Not Your Typical ‘Back in the Day’ Story

Recently, I have had the opportunity to listen to several outstanding presentations regarding the clinical practice of endodontics and I can sincerely say, I wish I were starting all over again!! The advances in instrumentation alone are mind boggling considering when I started in endodontics. At the University of Iowa, in 1978, my dental class was introduced to the specialty of endodontics and was shown how to use (or misuse, depending on your ilk!) endodontic files and reamers. In our laboratory classroom, no handpiece driven files existed! (Of course, in fact, there were some broaches and reamers that were used with the once infamous, “Giromatic” reciprocating handpiece attachment, made famous by Dr. Angelo Sargenti. These weren’t even shown to us in dental school because the faculty probably knew we would have “put our eye out” with them!)

As we progressed into the junior clinics and the Department of Endodontics, we found that four to five patient visits to complete the case was the norm. We cultured using thioglycolate broth (strictly aerobic culturing) and were required to have a negative culture prior to being able to obturate. Roth’s 801 and lateral condensation was the obturation technique using a D-11 or D-11T spreader. Heat for gutta percha removal was provided by the same gas burners used throughout the school  and at least one faculty a year would back into a burner and catch their lab coat on fire! No final restorations were ever placed and cotton and cavit, or temporary stopping  were acceptable as final temporary fillings for the access. It was a heart sinking moment when our D speed  film dropped out  of the processor, stuck together with two other films and you realized that the patient who just about tossed everything had to be asked to reshoot the film! I know this is sounding like a “back in the day…” story, and I guess it is, but I wanted to put the currently available technology in perspective in contrast to when I finally started my residency.

The latest technological innovation for me in 1981 was the K-flex file and Gates-Glidden drills were the only rotary instruments out there! For the first six months of the residency, instrumentation was always a two- or three-visit affair because we were required to use only hand files. It was tedious, arduous and fraught with opportunities for errors. I found out very quickly that as the canal curvature increased, I could begin to ledge, zip and straighten out just about any canal with my serial step-back hand filing technique. I don’t think carpal tunnel problems were identified at that time as the repetitive stress injury it is, but after working for a few hours, you could definitely feel muscle fatigue from twiddling files. At times, I felt like I would never develop the finesse needed with hand files to avoid all of these errors. The standard joke was, “There is always pharmacy”. But eventually I had fewer and fewer errors and after six months, I was shown how to use Gates-Glidden instruments to obtain straight line access and things improved. A new respect for the middle and coronal thirds developed after the first strip perforation and, lo and behold, I eliminated the occurrence of that catastrophic error. As part of the residency, we were required to make duplicate radiographs of all of our cases and show them to our fellow residents when our time came. The triumphs and tragedies were blown up on an 8-foot screen, magnifying all our skill and our ineptitude. I was made to be humble by the best — Drs. Sandra Madison, Eva Dahl, William T. Johnson, Jim Jostes, Rex Holland, Gerry Scott and Rich Beatty — to name a few. By the time Dr. Walton got to Iowa, there were fewer public hangings, but I knew I had to always be humble!

Today’s technologies in just the realm of cleaning and shaping are absolutely incredible! The advent of Nitinol files was a giant step into what was possible, even with an inexperienced dentist. Ironically, the first dental use of nitinol wire was with orthodontic arch wires and was developed at the University of Iowa, by Dr. George Andreasen. (I guess we missed what was literally two floors below us!) Without going through all of the metamorphosis that have occurred in the last 15 years, let me just say there are many instrumentation systems that, when properly used, can provide breathtaking results that can be more quickly achieved by a skilled clinician than before. Yes, we could get the same results with hand files alone 40 years ago, but only after developing “finesse” and treating the first 10,000 cases! Of course, with new technology comes new headaches and everything can be broken. The last five years of my private practice saw a surge in referrals for instrument retrieval. And at least, with the microscope it was possible to see what you needed to do to fix the problem, but even within the last three years, new techniques and equipment have been developed facilitating instrument retrieval from even curved canals. The separated file cases I have seen by presenters are truly making the impossible seem possible!

Lastly, for me, the advent of CBCT and three-dimensional radiography may be the top improvement in helping us make more accurate diagnoses and long term evaluations of success. As one example, I was seeing one to two resorption cases a week in the last six months of private practice and with our new cone-beam I was able, for the first time, to show the patient exactly what I was talking about. The graphic display of a resorptive defect in a rendering, allowed me to know, size, location, remaining structure and restorability. I would then fully explore the images and rendering with the patient and help them make an  informed decision with all of the visual information in front of them. On a more personal note, as the machines and software improve, I am told one day (maybe even soon) you will be able to see cracks and fractures and know the exact extent and depth of the event. Hopefully, this would allow for earlier crack recognition and quicker treatment with just a restoration, or in teeth requiring root canal treatment, more accurate barrier placement and improved prognosis.

Yes, I wish I could start over with all of the new technology, because I think it would have helped make me become an even better endodontist than I am. In perplexing cases, I frequently consulted with other specialists to obtain the best available information and perspective to help with my final treatment decision. In the not-too-distant future, you will have artificial intelligence to call upon and probably an app (courtesy of the AAE!) to plug into for help. I think technology will only make us better, but a word to the wise: always be humble!