The New Mexico Legislature is considering Senate Bill 151, a broad tax package that introduces new deductions and credits aimed at supporting healthcare practitioners, affordable housing development, local journalism, and corporate tax alignment. While the bill includes provisions designed to strengthen the healthcare workforce, it does not clearly include oral health care professionals within its eligibility framework.
SB 151 establishes tax deductions for certain healthcare-related in-office equipment and medication sales, along with tax credits intended to support providers delivering care within the state. These incentives recognize the financial realities facing healthcare professionals and seek to promote workforce sustainability and patient access. However, without explicit inclusion of dentists and dental specialists, oral health providers may be excluded from these benefits.
Oral health is essential health. Endodontists—specialized dental professionals trained to diagnose and treat dental pain and infection—provide medically necessary care that often must be delivered urgently to prevent systemic complications. Their practices rely on advanced diagnostic imaging, surgical equipment, and in-office medications that are integral to patient treatment. Excluding oral health care professionals from healthcare-focused tax relief measures creates inequitable treatment across disciplines and reinforces the outdated separation of dental care from overall healthcare policy.
In response, the AAE submitted a formal letter requesting that SB 151 be amended to explicitly include licensed dentists and dental specialists within the definition of eligible healthcare practitioners. Our advocacy emphasized the importance of parity in tax policy and the need to ensure that oral health professionals are treated equitably alongside other healthcare providers.
By seeking this amendment, the AAE is working to protect practice sustainability, promote workforce stability, and safeguard patient access to specialty dental care in New Mexico. We will continue engaging with lawmakers to ensure oral health is recognized as an essential component of the healthcare system.
Across multiple states, lawmakers are introducing legislation to regulate the use of virtual credit cards in health and dental insurance reimbursement. These measures address a growing concern among providers: insurers issuing payment via single-use virtual credit cards that may carry processing fees, often without clear advance disclosure or provider consent.
Virtual credit card payments can impose transaction fees that reduce reimbursement for services already rendered. In many cases, providers are automatically enrolled in these payment methods without meaningful notice or are not offered a no-fee alternative. For endodontists providing urgent, medically necessary treatment, reduced reimbursement and administrative complexity can create barriers to delivering timely care.
The legislation under consideration would prohibit insurers from requiring virtual credit card payments as the sole reimbursement method, mandate disclosure of any associated fees, and ensure that providers have the option to select alternative payment methods. Some measures also prohibit transmission fees unless the provider affirmatively consents.
The AAE submitted formal letters of support for these bills, highlighting the importance of payment transparency and provider choice. Our advocacy emphasized that reimbursement practices must be fair, predictable, and free from hidden administrative costs that diminish compensation for patient care.
By promoting transparency and consent-based payment systems, these reforms strengthen practice sustainability and reduce unnecessary administrative burdens. The AAE will continue to advocate for policies that protect providers from unfair reimbursement practices and preserve patient access to specialty dental care.
The Massachusetts Legislature is considering legislation to increase transparency in the practice of dental leased networks—commonly associated with “silent PPO” arrangements. These practices occur when a dental plan leases its contracted provider network to third-party entities without the provider’s clear knowledge or consent. The result can be reduced reimbursement, altered contractual terms, and confusion for both providers and patients.
Under the proposed legislation, provider network entities would be required to disclose third-party health plans that access their networks, identify applicable fee schedules, and notify dentists of any material changes affecting reimbursement. The bill also strengthens oversight of these arrangements and ensures that providers are aware of which entities are accessing their contracted rates.
Silent PPO arrangements undermine the integrity of provider contracts. When dentists agree to participate in a network, they do so with an understanding of the reimbursement terms and administrative obligations. Network leasing without transparent disclosure can lead to reduced payments under unfamiliar plans, administrative confusion, and difficulty resolving disputes. For endodontists delivering specialized and often urgent care, unexpected reimbursement reductions can directly affect practice sustainability and patient access.
The AAE submitted a formal letter of support for this legislation, emphasizing that transparency and contractual integrity are essential to maintaining fair relationships between insurers and dental professionals. We underscored that providers must have clear notice of which entities are accessing their networks and must be protected from reimbursement reductions that occur without consent.
By strengthening disclosure requirements and ensuring accountability in network leasing practices, this bill protects providers from hidden contracting practices and supports stable, predictable reimbursement structures. The AAE remains committed to advancing policies that promote fairness, transparency, and high standards of patient care.
State legislatures across the country are advancing dental loss ratio (DLR) legislation intended to improve transparency and accountability in dental benefit plans. At its core, a dental loss ratio establishes the percentage of premium dollars that insurers must spend on patient care rather than administrative expenses, marketing, or executive compensation. Without enforceable DLR standards, a substantial portion of premium revenue may never reach the patients it was intended to serve. For endodontists and the patients who rely on timely, medically necessary treatment, these policies directly affect access to care and fairness in the dental marketplace.
In recent years, policymakers have increasingly looked to the federal medical loss ratio model under the Affordable Care Act as a framework for reform. That model requires health insurers to devote a defined percentage of premium dollars to clinical care or issue rebates to policyholders. Similar guardrails in the dental market would ensure that premium spending is directed toward treatment—not overhead. However, not all DLR proposals include the strong enforcement mechanisms necessary to deliver meaningful reform. Transparency alone is not enough. Without a clearly defined minimum threshold and annual rebate requirement, reporting measures risk becoming administrative exercises rather than patient protections.
The AAE has taken clear positions on several DLR proposals this legislative cycle.
Where AAE Supports Strong Reform
The AAE supports legislation that establishes a specific minimum dental loss ratio of 85 percent and requires insurers to provide annual rebates if they fail to meet that benchmark.
We have submitted formal support for:
- Missouri – SB 1596
- West Virginia – HB 4810 / SB 548
- Washington – HB 1535
These bills pair transparency with enforceable standards. By requiring dental plans to dedicate the majority of premium dollars to patient care and refund excess administrative retention, they prioritize patients and introduce real accountability into the marketplace. This approach reflects the balanced, proven model that has protected medical insurance consumers for more than a decade.
Where AAE Opposes Reporting-Only Measures
The AAE has also expressed opposition to proposals that focus primarily on reporting requirements without establishing enforceable minimum thresholds.
We oppose:
- Mississippi – HB 1117 / SB 2479
- New York – A 3919 (A/B versions)
While transparency is an important component of reform, reporting alone does not prevent harmful insurer practices, reduce administrative burdens, or ensure that premium dollars are directed toward care. Without a mandatory minimum loss ratio and automatic rebate mechanism, these bills may fall short of meaningfully improving patient access. The AAE continues to urge lawmakers in these states to adopt stronger, enforceable protections.
Where AAE Urges Amendments to Strengthen Protections
In several states, legislation moves in the right direction but requires strengthening to fully protect patients.
We are urging amendments to:
- Alabama – SB 81
- Hawaii – SB 2132
- Nebraska – LB 639
Although these bills establish loss ratio requirements, they lack sufficiently robust enforcement mechanisms or clearly defined rebate structures to ensure consistent compliance. Without clear standards and annual accountability, insurers may retain flexibility that weakens the intended patient protections. The AAE is working with lawmakers to refine these proposals so that they deliver meaningful, enforceable reform.
Protecting Patients and the Integrity of Care
For endodontists, dental loss ratio reform is not an abstract policy debate. Administrative denials, delayed reimbursements, and coverage limitations affect real patients seeking urgent care. When premium dollars are diverted away from treatment, patient access suffers.
Our message to legislators nationwide is consistent: dental loss ratio legislation must include strong, enforceable standards that ensure premium dollars support patient care. Through direct engagement, formal comment letters, and ongoing collaboration with policymakers, the AAE continues to advocate for reforms that protect patients and uphold the integrity of specialty dental care.
This work reflects the AAE’s ongoing commitment to advancing policies that promote transparency, fairness, and access to high-quality endodontic treatment.
Artificial intelligence is not new. The concept emerged in the early 1950s and has progressed through multiple stages of development. However, beginning in 2022–2023, large language models, powered by advances in computing power, big data, and neural networks, significantly accelerated its capabilities, producing breakthroughs in image recognition, speech processing, and natural language understanding.
AI is no longer theoretical in healthcare either. It is actively influencing how we diagnose, communicate, and deliver care.
As endodontists, specialists who have long embraced precision, innovation, and advanced technology, we are uniquely positioned to lead in this space.
Across healthcare, and particularly within dentistry, AI is being applied to imaging interpretation, predictive analytics, treatment planning, education, quality assurance, and even regulatory and payer decision-making. Some developments are promising. Others raise important questions. And many are unfolding around us rather than being shaped by us.
That reality prompted a fundamental question at the AAE:
If AI is going to shape the future of endodontics, who should help shape AI?
The answer, we believe, is the AAE.
Who Should Help Shape AI?
From enhanced imaging analysis and CBCT interpretation to predictive analytics and workflow automation, artificial intelligence has the potential to strengthen diagnostic accuracy, improve efficiency, and support better patient outcomes. In endodontics specifically, AI tools are being developed to assist in identifying periapical pathosis, detecting missed canals, assessing fracture patterns, and supporting treatment planning decisions. In the future, augmented robotics may even assist in performing portions of endodontic procedures.
But while the technology is powerful, our responsibility remains clear: AI must enhance clinical judgment—not replace it. The art and science of endodontics rely on training, experience, and critical thinking. AI can generate data and insights, but it is the endodontist who interprets that information within the full clinical context of the patient in the chair.
That balance, innovation guided by expertise, is precisely where the American Association of Endodontists is focused.
Over the past year, your Board of Directors supported the formation of a dedicated initiative to examine the implications of AI for our specialty. This formally launched with the Artificial Intelligence in Endodontics Think Tank, a strategic advisory body reporting directly to the Board through a designated liaison. The Think Tank was intentionally structured to bring together leaders in clinical endodontics, research, education, advocacy, technology, and organized dentistry, alongside senior AAE and Foundation staff.
Its charge is forward-looking and clear: to explore, evaluate, and develop a comprehensive framework for the responsible integration of AI in endodontics.
During its inaugural meeting, participants reviewed the rapidly evolving AI landscape, identified priority areas, and began outlining measurable next steps for how the AAE can guide the specialty responsibly.
Priorities
Priority areas under consideration include:
- Enabling responsible clinical adoption while preserving professional judgment and patient safety
- Preparing the future workforce by integrating AI concepts into education and lifelong learning
- Translating insights from medicine and broader dentistry into specialty-specific applications
- Defining the role of the AAE Foundation in supporting AI-related research
- Developing advocacy principles regarding regulation, payer decision-making, and utilization review
- Clarifying terminology, including the distinction between “artificial” and “augmented” intelligence
- Establishing clear guardrails and standards that define appropriate use and boundaries
In short, this initiative is about stewardship.
It is about ensuring that endodontists lead the conversation, shape policy, and define standards, so that artificial intelligence strengthens patient care, supports clinical excellence, and advances our specialty rather than undermines it.
AEO
Just as importantly, we are advancing the AEO (Answer Engine Optimization) initiative—our strategic effort to optimize the AAE’s patient website so that accurate, evidence-based endodontic information is accessible not only to patients directly, but also through large language models and AI-driven search tools. As more people turn to AI platforms for health information, it is critical that the content being surfaced reflects the expertise of endodontists. Through enhanced structure, expanded FAQs, clear data points on outcomes and longevity, and carefully developed educational copy, AEO ensures that when patients ask AI about root canals, tooth pain or saving their natural teeth, the answers are grounded in science and aligned with our specialty’s standards of care.
Another visible example of our dedication to AI is our Save Your Tooth Month AI agent. Designed to help patients access credible, science-based information about endodontic care, this tool reflects our commitment to combating misinformation while leveraging emerging technology for public education. I am proud to share that the AI agent has already received multiple awards and is currently a finalist for PRWeek’s Best AI Healthcare Innovation award, with formal recognition to be announced in May. As a finalist, the AAE will receive national industry acknowledgment for this groundbreaking work.
This achievement underscores an important point: AI is not just a clinical tool. It is also a communications tool, an educational tool and a platform for extending our mission to save natural teeth.
Education
Education, of course, remains at the core of everything we do. At AAE26, we are offering a robust slate of AI-focused programming designed to move beyond theory and into practical application. Dedicated sessions explore the current AI landscape in endodontics, real-world clinical integration, ethical considerations and the evolving regulatory environment. In addition, hands-on workshops provide members the opportunity to examine AI-driven imaging analysis, diagnostic support technologies and workflow tools in a structured learning environment. These sessions are designed not simply to demonstrate innovation, but to help clinicians critically evaluate emerging tools—asking what problem they solve, how their outputs should be validated and where the boundaries of appropriate use must remain firmly in the hands of the endodontist.
Our goal is not to encourage adoption for adoption’s sake. Rather, it is to ensure that endodontists are equipped to evaluate AI tools critically, integrate them responsibly and maintain the highest standards of patient care.
As we look ahead, several guiding principles remain paramount:
First, patient trust must always come first. Transparency about how AI is used in diagnosis or treatment planning is essential.
Second, data integrity and privacy cannot be compromised. Safeguarding patient information is a professional and ethical obligation.
Third, continuing education is vital. The technology will evolve; so must we.
Endodontics has always been a specialty grounded in precision and driven by progress—from the adoption of the operating microscope to advances in rotary instrumentation and 3D imaging. Artificial intelligence represents another chapter in that tradition. If approached thoughtfully, it can enhance our ability to diagnose earlier, treat more effectively and communicate more clearly with patients and referring colleagues.
The AAE will continue to serve as your trusted resource in navigating this rapidly changing landscape. Through structured Think Tank oversight, strategic initiatives like AEO, comprehensive educational programming at AAE26 and award-winning public outreach, we are committed to ensuring that AI strengthens—not disrupts—the standard of excellence that defines our specialty.
I encourage you to explore the AI offerings at AAE26, engage in the conversation and consider how these tools may support your practice and your patients. Together, we can lead dentistry forward—responsibly, ethically and confidently.
Thank you for your dedication to saving natural teeth and for your continued commitment to innovation in endodontics.
It is with great sadness that we announce the passing of Mbachan Collins Okwen, DDS, MBA, MSD, endodontist, educator, and leader, who died on January 21, 2026, in Conroe, Texas. A former Board member of the AAE (District V Director), Dr. Okwen was known for his contributions to endodontic education in Africa, his deep commitment to patient care, and his unwavering spirit of service that touched many lives across continents.
Dr. Okwen was born on June 29, 1972, in Bamenda, Northwest Region of Cameroon. From an early age, he demonstrated a blend of intellect, humility, creativity, and compassion for others.
He began his primary education at G.S. Batibo, laying the academic foundation that would define his life. He later attended the prestigious Sacred Heart College Mankon, where he excelled and obtained both his Ordinary and Advanced Level certificates. Even in his youth, he stood out—not only for his intelligence, but for his discipline, curiosity, and emerging leadership qualities.
He went on to pursue dentistry at the University of Benin, Nigeria, where he earned a Bachelor of Dental Surgery and a Doctor of Dental Surgery. His commitment to excellence was evident in his studies and in his dedication to mastering his profession.
Driven by a desire to expand his knowledge and global opportunities, Dr. Okwen later moved to the United States, where he earned a Master of Business Administration, MBA, further demonstrating his remarkable intellectual range and versatility. Yet dentistry remained his calling.
In 2014, eager to return fully to dentistry and elevate his specialty training, he was accepted into a preceptorship at UT Health Houston. He pursued graduate training in endodontics while simultaneously carrying a bold vision: to initiate and develop a formal endodontic training program in Africa. He completed his graduate endodontic training at UT Health Houston in 2016, earning his Master of Science in Dentistry, MSD.
During his preceptorship, Dr. Okwen purchased used microscopes and endodontic instruments from the university at auction and transported them to Nigeria. With these tools, he helped establish the first endodontic training program in western central Africa at the University of Benin. His mission was clear and uncompromising.
“The goal was to get them to do exactly what we do here and nothing less,” he had said. “Of course, there’s always tons of patients…”
He later became a Diplomate of the American Board of Endodontics and served as a Clinical Assistant Professor in Endodontics, mentoring the next generation of specialists.
Dr. Okwen founded 1488 Dental in The Woodlands, Texas, where he served the greater Houston community with exceptional dedication. His patients were not merely clients; they were family. Known for his availability and commitment, he devoted himself fully to his craft.
His leadership extended to the AAE, where he served on the Board of Directors from 2022 to 2025. He also served on the AAE Nominating Committee and was actively involved with the AAE Foundation for Endodontics, championing mentorship and professional responsibility.
His commitment to giving back was further reflected in the founding of the Ralph Okwen Foundation, a family trust established to support excellence in science at Sacred Heart College Mankon, Bamenda, and to expand access to high-quality endodontic care in Africa, relieve suffering, and inspire others to give back so that people everywhere could experience the joy of being free from dental pain.
Beyond dentistry, Dr. Okwen was a musician. He also held certifications in Cisco networking and server maintenance and maintained a strong interest in artificial intelligence, particularly systems that could empower Africa. Developing children’s stories was another passion he carried.
“During my many conversations with him over the two years I served as his District Co-Director, it became abundantly clear that he was an exceptionally devoted father,” said AAE Treasurer Dr. Brad Gettleman. “I truly cannot recall a single conversation that did not, at some point, circle back to his children, whom he loved more than anything in the world.”
Dr. Okwen was known to be humble, generous, and deeply grounded. He believed material possessions were tools for meaningful impact. He confronted challenges directly and pursued excellence relentlessly. He will be missed.
Further reading: Learn more about Dr. Okwen’s incredible passion for endodontics in this Foundation for Endodontics article.
By Feng-Ming Wang, DDS, PhD
Deroofing of the jaw cyst (the original strategy of decompression) was first suggested by Partsch in the German literature in 1892 (1). In 1964, Patterson reported a successful decompression by using a polyethylene tube and stint for drainage on a large periapical lesion associated with the left central and lateral incisors on a 26-year-old patient (2). This was right after endodontics being formally approved as the 8th dental specialty by the American Dental Association House of Delegates in 1963. After many years, decompression appears to be an overlooked alternative approach for managing large cystic periapical lesions (3).
Nonsurgical root canal treatment on anterior teeth has a success rate of 74% in a 2004 study (4) and 59% in a 2024 study (5). In the latter study, if the outcome was evaluated by Cone-Beam Computed Tomography (CBCT), the success rate dropped to 20% (5). Endodontists have seen that despite the advancement of the knowledge of endodontics and modern technology, there are lesions that do not heal after nonsurgical root canal treatments. Often, periapical surgery is chosen to address the situation of non-healing periapical lesions following nonsurgical treatments and retreatments. But challenges exist due to the pitfalls of periapical surgery. Most common ones include jeopardizing the osseous support of adjacent teeth, damage to the blood vessels, nerves of adjacent teeth, and anatomic structures like canalis sinuosus in the anterior maxilla (6), and occurrence of a surgical defect. Sometimes patients cannot tolerate the procedure well because of their age and/or health conditions. Thus, it is important to know that decompression can be a great substitute of periapical surgery when such dilemma presents.
Understanding the pathogenesis of periapical cyst would help us understand the decompression technique so that we could use it comfortably to manage large cystic periapical lesions. There are at least three popular theories regarding the formation of periapical cyst. First, in the nutritional deficiency theory, as islands of epithelium expand, more central epithelial cells are distanced from their nutritional supply and undergo necrosis. A cystic cavity results in the center of the cell mass as liquefaction necrosis occurs (7). Second, in the immunological reaction theory, inflammatory mediators from the immune reactions stimulate epithelial cell rests of Malassez (ERM) to proliferate, resulting in cystic lined lumen formation (8). Third, in the abscess theory, cavity comes into existence and starts to be lined by the epithelium from the proliferating ERM led by inflammatory mediators; cavity enlarges due to osmotic pressure with the lack of lymphatic circulation and pressure-induced resorption of the surrounding bone (9-11). The degenerative characteristics of epithelial linings continues enhancing osmolality of the cyst contents till pressure is relieved. Although the pathogenesis of the periapical cyst remains to be elucidated, clinical cases evidenced that irrigation after aspiration with or sometimes even without long-term decompression can achieve optimal outcomes. The possible explanation of treatment efficacy could include the following: 1) diminishment of osmotic pressure after the integrity of the lesion wall is disrupted; 2) reduction the impact of inflammatory mediators on epithelial cells after the lesion content is aspirated and rinsed; 3) introduction of bleeding and blot clotting followed by new blood vessel formation and then tissue regeneration, especially bone formation as a wound healing process. Further, it has been proposed that the epithelial cells would experience programmed cell death (apoptosis) in response to the lack of the inflammatory mediators (12).
According to Glossary of Endodontic Terms, decompression aims to reduce the size of a large cystic periapical lesion using two primary techniques: 1) the surgical incision through a wall and insertion of a drain; 2) the penetration of the cyst in two locations with two large gauge needles and flushing with sterile saline (13). There are several types of drain technique described in the literature (3). Manjarrés and colleagues developed a 3D-printed educational model for decompression and nicely showcased its application clinically (14). The author of this Communiqué article has recently successfully used Penrose drain in treating several cases of large cystic periapical lesion. One of the author’s publications showed that decompression using the Penrose drain significantly induced bone regeneration and reduced lesion size before periapical surgery was performed later (15). Penrose drain was named after Charles B. Penrose (1862-1925) physician specializing in gynecology. Penrose drain is soft, radiopaque, and inert, with minimal foreign body reaction. It provides patients with comfort and can be located radiographically. The length of drainage in literature ranged from 2 days (16) to 5 years (17). The author found that 4-week period had worked well in all their cases. Hoen and colleagues reported that aspiration followed by irrigation without further placement of drain achieved great results as well (18). As shown in Figure 1, the healing of large cystic lesion associated with teeth #7 and #8 in an 85-year-old female was demonstrated by CBCT imaging following aspiration and irrigation only. Nevertheless, the author recommends that clinicians should determine the length of drainage case by case. Of note, it appears unnecessary or sometimes impractical for patients to perform self-irrigation of the lesion with saline or some type of antibacterial agent.
Figure 1 – Management of large periapical lesion by decompression. An 85-year-old female presented with pain and swelling in the anterior palate. A-D) Preoperative limited field of view CBCT scan. A) Axial view. B) Coronal view of teeth #7 and #8. C) Sagittal view of tooth #7. D) Sagittal view of tooth #8. E) Decompression by aspiration using an 18-gauge needle. F) Irrigation of the lesion with saline using 2 needles. G-J) Three-year follow-up CBCT scan. G) Axial view. H) Coronal view of teeth #7 and #8. I) Sagittal view of tooth #7. J) Sagittal view of tooth #8. (This work was done by Dr. Wang together with his former resident Dr. Ghazaleh Rezaei, who currently practices at Las Vegas Endodontics. CBCT scans were kindly provided by Dr. Matthew Massey at Heart of Texas Endodontics.)
It is worth mentioning that a large periapical lesion does not automatically mean a cyst. The proportion of periapical cysts increases when lesion increases in size (19). But some very large lesions have been confirmed to be granulomas through biopsy. Provisionally, a periapical lesion could be diagnosed as a cystic lesion when it involved one nonvital tooth and the straw-colored fluid was aspirated from the lesion (20).
In general, decompression may be considered in cases involving nonvital teeth or teeth associated with a large radiolucent lesion (more than 200 mm2) when needle aspiration demonstrates a straw-colored fluid or copious drainage from the canal during root canal therapy. The cystic cavity should allow free placement of a tube or drain within the lesion. Decompression should not be recommended for lesions with a chronic sinus tract. If upon attempting aspiration, the clinician is unable to remove fluid from the bony cavity, this would indicate the presence of granulomatous lesion which is unsuitable for decompression. Like any other surgical procedures, it is always important to review medical and dental history and evaluate risks thoroughly prior to decompression of large periapical lesions.
In summary, decompression is a preservative and minimally invasive approach to manage large cystic periapical lesions. Endodontists should be aware of this treatment option and may offer it to understanding and motivated patients before more aggressive surgical procedures are selected.
Dr. Feng-Ming Wang is a Clinical Associate Professor of Endodontics in Texas A&M University College of Dentistry and maintains a private practice at Precision Endodontics in Plano, Texas. The author would like to thank Dr. James L. Gutmann for kindly reviewing the article.
Reference
- Partsch C. Über kiefercysten. Deutsche Monatsschrift Fur Zahnheilkunde. 1892(10):271-304.
- Patterson SS. Endodontic therapy: Use of a polyethylene tube and stint for drainage. J Am Dent Assoc 1964;69(6):710-714.
- Gutmann J, Ferreyra S. Alternative and contemporary management of large periradicular lesions. ENDO (Endodontic Practice Today) 2010;4(2):127-144.
- Caliskan MK. Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: a clinical review. Int Endod J 2004;37(6):408-416.
- Artaza L, Campello AF, Soimu G, Alves FRF, Rocas IN, Siqueira JF, Jr. Outcome of Nonsurgical Root Canal Treatment of Teeth With Large Apical Periodontitis Lesions: A Retrospective Study. J Endod 2024;50(10):1403-1411.
- Veronezzi MC, Pinheiro IHS, Tolentino ES, Camarini C, Takeshita WM, Iwaki LCV, et al. Anatomical variations in the maxillary anterior region: a cone beam computed tomographic study of the canalis sinuosus and its accessory canals. Gen Dent 2023;71(4):16-22.
- Ten Cate AR. The epithelial cell rests of Malassez and the genesis of the dental cyst. Oral Surg Oral Med Oral Pathol 1972;34(6):956-964.
- Torabinejad M. The role of immunological reactions in apical cyst formation and the fate of epithelial cells after root canal therapy: a theory. Int J Oral Surg 1983;12(1):14-22.
- Toller PA. Newer concepts of odontogenic cysts. Int J Oral Surg 1972;1(1):3-16.
- Valderhaug J. A histologic study of experimentally induced periapical inflammation in primary teeth in monkeys. Int J Oral Surg 1974;3(3):111-123.
- Nair PN, Sundqvist G, Sjogren U. Experimental evidence supports the abscess theory of development of radicular cysts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(2):294-303.
- Lin LM, Huang GT, Rosenberg PA. Proliferation of epithelial cell rests, formation of apical cysts, and regression of apical cysts after periapical wound healing. J Endod 2007;33(8):908-916.
- American Association of Endodontists. (2020). Decompression. In Glossary of Endodontic Terms (10th ed., p. 14).
- Manjarrés V, Bonilla C, Guerrero M, Gutmann JL. A 3D-printed educational model for decompression and case report. ENDO (Endodontic Practice Today) 2020;14(1):71-78.
- Wang FM, Liang H, Glickman GN, Gutmann JL. Use of a penrose drain for decompression of a large periapical lesion: A case report with 4.5-year follow-up. J Endod 2024;50(10):1521-1526.
- Loushine RJ, Weller RN, Bellizzi R, Kulild JC. A 2-day decompression: a case report of a maxillary first molar. J Endod 1991;17(2):85-87.
- Rees JS. Conservative management of a large maxillary cyst. Int Endod J 1997;30(1):64-67.
- Hoen MM, LaBounty GL, Strittmatter EJ. Conservative treatment of persistent periradicular lesions using aspiration and irrigation. J Endod 1990;16(4):182-186.
- Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size to diagnosis, incidence, and treatment of periapical cysts and granulomas. Oral Surg Oral Med Oral Pathol 1984;57(1):82-94.
- Eversole RL. Clinical outline of Oral pathology: diagnosis and treatment, 2nd edition. Philadelphia, PA: Lea & Febiger; 1984.
Author: Dr. Brandon Barnett
Case submitted courtesy of Dr. Claudia Garces
Case History: A 49 year old male presented for evaluation and treatment of teeth #19 and #20 with the following chief complaint “My dentist said I have an infection, but it doesn’t hurt.”
Medical history: Non-contributory, ASA I
Medications: None
Allergies: NKDA
HPI: #19 RCT completed in 2020 and #20 RCT completed in 2009 both with a prior dentist. Pt reports a sinus tract of about 3 weeks duration which has partially resolved after taking Augmentin 875-125 BID for an unspecified duration.
Radiographic evaluation: Periapical and bitewing radiographs of the mandibular left posterior quadrant show existing PFM crowns and prior root canal therapy on teeth #20 and #19, with a small, nonretentive post on #20. A large periapical radiolucency is noted at the M root of #19 which is confluent with a secondary large radiolucency at #20. The radiolucency on the M root of #19 extends towards the furcation.
A limited FOV CBCT was exposed revealing an area of low density encompassing the root apices of #19 and #20. There was no evidence of missed/non-negotiated secondary anatomy. Existing root fills are greater than 0.5mm from the radiographic apex. The areas of reduced radiographic density are consistent with the appearance of apical periodontitis, and are not in close proximity to the inferior alveolar nerve.
Clinical evaluation: Probing depths ranged between 2-3mm in the mandibular left posterior quadrant save for the MB of tooth #19 where a probing depth of 10mm was noted. Sinus tract on the attached gingiva buccal to #19 was noted. Teeth #20 and #19 have class 1 mobility. Both PFM crowns on #19 and #20 present with clinically intact margins.
Testing:
#18 cold (+), percussion (-), palpation (-)
#19 cold (-), percussion (-), palpation (-)
#20 cold (-), percussion (-), palpation (-)
Diagnoses:
Tooth #20 Previously Treated, Asymptomatic Apical Periodontitis
Tooth #19 Previously Treated, Chronic Apical Abscess.
And now let's review the results from January's Case Challenge!:
Poll Results:
What would be your primary treatment choice?
- Non-surgical retreatment of #8 24%
- Apical surgery #8 53%
- Decompression 12%
- Non-surgical retreatment #8 with immediate apical surgery
- Non-surgical retreatment of #8 with immediate decompression 6%
- Intentional replantation #8
- Extraction #8 with replacement
- Extraction #7 and #8 with replacement 6%
- No treatment and monitor
Treatment Rendered: Sometimes we have the opportunity to combine multiple treatment strategies in complex cases. In this case, non-surgical retreatment of #8 was performed in tandem with decompression. After discussing his treatment plan with the referring GD, the patient was seen first by his GD for removal of the existing crown and placement of a long-term milled temporary crown. The patient then returned to our office for the post and gutta-percha removal with placement of intracanal calcium hydroxide. This was followed by immediate decompression of the lesion. The decompression technique used was the simultaneous needle aspiration and irrigation method described by Hoen et al. (JOE, 1990). This involves placement of two 16 gauge needles into the lesion with simultaneous aspiration and irrigation with saline (no long-term drain was used). 30ml of saline was used to irrigate the lesion until the aspirated fluid was clear.
After one month, the patient returned for follow-up and the buccal sinus was still present. The tooth was re-accessed and the calcium hydroxide was replaced. At the two month mark, the buccal sinus tract was healed, but the canal still had continued mild drainage internally. A third round of calcium hydroxide was applied and left in place for 3 months. When the patient returned (5 months after initiating treatment), evidence of healing was observed radiographically around #7 and #8. RCT #8 was completed with an MTA obturation and RMGI orifice barrier. Sufficient ferrule and peripheral tooth structure was present and another post was considered not necessary.
After 2 months of calcium hydroxide. Early evidence of periapical healing, The buccal sinus tract healed but the canal was still draining internally. PA taken immediately after third round of calcium hydroxide (powder) applied.
Immediate Post-op (after long-term CaOH for 5 months)
6-month recall: Tooth #8 was asymptomatic and with no buccal sinus tract present. Tooth #7 remains responsive to cold testing. The patient had not returned to their GD for the permanent crown. The mobility in #8 was notably reduced and significant healing was observed radiographically. The lesion may heal with an apical scar, but apical surgery will likely not be necessary. The patient was scheduled for a 12-month recall and advised to return to their GD soon for the permanent crown.
By Dr. Adam Gluskin
Some of my earliest childhood memories include conversations about endodontics at the dinner table. My dad, a full-time professor of endodontics, would spend his evenings refining lectures, studying radiographs, and drafting manuscripts at the end of a long workday. Long before I understood anything about the mechanics of root canal treatment or the impact it could have on a patient’s life, I understood that this specialty mattered deeply to him.
Choosing endodontics for myself brought new depth to a familiar path. Endodontics demands precision, patience, and humility. My father often reflects back on the humility of his greatest mentor, Dr. Sam Seltzer, who would often say “you could fill 20 libraries with what we don’t know”. Dr. Seltzer was not only his program director, but a pioneer in our fundamental understanding of endodontics. Even as technology advances at remarkable speed, we are still guided by the biologic principles that Dr. Seltzer and his contemporaries laid down for us.
Sharing this profession with my father has been one of the great privileges of my life. We represent different generations of the same specialty. He trained well before microscopes were commonplace; I trained never knowing a world without them. He adapted to the rise of nickel-titanium instrumentation; I entered a field already transformed by it. Today we practice with CBCT-guided diagnostics, advanced irrigation, microscopic precision, and expanding regenerative concepts. What once seemed aspirational is now routine. My conversations with my father often reflect how far endodontics has come, and how much its core principles remain unchanged.
We also both agree that despite these advancements, the essence of endodontics is still profoundly human. It is relieving pain. It is earning trust. It is connecting with patients in a moment when they feel most vulnerable.
For those entering the field without a family connection to endodontics, I want to emphasize something equally important: mentorship is core to this specialty. I have had the unique privilege of learning alongside my father, but every endodontist has access to a professional family. Our mentors, co-residents, program directors, and colleagues become the support system that carries us through challenging cases and pivotal career decisions.
Lean into that community. Call a former co-resident. Reach out to a mentor. Attend professional meetings. Ask a lot of questions. Endodontics rewards curiosity and humility, and no one succeeds in isolation.
As residents and new practitioners, we are starting our careers at an exciting moment in the evolution of our field. The pace of endodontic innovation feels extraordinary right now. But the most important constant is not the technology, but the commitment to excellence that defines our specialty. I am grateful not only for the opportunity to practice endodontics, but for the legacy, mentorship, and community that shape it. It is a specialty built on progress and sustained by those willing to continually learn and teach.
For those just beginning this journey: lean in and engage. The future of endodontics is bright, and you are an essential part of it.
By Priscilla L. Carpenter Lockhart, DDS, MS
February has a way of making us a little sentimental. Hearts, roses, sweet treats; and if you’re anything like me, maybe just a faint hint of sodium hypochlorite in the air. (Romantic, I know.)
But jokes aside, this time of year is actually a great reminder of something we don’t always pause to say: we really love endodontics.
A Love Letter to Endo
What is it about this specialty that pulls us in and keeps us here?
Maybe it’s the quiet satisfaction of finding those elusive canals.
Maybe it’s the moment a patient who walked in miserable leaves relieved.
Maybe it’s the precision, the problem-solving, the constant evolution of our field.
Endodontics is equal parts art, science, and patience, and let’s be honest, just enough challenge to keep us humble. We’ve all had those cases that test our skills (and our emotional stability), but that’s part of the love story too. The growth. The grit. The wins that feel really earned.
Sharing the Endo Love
Love for this specialty doesn’t just live in our operatories, it grows when we share it.
- Mentor a student who’s endo-curious.
- Teach a referring doctor something new.
- Encourage a co-resident before boards.
- Share a clinical pearl that makes someone’s day easier.
- Show patients what modern endodontics really looks like.
Passion is contagious. Knowledge multiplies. And our specialty gets stronger every time we lift someone else up.
Mark Your Calendars ❤️📅
MTA March Madness
Be on the lookout for more information as we gear up for some good basketball and friendly competition! There’s a nice prize at the end of this rainbow.
AAE Foundation Freedom Scholarship – Due March 6, 2026
The AAE Foundation Freedom Scholarship supports residents pursuing advanced endodontic education, with three residents selected to receive this prestigious award. If you or someone you know may be eligible, now is the time to apply and spread the word.
ABE Oral Examination – March 6–7, 2026
St. Louis, MO
To everyone preparing: we see the work you’ve put in. Stay focused, you’ve got this!
AAE Annual Meeting – April 15–18, 2026
Salt Lake City, UT
One of the best times of the year to reconnect, recharge, and re-energize your love for endodontics. Start making your plans now!
APICES – August 14–15, 2026
St. Louis, MO
It may feel far away, but it will be here before we know it. Stay tuned for more details on this can’t-miss event.
As we move through February, I hope you take a moment to reflect on what first made you fall for this specialty, and maybe find a small way to share that enthusiasm with someone else.
Because whether it’s love in the air… or just NaOCl… one thing is certain:
Endodontics still has our hearts.
With Love (and properly irrigated canals),
Priscilla Carpenter Lockhart, DDS, MS, is Chair, Resident and New Practitioners Committee and Diplomate, American Board of Endodontics.