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By Dr. Dakota Bailey, DDS 

The journey to specialize, in whatever specialty, should be after careful consideration and hands-on experience. I originally had planned to be a general dentist. I had grown up shadowing my general dentist practice and envisioned myself taking over his office after graduation. During dental school it became quite clear to me that specializing in endodontics was how I wanted to redirect my career path. This decision was made from excellent mentorship and my involvement with the American Association of Endodontists (AAE). 

As I got my application together to apply to endodontic residency, it was recommended to me that I take some time to work either in private practice or complete a General Practice Residency (GPR) to “strengthen my application” and to “get experience”. I’ll admit- I was frustrated. I felt ready. I had well surpassed the requirements for root canals needed to graduate and I was even chosen as a teaching assistant for the endodontics lab. Even so, after graduation I went to a General Practice Residency at the University of Tennessee Medical Center in Knoxville, TN. 

While I was a resident, we were able to work closely with several endodontic practices and met for study clubs learning the newest and most innovative practices involving endodontic therapy. I taught myself how to operate using a microscope and routinely performed advanced endodontic procedures—cases that would have been impossible to take on during dental school. The clinical experience was invaluable, but what truly stood out was the importance of treatment planning. I cannot stress how critical a year of general practice is when becoming an endodontist. 

In school we learn the textbook definition about what “restorability” of a tooth is. In practice, understanding restorability is an entirely different concept- deep margins, soft tissue management, and what can realistically be restored. In school you learn the ideal presentation of a crown, restoration and extraction. Life is never so simple and rarely ever ideal. I learned what the restorative dentist will likely look for because I was the restorative dentist. 

After my year in Knoxville, I went back to West Virginia University for endodontic residency, where I had attended dental school. Now in my second year, I continue to build on the foundation laid during my GPR as well as the skills I gained in my first year of residency—managing complex cases, refining my efficiency under the microscope, and deepening my diagnostic ability. Since I had already become comfortable using the microscope for both root canals and restorative procedures, the transition into residency felt more natural. More importantly, I found that being able to communicate treatment expectations from both a specialist and general dentist’s perspective helped me foster stronger relationships with both patients and referring doctors. 

I wanted to share this experience because I had the mindset of many of the dental school graduates ready to immediately take the next step to specialize. An extra year to learn, gain confidence, and practical understanding has made me a better practitioner, and I encourage others considering specialization to explore the same path. 

AAE President Dr. Steven Katz will appear in Cleveland-area issues of the September/October issue of Travel + Leisure. The article advises vacationers about what to do if dental trauma occurs while traveling. Click below to read:

The American Association of Endodontists (AAE) joined forces with members of the Organized Dentistry Coalition (ODC) in urging the U.S. Department of Education to protect dental students and residents from the adverse effects of eliminating the Graduate PLUS Loan program and imposing new federal loan caps. The coalition remains concerned that the implications of the recent changes will negatively impact the dental profession, and ultimately, the oral health of the nation. 

With the cost of dental education often exceeding $400,000, Graduate PLUS Loans remain a critical lifeline for students. Without them, many would be forced into private loans with higher interest rates, fewer protections, and less flexibility. AAE and its partners stressed that these changes could deter qualified students from pursuing dental careers, adversely impact enrollment trends, and worsen workforce shortages and access to care, particularly in underserved areas. 

The joint letter called on the Department to track tuition trends, monitor private loan terms, and study how debt pressures influence career decisions. AAE and its coalition partners emphasized that these policies could de-incentivize new dentists from choosing a career in independent practice, academia, or public health. 

AAE’s participation in this effort shows members that their Association is actively defending the profession’s future. By joining with its ODC partners, AAE is working to ensure that dental education remains accessible and that the endodontic specialty continues to attract the best and brightest. 

Link to Letter  

The American Association of Endodontists (AAE) continues to uphold its role as a champion of public health and scientific integrity by supporting legislation that preserves access to effective, evidence-based oral health interventions. Through its endorsement of the Protect Our Treatment for Enamel, Erosion, and Tooth Health (TEETH Act – H.R. 4556), the AAE joins a coalition of national dental organizations working to ensure that regulatory decisions affecting community water fluoridation are grounded in robust scientific review. 

Fluoridation of public water systems policy rooted in more than 80 years of research and practice—remains one of the most impactful and cost-effective public health measures in modern dentistry. The AAE is committed to safeguarding this trusted intervention by advocating for science-led policymaking, especially amid mounting concern over efforts to weaken the evidentiary standards that guide drinking water regulations. The TEETH Act would require the Environmental Protection Agency (EPA) to commission a rapid-response review from the National Academies of Sciences, Engineering, and Medicine before proposing changes to drinking water regulations that affect community water fluoridation. This is especially timely considering the EPA’s July 18 announcement eliminating its Office of Research and Development, the very office responsible for developing the scientific evidence that informs regulatory policy. Without this scientific infrastructure, critical decisions could be shaped by flawed, mischaracterized, or isolated studies, putting communities at risk and compromising public trust in preventive care. 

Community water fluoridation involves the controlled adjustment of naturally occurring fluoride levels to the optimal concentration of 0.7 mg/L as recommended by the U.S. Public Health Service. This simple and safe practice has been shown to reduce cavities by approximately 25 percent in children and adults. The Centers for Disease Control and Prevention have recognized it as one of the ten most significant public health achievements of the 20th century. As the cost of dental care continues to rise and provider shortages expand, eliminating or weakening support for this measure would disproportionately impact underserved populations, increase long-term health expenditures and exacerbate oral health disparities nationwide. 

AAE’s support for the TEETH Act reinforces its long-standing mission to protect access to scientifically validated equitable oral health interventions. Earlier this month, the Association joined with the American Dental Association and other organizations in a unified letter to Congress urging swift passage of the TEETH Act. This collective advocacy emphasizes the profession’s shared understanding that regulatory decisions must be anchored in comprehensive, peer-reviewed research, especially when those decisions have far-reaching implications for public health and cost-effective care. 

By standing firmly in support of H.R. 4556, the AAE calls on lawmakers to uphold scientific rigor, protect preventive oral health, and resist regulatory shifts based on misinformation or incomplete data. In doing so, the Association continues its leadership in preserving a strong, evidence-based foundation for dental practice and policy. AAE remains committed to working alongside policymakers, public health leaders, and the Organized Dentistry Coalition to ensure that sound science—not politics—guides the future of community oral health. 

Link to Letter 

AAE Membership Is More Than a Benefit. It’s a Professional Imperative.

Each year, as we enter our annual membership drive at the AAE, I find myself reflecting on two essential questions: “Why do members renew?” and “How do we get non-members to join?”

Membership, after all, is not a one-size-fits-all proposition. It means different things to different people. For some, it’s about access to cutting-edge education and training. For others, it’s a connection to a professional network or a platform for giving back. Or it could provide resources, not available elsewhere, like the leading publication and premier AAE member benefit, our Journal of Endodontics (JOE), or marketing and communications resources. Regardless, across the board, one truth holds: Membership must offer value. And not just in a transactional sense, but in the form of purpose (advocacy), community (networking), and professional empowerment (education and training, career advancement, resources and tools, and support for the specialty).

Years ago, American Express (AmEx) had a marketing campaign that redefined what it meant to be part of a membership community with the now-iconic campaign, “Membership Has Its Privileges.” Up to this point, credit cards functioned solely as a transactional tool to facilitate the purchase of goods and services. Typically, there were no fees — or rewards — for the consumer. American Express changed all of that! By convincing consumers there was value to owning and using an AmEx card, consumers adopted a pay-to-play mindset and were suddenly willing to pay to use the card.

This campaign launched a revolution in the credit card market and today, consumers regularly pay annual fees—sometimes thousands of dollars—for the perceived value of carrying a specific card. And it all started with the idea that membership, when done right, should offer more than just function—it should deliver meaning! From green to gold and black to platinum, with perks from cash back to lounge access and flight upgrades, the credit card industry has found a way to convince their members that there is value in owning their card.

So what does that mean for the AAE? How do we create and deliver that kind of value? Not just to inspire loyalty, but to cultivate leadership, foster connection, and elevate our specialty?

A Strong Foundation … With Room to Grow

Today, approximately 82% of the endodontists in the United States belong to the AAE, significantly higher than the majority of other dental specialty organizations and general dental membership, which has been struggling for years and currently hovers around 50%. AAE’s resident-to-member conversion rate is 92%, and our overall retention rate floats at about 94%.

While these are strong numbers, we are confident we can do better! We believe we can offer something meaningful for everyone, across every stage of their professional journey such as:

  1. Clinical Excellence and Education at Every Level. AAE provides unmatched access to world-class education, designed to keep members on the leading edge of endodontics.
    • Annual Session. AAE 2026 heads to Salt Lake City, Utah for the first time, April 15–18. After record attendance in Boston, our next Annual Session promises even more breakthrough content, innovations, and networking.
    • On-Demand CE and Webinars. 24/7 access to online learning on emerging topics in endodontics.
    • Subscription to the JOE, Colleagues for Excellence, this very Communiqué, and several more e-newsletters.
  1. A Force for Advocacy. AAE doesn’t just support its members. It protects their future.
    • Legislative and Regulatory Advocacy. From specialty recognition and scope of practice to insurance and student debt relief, AAE ensures endodontists are heard in both state and federal policy debates.
    • Recent Wins. Read more in our August issue about recent victories in Ohio and on Capitol Hill regarding PTET.
    • Coalition work. We partner with leading dental and healthcare organizations to amplify our collective voice on public health issues like fluoride, licensure portability, and dental loss ratios (DLR).
  1. Advancing Research and Innovation. Through the Foundation for Endodontics, the AAE invests in:
    • Research Grants and Funding
    • Access to Care Initiatives that bring our specialty to underserved communities.
    • Support for academic pathways and innovation in the science of endodontics.
  1. Career Development and Leadership Support. From residency through retirement, we walk alongside our members. Whether you’re seeking your first position or shaping the next generation of leaders, AAE is a resource and a partner.
    • Job Boards, Career Fairs and Mentorship. Job postings monthly in the JOE, career fair annually at AAE annual session. Mentorship at all career stages.
    • Leadership Training. Bi-annual Leadership Development Program.
    • Resident-Centered Programs. APICES
  1. Community, Connection, Contributing. AAE fosters a sense of belonging and collaboration. We are stronger together—and our members bring that strength to life.
    • Regional and National Events
    • Online Forums for Peer Connection
    • Volunteer Opportunities through the Foundation for Endodontics
  1. Practice Support and Patient Communication. AAE equips members with tools to succeed in private practice:
    • Patient Education Materials. Brochures, videos.
    • Risk Management Tools. Webinars and insurance resources.
    • Marketing resources to support referrals and practice growth. Marketing and social media “toolkits”, Save Your Tooth Month, Worth Saving Campaign, Satellite Media Tours.
    • Guidance on coding, compliance. Practice Affairs Committee, Code Maintenance Committee.

More Than a Membership

As you can see, the AAE offers something meaningful for everyone—whether you’re advancing your clinical skills, advocating for the specialty, mentoring future leaders, building your network, or growing your practice.

Our goal is not simply to maintain strong membership numbers. It is to ensure every member finds purpose, value, and connection. And if you don’t yet see a program or initiative that speaks to your goals or those of a colleague, I invite you to reach out.—because your voice shapes what comes next.

At its heart, membership in the AAE is not just about access to resources—it’s about alignment with your values, your aspirations, and our profession’s future. Membership has its privileges, yes, but more importantly, it has impact. By investing in the AAE, you are investing in yourself, your colleagues, and the enduring strength of endodontics.

In short: AAE membership does indeed have its privileges—because it’s built around you.

By M. A. Saghiri, DEng, MS, PhD

Abstract:
Diabetes mellitus induces significant changes in root canal dentin, altering both its mineral content and nanoscale crystal organization. These modifications influence the precision of canal shaping, the effectiveness of adhesive bonding, and the long-term prognosis of endodontic treatments. Despite growing evidence of these substrate differences, most clinical protocols remain uniform for all patients. It reviews the key chemical and structural alterations observed in diabetic dentin and presents practical recommendations for integrating a systemic-aware workflow to improve safety, efficacy, and treatment outcomes.

Introduction:
Successful endodontic therapy depends on predictable dentin properties to guide instrumentation, ensure reliable adhesion, and achieve a fluid-tight seal. In patients with diabetes mellitus, chronic hyperglycemia disrupts mineral homeostasis and leads to non-enzymatic glycation and oxidative stress that affect dentin microstructure1. As the global prevalence of diabetes continues to rise, clinicians must recognize and adapt techniques to address the unique characteristics of diabetic dentin2. A proactive, systemically informed approach that accounts for medical conditions can help reduce treatment risks.

Most clinical protocols overlook structural and chemical changes in dentin caused by diabetes. Reduced trace minerals, altered collagen and disrupted crystal organization can weaken dentin, impair smear layer formation and reduce bonding effectiveness3-5. These changes may increase the risk of procedural errors and restorative failure if not addressed. They can also affect how dentin responds to instrumentation, irrigation and obturation materials6. As a result, untreated variations in diabetic dentin may compromise both immediate and long-term treatment success. The purpose of this study is to examine these alterations in diabetic root dentin and to propose practical adjustments that support safer and more effective endodontic treatment in patients with diabetes.

Methods:
This study was conducted in accordance with the ethical guidelines approved by the Institutional Review Board at Rutgers School of Dental Medicine (Protocol No. Pro2019002923). A total of 20 extracted human molars were collected, anonymized, disinfected in 0.1% thymol, and stored at 4°C. All teeth were used within three months of extraction. The samples were evenly divided into two groups: individuals with type 2 diabetes mellitus (n = 10) and non-diabetic controls (n = 10). The diabetes group included individuals with a diagnosis of at least five years and HbA1c values of 7.0% or lower, recorded within three months of extraction7. Age- and sex-matching was applied across groups. Information about diabetes medications such as insulin or metformin was recorded when available but was not used as a selection criterion. Each tooth was sectioned at the cementoenamel junction, and dentin discs were prepared from the mid-root region (5–7 mm from the apex) using a low-speed diamond saw under continuous water irrigation7. The discs were rinsed with deionized water and stored in sealed, contamination-free tubes until analysis.

Elemental analysis was performed using inductively coupled plasma mass spectrometry (ICP-MS; Agilent 7900, USA) following acid digestion in high-purity nitric acid (70% HNO₃, Fisher Optima). Each sample was analyzed in triplicate. Calibration was performed using certified multi-element standards (Inorganic Ventures), and elements measured included lithium, magnesium, manganese, zinc, strontium, copper, and selenium8, 9. Detection limits were 0.5 parts per billion (ppb) for lithium and 1.2 ppb for selenium. Statistical analysis was conducted using SPSS version 27.0 (IBM Corp.). Group comparisons were performed using one-way analysis of variance (ANOVA), followed by Tukey’s post hoc test. Statistical significance was defined as p < 0.05. Confidence intervals (95%) and Cohen’s d effect sizes were also calculated.

Findings:
Our comparative analysis of molar dentin from well-controlled diabetic donors and matched non-diabetic controls revealed two primary alterations. First, diabetic dentin showed a 20 to 35% reduction in key trace minerals, magnesium, zinc, strontium, lithium, manganese, and selenium, with a 15% increase in copper levels. Since magnesium and zinc support crystal hardness and strontium and selenium contribute to antimicrobial defense, their depletion paired with higher copper (a marker of oxidative stress) creates a chemically distinct substrate with compromised mechanical and biological properties10, 11 (Fig 1) illustrates the loss of Mg²⁺/Zn²⁺ and concurrent enrichment of Cu²⁺ in the diabetic dentin lattice compared to healthy dentin. Second, imaging analysis showed diabetic dentin contains 2.5 times more mineral crystallites per unit area. However, each crystallite is 20 to 30% smaller and arranged in a less compact, mixed polycrystalline and amorphous network. This finer, heterogeneous scaffold increases surface area while weakening intercrystalline bonds, making the dentin more vulnerable to procedural damage and less receptive to adhesive infiltration12.

Clinical Implications:

The softer, heterogeneous nature of diabetic dentin raises the risk of procedural errors. Rotary or reciprocating files may overcut or deviate in areas of reduced hardness, leading to ledges, canal transportation, or perforations13. Altered smear layer characteristics and ion deficiencies can undermine resin infiltration and polymerization, increasing the potential for microleakage and restoration failure. The weakened crystal network increases susceptibility to vertical root fractures (VRFs), as reduced crystallite size and disordered mineral alignment have been linked to diminished fracture resistance in dentin14. A conservative recall schedule of every 6 to 12 months is advised to monitor restoration integrity and early signs of failure, although long-term clinical data in diabetic populations remain limited.

Recommended Protocol Adjustments:

Incorporating systemic health considerations into endodontic treatment protocols is essential for optimizing outcomes in patients with diabetes mellitus (Fig 2) shows each dentin change next to the matching treatment step for easier comparison. Risk stratification should begin with documentation of the patient’s diabetes status, including HbA1c levels and disease duration, followed by a clear discussion of how these systemic factors may compromise dentin structure and influence clinical decision-making. Access preparation must be deliberately conservative, providing sufficient visibility and straight-line canal access while minimizing unnecessary removal of pericervical dentin. A manual glide path should be established using size 10 or 15 stainless-steel hand files prior to introducing rotary instruments. During shaping, rotary files should be operated at 150–200 rpm with a torque limit of 1.0–1.5 N·cm to reduce stress on dentin that may already be weakened by microstructural alterations associated with chronic hyperglycemia6. Irrigation protocols should include the use of 17% EDTA for no longer than 1–2 minutes to avoid excessive demineralization, followed by a thorough saline rinse15. To minimize the risk of microcrack propagation in brittle dentin, irrigant activation should employ low-frequency sonic devices (1–2 kHz) rather than high-powered ultrasonics16. During obturation, the use of bioactive, ion-releasing sealers that liberate magnesium, strontium, or zinc may support remineralization and enhance dentin stability17, 18. Adhesive strategies should be adapted to diabetic substrates by selectively removing the smear layer, utilizing primers containing functional monomers such as 10-MDP, and maintaining a moist dentin surface to facilitate optimal resin infiltration19. Final restorative planning must emphasize ferrule preservation and cuspal coverage to distribute occlusal forces and prevent structural failure. Radiographic follow-up at 6- to 12-month intervals is recommended to monitor healing and detect early signs of post-treatment complications, particularly in patients with suboptimal glycemic control20.

Future Directions:

Future research should focus on developing tailored biomaterials such as sealers with controlled ion-release kinetics or nanoparticle additives to reinforce crystal networks. Instrument manufacturers could design novel alloys and file geometries specifically for low-hardness substrates. Well-designed clinical trials comparing systemic-aware workflows to conventional protocols will be essential to validate these approaches and measure technical outcomes as well as patient-centered metrics like postoperative sensitivity and tooth survival.

Conclusion:
Diabetes causes profound chemical and structural changes in root canal dentin. Recognizing these alterations and adopting a systemic-aware endodontic protocol, including risk assessment, conservative access, gentle shaping, controlled irrigation, bioactive materials, enhanced bonding, and protective restorations, can reduce procedural complications, improve adhesive performance, and extend the functional lifespan of endodontically treated teeth in diabetic patients.

Figures:

Figure 1. Ion Displacement and Lattice Destabilization in Diabetic Dentin
This image compares healthy and diabetic dentin at the nanoscale. Healthy dentin has a stable calcium network with trace ions such as magnesium, zinc, strontium, selenium, and copper, which are evenly embedded and support strong cutting and reliable bonding. In diabetic dentin, high blood sugar causes nonenzymatic glycation that breaks calcium links, forcing out magnesium and zinc and allowing extra copper to fill the gaps. This disruption makes the dentin more brittle, produces uneven debris during cutting, and weakens sealer bonding.

Fig. 2. Systemic-Aware Endodontic Protocol for Diabetic Dentin
From left to right, the figure assesses the patient’s medical history and obtains informed consent, prepares a conservative access cavity to protect compromised dentin, employs gentle low-torque instrumentation for canal shaping, places a bioactive sealer with activated irrigation to maximize disinfection and seal integrity, and arranges more frequent follow-up visits for early detection of leaks or fractures.

References:

  1. Bueno EM, Glowacki J. Biologic foundations for skeletal tissue engineering: Morgan & Claypool Publishers; 2011.
  2. Kidambi S, Patel SB. Diabetes mellitus: considerations for dentistry. The Journal of the American Dental Association. 2008;139:8S-18S.
  3. Goldberg M, Kulkarni AB, Young M, Boskey A. Dentin: Structure, Composition and Mineralization: The role of dentin ECM in dentin formation and mineralization. Frontiers in bioscience (Elite edition). 2011;3:711.
  4. Vital SO, Gaucher C, Bardet C, Rowe P, George A, Linglart A, et al. Tooth dentin defects reflect genetic disorders affecting bone mineralization. Bone. 2012;50(4):989-97.
  5. Saghiri MA, Vakhnovetsky J, Samadi E, Napoli S, Samadi F, Conte M, et al. Effects of Diabetes on Elemental Levels and Nanostructure of Root Canal Dentin. J Endod. 2023;49(9):1169-75.
  6. Saghiri MA, Aminsobhani M, Gutmann JL, Kawai T, Nath D, Hirschberg C. Effect of Diabetes on Rotary Instrumentation of Dentin. J Endod. 2021;47(8):1301-7.
  7. Saghiri MA, Rahmani B, Conte M, Nath D, Peters O, Morgano S. Diabetes Mellitus Affects the Microhardness of Root Dentine: An in-vitro Study. Eur Endod J. 2022;7(2):122-8.
  8. Attinger D, Moore C, Donaldson A, Jafari A, Stone HA. Fluid dynamics topics in bloodstain pattern analysis: Comparative review and research opportunities. Forensic science international. 2013;231(1-3):375-96.
  9. Kumagai A, Fujita Y, Endo S, Itai K. Concentrations of trace element in human dentin by sex and age. Forensic science international. 2012;219(1-3):29-32.
  10. Shaik I, Dasari B, Shaik A, Doos M, Kolli H, Rana D, et al. Functional Role of Inorganic Trace Elements on Enamel and Dentin Formation: A Review. J Pharm Bioallied Sci. 2021;13(Suppl 2):S952-S6.
  11. Saghiri MA, Vakhnovetsky J, Vakhnovetsky A, Ghobrial M, Nath D, Morgano SM. Functional role of inorganic trace elements in dentin apatite tissue-Part 1: Mg, Sr, Zn, and Fe. J Trace Elem Med Biol. 2022;71:126932.
  12. Noohi P, Abdekhodaie MJ, Nekoofar MH, Galler KM, Dummer PM. Advances in scaffolds used for pulp–dentine complex tissue engineering: A narrative review. International endodontic journal. 2022;55(12):1277-316.
  13. Peters OA, Arias A. Rotary and reciprocating motions during canal preparation. Endodontic Advances and Evidence‐Based Clinical Guidelines. 2022:283-310.
  14. Patel S, Bhuva B, Bose R. Present status and future directions: vertical root fractures in root filled teeth. International Endodontic Journal. 2022;55:804-26.
  15. Wagner MH, Da Rosa RA, de Figueiredo JAP, Duarte MAH, Pereira JR, Só MVR. Final irrigation protocols may affect intraradicular dentin ultrastructure. Clinical oral investigations. 2017;21(7):2173-82.
  16. Sachdeva N, Nikhil V, Jha P. Effect of ultrasonic root-end cavity preparation on dentinal microcrack formation: A micro-computed tomography study. Journal of Conservative Dentistry and Endodontics. 2019;22(4):362-6.
  17. Pires PM, Neves AdA, Makeeva IM, Schwendicke F, Faus-Matoses V, Yoshihara K, et al. Contemporary restorative ion-releasing materials: Current status, interfacial properties and operative approaches. British Dental Journal. 2020;229(7):450-8.
  18. AlGhannam MI, AlAbbas MaS, AlJishi JA, AlRuwaili MA, AlHumaid J, Ibrahim MS. Remineralizing effects of resin-based dental sealants: a systematic review of in vitro studies. Polymers. 2022;14(4):779.
  19. Pegado REF, do Amaral FLB, Flório FM, Basting RT. Effect of different bonding strategies on adhesion to deep and superficial permanent dentin. European journal of dentistry. 2010;4(02):110-7.
  20. Caussin E, Izart M, Ceinos R, Attal J-P, Beres F, François P. Advanced material strategy for restoring damaged endodontically treated teeth: a comprehensive review. Materials. 2024;17(15):3736.

By Keith R. Boyer, DDS

The concept of Artificial intelligence (AI) has existed for many years, but recent advances in technology, such as ChatGPT, have brought AI to the forefront of our daily lives. This explosive growth of technology has a profound opportunity to reshape medicine, research, and education. Machine learning, a subset of AI with particular relevance to dentistry, trains models to recognize patterns in data such as images: This has allowed for computer assistance in detecting various findings in radiographic images with a high degree of accuracy.1 AI-powered clinical decision support (CDS) tools based on machine learning are used in dentistry to efficiently aid clinicians in diagnosis, to process insurance claims, and more recently, to assist in dental education.2

“You don’t know what you don’t know.”

As the above adage goes, AI models and dental students alike cannot find what they are not taught to see. For AI software, the output depends on how it was trained and the algorithms employed in decision-making, and this process is not always readily transparent.1 Therefore, clinicians should exercise caution interpreting results from AI CDS tools. When teaching radiographic interpretation to dental students, faculty describe features of caries and periapical radiolucent lesions (PARLs) and provide sample illustrations. Students then build upon this foundational knowledge through clinical encounters. AI CDS tools can augment this experience with the simple click of a button, showing students what to look for in an unlimited number and variety of clinical examples (Figure 1), helping to bridge the gap between novice and expert dentist. This technology may also assist in patient education and case acceptance by giving patients with untrained eyes the ability to clearly see areas of concern.

Figure 1: First image, a periapical radiograph without AI CDS tools. Second image, a periapical radiograph in which Overjet AI software highlights caries, periapical radiolucency, and the pulp space of each tooth shown.

As part of their training, students are instructed to interpret the entire image, but PARLs may be missed due to lack of a related chief complaint or because of the difficulty identifying such lesions in 2D imaging due to overlapping structures.3 Busy faculty may overlook such findings as well. One study of radiographic periapical diagnosis of posterior teeth showed a sensitivity of 65% and a specificity of 78%, suggesting that many PARLs go undetected or are misdiagnosed as false positives by clinicians.4 AI tools trained to detect PARLs in 2D radiographs and 3D CBCT imaging may result in greater accuracy than unaided practitioners. A recent systematic review with meta-analysis of AI detection of PARLs in 2D and 3D imaging showed pooled sensitivity of 92.5% and specificity of 85.2%.5 Another found pooled sensitivity of 94% and specificity of 96%.6 While this is aggregate data of PAs and CBCTs, these examples suggest that artificial intelligence may improve practitioners’ ability to recognize PARLs more consistently. One potential benefit of AI CDS tools in dental education is to act as a failsafe and quality assurance to identify undocumented PARLs and possibly address instances of untreated disease.

On the other hand, endodontic residents will be faced with referring dentists who are using AI CDS tools, and they may be pressured to “treat the radiograph.” When a commercial AI-based platform was used to evaluate outcomes of endodontic treatment, the software resulted in lower specificity compared to clinicians, which if used without checking could result in overdiagnosis and unnecessary retreatment.7 Endodontic residents need to be prepared to discuss why this technology is not foolproof. To most efficiently implement such software, one must learn its limitations, understanding the strengths and weaknesses.

It is crucial that educators teach students to use technology responsibly. As dental students graduate and enter modern practice, the hope is they do not blindly trust what AI software tells them. Instead, they should utilize it with a critical eye for its intended purpose, to support and assist diagnosis. Large carious lesions or the presence of PARLs should alert the clinician to evaluate the pulpal status of teeth in question. It should not be assumed that every tooth with PARL needs endodontic therapy. Practitioners can use AI CDS systems to assist in the screening of images but must integrate all available diagnostic information and clinical judgment to establish periapical diagnoses. An educator’s responsibility is to ensure that graduates will be prepared to practice safely and with confidence in this world of ever-changing technology.

References

  1. Arsiwala-Scheppach LT, Chaurasia A, Muller A, Krois J, Schwendicke F. Machine Learning in Dentistry: A Scoping Review. J Clin Med. 2023; 12(3).
  2. Aminoshariae A, Nosrat A, Nagendrababu V, Dianat O, Mohammad-Rahimi H, O’Keefe AW, et al. Artificial Intelligence in Endodontic Education. J Endod. 2024; 50(5): 562-578.
  3. Endodontists AAo. Competence in the Diagnosis of Endodontic Treatment. 2017.
  4. Bohay RN. The sensitivity, specificity, and reliability of radiographic periapical diagnosis of posterior teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 89(5): 639-42.
  5. Sadr S, Mohammad-Rahimi H, Motamedian SR, Zahedrozegar S, Motie P, Vinayahalingam S, et al. Deep Learning for Detection of Periapical Radiolucent Lesions: A Systematic Review and Meta-analysis of Diagnostic Test Accuracy. J Endod. 2023; 49(3): 248-261 e3.
  6. Pul U, Schwendicke F. Artificial intelligence for detecting periapical radiolucencies: A systematic review and meta-analysis. J Dent. 2024; 147: 105104.
  7. Allihaibi M, Koller G, Mannocci F. Diagnostic Accuracy of a Commercial AI-based Platform in Evaluating Endodontic Treatment Outcomes on Periapical Radiographs Using CBCT as the Reference Standard. Journal of Endodontics. 2025; 51(7): 898-908.e8.

Keith R. Boyer, DDS is an Associate Professor and Coordinator of Endodontic Care at Western University of Health Sciences, College of Dental Medicine in Pomona, CA. He has no conflicts of interest to report.

Disclaimer

The views and opinions expressed by authors are solely those of the authors and do not necessarily reflect the official policy or position of the American Association of Endodontists (AAE). Publication of these views does not imply endorsement by the AAE.

Compiled by Rae Burach

Dr. Samuel Dorn is the President of the Asian Pacific Endodontic Confederation (APEC). He is the Past President of the AAE (2002-2003), the International Federation of Endodontic Associations (IFEA, 2014-2016), and the Florida Association of Endodontists, and a Diplomate of the American Board of Endodontics. Dr. Dorn has been a revered educator and leader at several institutions and was the AAE’s 2013 Edgar D. Coolidge Award recipient.

We spoke with Dr. Dorn about his role as APEC President and what attendees can expect at APEC 2025 PanEndo. The conference will take place December 3-5, 2025, in Cairo, Egypt. For more information and to register, click here.

AAE: When did you join the APEC and how did you become involved in volunteer and leadership roles?

Dr. Samuel Dorn: The Asian Pacific Endodontic Confederation (APEC) is an organization that is similar to other international endodontic groups such as the International Federation of Endodontic Associations (IFEA), the Societie Endodoncia de Latin America (SELA), and the European Society of Endodontology (ESE). These are groups of national endodontic societies, which means that all members of the national society, such as the AAE, are automatically members of the international group.

The AAE joined APEC in 2003, when I was AAE President, at the urging of the Canadian Association of Endodontists (CAE), since we were part of the Pacific Rim. I became involved in volunteer roles when I graduated from my endodontic residency and was asked to help in local organizations such as the South Florida Endodontic Study Club. This led to the Florida Association of Endodontists and to the AAE. I didn’t know how to say “NO.”

AAE: You have led many endodontic organizations in the past, including the AAE and IFEA. How have those experiences prepared you for your role as APEC President?

Dr. Dorn: My first international meeting was the first-ever IFEA meeting in Mexico City. There, I met many talented endodontists from all over the world—primarily Europe and South America—many of whom had trained in the United States but brought unique perspectives and skills from their own countries. That experience quickly taught me that American endodontists are not the only high-caliber practitioners in the field.

Since then, I’ve attended and lectured at numerous international endodontic meetings, exchanging ideas and techniques with colleagues from across the globe. While serving as a Director of the ABE, I even had the opportunity to help dentists in other countries gain recognition for endodontics as a specialty. These experiences broadened my understanding of the specialty, sharpened my leadership skills, and strengthened my belief in the power of global collaboration.

AAE: From your perspective, why are international organizations like APEC crucial to the evolution of our specialty?

Dr. Dorn: People are the same everywhere—teeth and pulpal tissues don’t change based on geography. What changes is how we approach diagnosis, treatment, and innovation. International organizations give us the chance to share research, compare techniques, and learn from one another’s strengths.

Personally, I’ve learned SuperEBA techniques from Dr. Pepe Oynick in Mexico, bone grafting from Dr. Gabriel Pecora in Italy, and early NiTi instrument applications from Dr. Henry Kim in South Korea. These exchanges not only improve patient care but also accelerate the pace at which our specialty evolves worldwide.

AAE: What can attendees expect from the combined APEC2025 and EAE’s PanEndo: From Africa to the World?

Dr. Dorn: Africa currently does not have a continent-wide endodontic organization—yet. When I chaired IFEA’s Education Committee, I was invited to help establish an endodontic department in Central Africa, where none existed. With the help of my resident, Dr. Collins Okwen, we founded the Department of Endodontics at Benin University. Later, as IFEA President, I was proud to hold our meeting in South Africa, home to many exceptional endodontists.

This combined meeting will give attendees a truly global perspective, with leading voices from Europe, Asia, the Pacific, and hopefully many from Africa. My hope is that the knowledge and inspiration gained will encourage the formation of a unified African endodontic body—ultimately helping to preserve more natural teeth and improve oral health across the continent.

AAE: What are you most looking forward to at APEC2025 PanEndo?

Dr. Dorn: Egypt is uniquely positioned at the crossroads of Europe, Asia, and Africa. I’m excited for the opportunity to bring together practitioners from these regions—and, ideally, from the Americas as well. The more diverse our gathering, the richer the exchange of ideas. Ultimately, my goal is simple: to work together to save more teeth and, in doing so, contribute to a healthier world.

Showing up, speaking out, and staying engaged matters—now more than ever.

Advocacy is more than just lobbying—it’s the power of citizens and professionals, like you, speaking out for what matters most. In this case, your patients, your practice, and the integrity of your profession.

We most often associate advocacy with lobbying corporations, such as Big Pharma, insurance, oil and gas, and tobacco, as these industries are known for influencing legislation through deep pockets and high-powered lobbyists. So we naturally associate ‘advocacy’ with negative connotations.

But that’s not the whole picture.

While it’s easy to think, “Why do I need to sign on to this? How can one endodontist affect policy on such a global scale?”, recent “wins” in dentistry demonstrate that meaningful policy change doesn’t always come from large industry—it often starts with individuals like you.

When Grassroots Advocacy Works: Ohio’s Specialty Law Scare

While large-scale lobbying dominates headlines, real impact often starts at the grassroots level. Such was the case in my own state of Ohio, where endodontists recently faced a quiet but serious threat to our profession.

An implant organization recently petitioned the state dental board to alter the definition of dental specialties. Their proposal would allow any dentist—regardless of formal postdoctoral training—to market themselves as a “specialist” after completing a weekend course and receiving a certificate. This change would blur the line between dentists who have undergone years of rigorous, accredited specialty training and those who have completed brief, non-accredited programs, often held at resort-style seminars. Under the proposed rule, a dentist could attend a short course on implant placement and then advertise themselves as an “implantologist”—despite the fact that no such recognized dental specialty exists.

Through local grassroots efforts, the AAE, the Ohio Association of Endodontists (OAE), and eventually other specialty groups and the ADA, mobilized quickly. Together, they petitioned the State Dental Board and the Governor to halt the changes. AAE provided template letters, built email campaigns, and made it easy for Ohio endodontists to speak out. The message: “This proposal was not aligned with the Board’s mission—to protect patient care” was clear, coordinated, and convincing—and it worked.

Ultimately, the dental board chose not to proceed with the change — for now. But make no mistake—it’s a temporary win. It’s important to recognize that if this were to pass in Ohio, other states would quickly follow in a snowball effect. The threat isn’t theoretical—it’s ongoing.

Advocacy at the Federal Level: PTET and Financial Equity

Another major advocacy effort came with the recent “Big Beautiful Bill” in Congress, which threatened to eliminate the pass-through entity tax (PTET) deduction. This deduction has been essential for most dental practices, especially in high-tax states like New York and California, where the state and local tax (‘SALT’) cap disproportionately affects small and mid-sized business owners. Preserving the PTET tax deduction matters because:

  • Most endodontic practices operate as pass-through entities—solo or small group practices.
  • PTET allows practice owners to reduce their federal taxable income, easing the overall tax burden.
  • More capital remains in the practice allowing for reinvestment in equipment, staffing, continuing education, and patient care initiatives.
  • It helps level the playing field with large dental service organizations (DSOs) and corporate dental models, which may already benefit from different tax structures and economies of scale.

In essence, this provision helps ensure that endodontists can remain competitive, independent, and focused on clinical excellence. Their financial sustainability is a public health win and a strategic reinforcement of the patient-centered dental model.

This legislative outcome underscores the power and necessity of professional advocacy. Organizations like the AAE and other dental coalitions played an active role in educating lawmakers about how tax policy directly affects access to specialty dental care. Thanks to AAE and ADA advocacy, members were encouraged to contact legislators using pre-filled forms and tailored messaging. It worked. The deduction was preserved.

This was the largest grassroots advocacy effort the AAE has ever participated in and it was successful — Because of you!

We Still Have Work To Do

Don’t misunderstand, there is still much work to do.

  • Ohio’s dental board will revisit the specialty rule. As will other states.
  • Two states have already removed fluoride from municipal water supplies. More will follow.
  • Tax, regulatory, and access-to-care issues continue to emerge. And re-emerge.

These issues, and others, will require us to act again. To mobilize. To show up. To speak up. To spread the word repeatedly about what is best for our patients and our practices.

As the policy landscape continues to evolve, dental professionals must stay engaged—working together to amplify our voices on healthcare, regulatory, and tax issues that shape the future of our profession. So the next time you think, “Why should I bother?”, remember this:

You already made a difference. And you can again.

Compiled by Elisabeth Lisican

When you think of community water fluoridation advocacy, an endodontist might not be the first professional who comes to mind. But Dr. Brandon Barnett is helping to change that. A Diplomate of the American Board of Endodontics and member of the AAE’s Resident and New Practitioner Committee, Dr. Barnett brings a unique blend of clinical expertise and public health training to the table. He completed dental school at the University of New England College of Dental Medicine, a GPR at UT Houston, endodontic residency at Rutgers School of Dental Medicine, and earned a Master of Public Health degree in Health Policy from the Yale School of Public Health. During Connecticut’s 2025 legislative session, he played a key role in supporting—and ultimately helping to pass—landmark legislation safeguarding water fluoridation. In this conversation, Dr. Barnett shares how a course project turned into state policy impact, how endodontists can contribute to prevention efforts, and what advice he has for colleagues interested in advocacy.

Lisican: Can you walk us through your involvement in the effort to preserve water fluoridation in Connecticut—how did it begin, and how did your role evolve?

Dr. Brandon Barnett: There were really two events that were pretty central to my involvement with my efforts to preserve water fluoridation in Connecticut. A health law project, and a fellowship with the Connecticut Oral Health Initiative (COHI)

During the Fall of 2024 in my masters at Yale, I was tasked with making a legal “toolbox” as a major project in a course on health law—since as we all know well, the law can be a powerful tool in public health both for better and for worse. Basically, the goal of this project was to identify a problem in public health and come up with strategies in which the law, or policy, could be used to address said problem. I had fully intended to write about Medicaid reimbursement in dentistry and access to care for procedures like root canals, but when the 2024 election ended and it became clear that vocal critics of water fluoridation might be taking key positions in public health, I very quickly shifted gears to discuss some of the ways we could preserve water fluoridation using the law instead.

The first part of the project which pieces together the legal and historical landscape of water fluoridation really became a robust analysis of fluoridation in nearly every major aspect, from 1945 until the now-infamous and deeply flawed California decision in Food & Water Watch, Inc. v. EPA, which alleged that water fluoridation presented an unreasonable risk of injury. Long story short; it was well received. So with the suggestion and guidance from my professor Shelley Geballe, we circulated this first part of my paper as a memo to the Connecticut Department of Public Health, and to a fellow grad student who worked with Sen. Anwar, one of the co-chairs of the Connecticut General Assembly’s public health committee. This was done under the correct assumption that water fluoridation would likely come up as a central issue in the upcoming legislative session.

When the 2025 legislative session came around I started working directly with the Connecticut Oral Health Initiative (COHI) at the state capitol. In addition to lobbying for quality, affordable oral health, COHI also saw water preserving fluoridation as a priority. So there, not only was I able to share my memo with the members of a rapidly growing oral health coalition from around the state, I was able to use what I learned from working on the topic of water fluoridation to function as a subject matter expert. So throughout the legislative session, I was able to talk about the importance of water fluoridation at length in every opportunity I had, at legislative breakfasts, conferences, zoom calls and of course in public health hearing testimony. In February, Sen. Anwuar introduced the fluoride bill (SB1326) which codified water fluoridation in Connecticut at a range 0.7 of a milligram per liter with a deviation limited to 0.15mg/L upper and lower limits which has long been proven to be a safe and effective dose. The language of this bill eventually made it to the state’s budget implementer and was signed into law by Gov. Lamont on June 30, with a press release on July 14. It was a huge win for everyone involved, a real team effort.

Lisican: What motivated you personally or professionally to take up this cause?

Dr. Barnett: As endodontists we often feel very isolated from the realm of public health. We’re interventionists, so by all accounts the work we do is not necessarily considered preventative. I was already doing an MPH in health policy with a major focus on quality of care, and increased Medicaid coverage  for endodontic procedures… but I was motivated to shift gears towards the topic of water fluoridation because for one, I wanted to prove to myself that even endodontists have a role to play in prevention, and two because we are at a critical moment in time for the future of water fluoridation.

Lisican: How did you go about drafting the fluoride memo? What key points did you want lawmakers to understand?

Dr. Barnett: So as you probably gathered my initial project wasn’t necessarily intended to be a memo. While writing for my project I certainly had imagined decision-makers reading it some day and hopefully taking something away that they could use to affirm that water fluoridation was indeed important. Given how far this memo circulated,  I certainly hope it helped lawmakers and stakeholders the way I intended. The main points in the memo that I wanted readers to understand is that we know that community water fluoridation is safe because there are well-documented side effects from fluoride exposure at levels that we can already prove. Moreover, if we hypothetically did want to truly limit “excessive” fluoride exposure in a legislative capacity one day, eliminating community water fluoridation would still not be the answer. I cite a study done on maternal urinary fluoride that shows that community water fluoridation may only account for only 43 – 50% of overall fluoride exposure. Unlike levels in the water supply, which are very strictly regulated and maintained, these other sources are almost entirely unregulated!

Lisican: What strategies did you use to build support among legislators and stakeholders?

Dr. Barnett: The first thing I did at the start of the legislative sessions was participate in several small virtual and phone meetings with legislators. This was the first time I had done something like this and it was part of my work with the Connecticut Oral Health initiative. The strategy of COHI, their policy director Sandra Ferreira-Molina and COHI Executive Director Rep. Gary Turco, was well thought out and involved these small meetings early on to build a sense of familiarity and to discuss our legislative priorities. We’re talking about meetings that were not even 5 minutes long in some cases. These initial meetings later expanded to invitations to several events that we organized, like legislative breakfasts, virtual town halls, and the COHI annual meeting. Simultaneously we held coalition meetings with representatives from oral health organizations across the state to come to discuss what we felt was really important to the cause, who then attended these events with legislators as well. It really built a sense of familiarity and brought all relevant stakeholders together. As the legislative session went on and the bills relevant to use evolved, the discussions at these meetings were able to maintain a real sense of continuity and you began to see support for our oral health initiatives like preserving water fluoridation grow.

Lisican: How did you leverage your clinical expertise to influence policy conversations?

Dr. Barnett: My clinical expertise really helped give me credibility. As dental providers we are as close as it often gets to being experts on fluoride and as endodontists we are certainly familiar with the consequences of what might be inadequate fluoride exposure. I often would share an anecdote from my clinical experience about the difficulties patients often have in accessing our services and tie in the fact that the fluoride from their water supply is actually the only real dental “intervention” many actually get in a given year, especially for those facing cost or access barriers to treatment.

Lisican: You gave testimony and participated in legislative breakfasts and Zoom calls. What messages did you prioritize in those settings?

Dr. Barnett: In each of these settings I reminded participants that, while not being the first state to have fluoridated water, Connecticut has a proud history of being the first state to require community water fluoridation by law—so a little state pride was thrown into the mix. I highlighted data showing that maintaining the optimal 0.7 mg/L level cuts tooth decay about 25%, which helps mitigate roughly two million emergency-room visits due to dental emergencies nationally—so we’re saving money by continuing to fluoridate our water. Of course, highlighting the access-to-care component was big too. Medicaid funding as an access-to-care modality is always an issue in the legislature, and many lawmakers struggle to find room in the budget to accommodate this. Framing community water fluoridation as sometimes the only dental “treatment” available to low-income residents gives legislators the opportunity to promote access to care without a heavy financial burden, since water fluoridation is quite inexpensive. I also frequently brought up the statistic I mentioned earlier about sources of fluoride exposure external to community water systems, which really seems to resonate with folks.

Lisican: Were there any moments during those testimonies or calls that stood out to you—positive or challenging?

Dr. Barnett: One positive moment during testimony that really surprised me was the broad support from the Public Health Committee at the original hearing for SB 1326. My testimony was fairly short because the committee members seemed strongly in agreement that community water fluoridation was still a good idea. This first hurdle of getting the bill out of committee was much simpler than anticipated, almost certainly because they had this consensus. Most committee members had read up on the topic prior to the hearing, benefiting from materials that others and I had submitted beforehand, so the heated debate one might expect never materialized. Instead, the hearing floor became a place for questions on water fluoridation to be answered on the public record.

Lisican: Did misinformation or public misconceptions around fluoride come into play? How did you handle that?

Dr. Barnett: It certainly did. Misinformation is really at the root of how this anti fluoridation sentiment has begun to gain momentum. The best way to combat this was to mention that the studies linking fluoride exposure to IQ were done in areas with fluoride over four times the amount we add to water here in the U.S. It’s also important to remember that many people with strong opinions against community water fluoridation are also just trying to stay healthy too, using that fact as common ground before combatting misinformation is a great place to start.

Lisican: How did it feel to learn that the bill had officially passed into law?

Dr. Barnett: I only played a small part, but seeing the payoff from being a part of a combined effort like this was really great. With all of the upsetting developments in anti-fluoride sentiment, it gave me hope that preserving community water fluoridation is doable.

Lisican: What do you think this legislation means for the future of public health in Connecticut—and potentially beyond?

Dr. Barnett: This is a big win for public health in Connecticut. Prior to this, fluoride levels were tied directly to recommendations from the department of health and human services. I imagine the idea at the time was that it would allow Connecticut to automatically adjust to new levels determined by emerging evidence at the federal level. But as a consequence, if the federal government were to stop recommending community water fluoridation altogether, this would have meant that Connecticut would instantly lose water fluoridation at the state level. The new law sets fluoride at 0.7mg/L but this concentration is actually the same level that has been in place since 2015. In other words, the law doesn’t create a new standard, it safeguards one that is tried and true.

Beyond Connecticut, and with all the buzz around Utah and Florida recently banning fluoride you might be surprised to hear that community-water fluoridation is actually only required by law in 13 states. Despite this around 66% of the United States has access to fluoridated water. What this means is that there is actually a lot of flexibility in how individual water systems can implement, and protect community water fluoridation, through local referendums, health department regulations, and city council resolutions just to name a few.

The public health implication of this is that a powerful strategy in the immediate short term to protect community water fluoridation might be to uncouple as many of these local and state level fluoride recommendations from the department of health and human services as possible. Previously, two of the 13 states with community water fluoridation mandates had “coupled” recommendations. Now that Connecticut has officially set 0.7mg/L as the standard we are down to one, leaving just Illinois still tethered to HHS guidance, so water fluoridation there is still quite vulnerable. At the local level, Albuquerque, NM, and Philadelphia, PA are in a similarly precarious situation.

Lisican: What advice would you give to other AAE members who want to make an impact through advocacy?

Dr. Barnett: This might sound like a lot, but I would suggest that any AAE member who wants to make an impact through advocacy needs to find out when your state legislature is in session, use the site’s search tool to look for any bill related to “oral health”, “dentistry”, “fluoride” and sign up to testify on the day of a relevant bill’s public hearing. This is an awesome and impactful first step. We are not all public health experts, and you don’t always need to write an op-ed or a memo. But during these public hearings you will quickly realize that you are often the only dentist in the room for important laws that relate to our profession. It may seem intimidating at first, but the committee members holding these hearings are really thankful to have us in the room because they trust our subject matter expertise. Even before a public hearing, discussions have paused mid-sentence for a person to turn and ask me, “…but, what do the dentists think?” There are registration deadlines, but literally almost anyone can sign up to testify, and if you don’t want to speak in front of the room you can always just submit written testimony too.

It also is a great idea to partner with a local oral health nonprofit like the Connecticut Oral Health Initiative. These groups are very happy to have dentists on board at all, let alone specialists, and can help you steer your efforts in the right direction. Notifying you about hearings, getting you in touch with legislators, and overall being a great resource to learn about the legislative process in your local community.

Elisabeth Lisican is the AAE’s assistant director of communications & publishing.