing to perform an ideal root treatment. Hopefully, on top of that, some treatments with stem cells could resolve for ever the problem (give my best regards to Imad). Cheers

Yes i'm working with my friend jean. Nice to meet you on researchgate. Greetings

I think is very difficult to succeed in an endodontic treatment of molars, but as regards the endo of incisors, canines and premolars, if you follow the relevant protocols and you are lucky enough not to have "lateral-hidden" unexpected root canals, any general dentist can do it successfully

Based on my practice, the quality is poor as a result of lack of the right instruments, wrong chair positioning to give your proper access into the canals, poor patients motivation. Imagine working in a place where the use of rubber dam is not common practice

The tooth to be root treated. There is an increasing level of difficulty with endodontic treatment as you progress from teeth number 1-8

Lack of the right armamentarium for endodontics

Poorly motivated patient, missing appointments and the longer the time interval between treatment the more likely treatment may fail

Just som key factors to help:

1. Case difficulty assessement by the AAE. This will advise and help if the case is adequate to the available qualifications and technology or refer out.

2. Comprehensive education (not only a week end course or one by a rep).

3. Ethical motivation instead of monetical.

4. Shift of paradigm: from mechanics to biology!

Because of insufficient knowledge. Most of the dentists just focus on eliminating the pain but not on the quality of treatment. this leads to insufficient removal of tissue & debris which further leads to inadequate cleaning & shaping and finally incomplete obturation.