When Does Endodontics Begin?

I was in Amman, Jordan, on a cold January’s night.  It was just recently.  I was with a group of endodontists at the Hotel Royal and we were having a very nice dinner in a Lebanese restaurant.  During this evening of discussion, one of my dear friends, Dr. Edmond Koyess, who is the Department Chairman of Endodontics at St. Joseph’s University in Beirut, Lebanon, turned to me and he said, “Cliff, when does endodontics truly begin?”

Well, this was quite a question and, as you can imagine, many people around the table had comments and, you know, observations.  But, it was an interesting question because I think it came from the recognition that the essence of endodontic success is disinfection. 

So, we have several steps that comprise start-to-finish endodontics.  To put the epidemiology in order, let’s kind of review that, in the United States alone, there were about 40-some million canals treated, or 20-some million teeth, and of course these people present in our offices with the signs and symptoms frequently of irreversible pulpitis.  Then, we know that inflammation runs it’s course and it flows down through ischemia, infarction, necrosis, and pulp death.  Of course, when they come to our office, if the decision is endodontics, we treat. 

The start-to-finish steps that we utilize after diagnosis are we make an axis; we secure a glide path; we shape these canals; then we can disinfect, and then we can talk about filling root canal systems.  So, the question begs, “When does endodontics truly begin?”  We have to realize that we’re going through a series of these steps, and each step builds upon the previous step and influences the next, subsequent step.  But, we really can’t begin to think about removing the pulp, the bacteria when present, and the related irritants and byproducts.  And, of course, when we do endodontics, we create a smear layer with our mechanical instruments that we use to secure glide paths and shape canals.  So, although we’re doing all these steps and it’s all moving towards disinfection, we really can’t talk about disinfection until we have the shape. 

So, the secret to disinfection is having a well-shaped canal.  Well-shaped canals hold a significant volume or reservoir of sodium hypochlorite.  If we want to then, we have the opportunity to use one of the newer disinfection methods, such as the EndoActivator which uses a nylon, non-cutting, highly flexible tip, and we can activate our solutions, our reagents, so we can get them to move off the shape, the canal.  These irrigants then can penetrate, circulate and digest tissue in the more inaccessible areas of the root canal system. 

So, when does endodontics truly exist?  When does it really begin?  When can we really perform the very essence of predictably successful endodontics?  Well, it would be when we have sufficient shape so we can begin to activate our intra-canal reagents.  So, that’s a little side-thought that you might think about when you’re working chairside.  You can really achieve finally what your purpose to do is to make sick people well.  You know, you’re going to treat those disease teeth and make sick people well.  So, if you’re going to really do that, you’ve got to make the access and you’ve got to get a glide path.  But, only when you’ve got the shape, can the reagents then be in the canal where you can begin to talk about disinfection, or the essence of predictability successful endodontics.