By Ashley L. Madern, DMD, MS
A student once asked after lecture, “If AI can see more pixels and grayscale than my eye can, shouldn’t I trust it when it identifies a periapical radiolucency?”
This question captures the complexity of AI in both clinical and educational contexts.
AI systems are being trained to detect patterns humans may overlook, and while they can identify radiographic findings well, identification is not the same as interpretation. AI can recognize patterns, but it cannot contextualize them with clinical reasoning, judgment, and experience.
The question also highlights another concern: newer clinicians are more likely to trust the computer over themselves. Confidence comes from experience, repetition, and occasionally being wrong. If learners allow AI to replace, rather than augment, development of diagnostic skills, they risk becoming dependent on it before building interpretive independence.
AI is no longer a future consideration in endodontics. It is here, and students are navigating it without formal guidance.
AI Has Already Entered Endodontics
Artificial intelligence is quickly expanding across endodontics. Software exists for treatment planning, guided access, and surgical guide creation. Deep learning models can detect periapical pathosis on CBCT scans, segment pulp space, classify C-shaped canals, and detect vertical root fractures on intraoral and cone beam imaging. These are not theoretical concepts; they are peer-reviewed applications with growing clinical relevance. For educators, however, the most important thing to teach is not how these tools work, but how to evaluate them.
Numbers Are Not the Whole Story
When a vendor advertises high sensitivity or accuracy, the first question should be: compared to what?
AI performance is measured against a human-labeled reference standard known as “ground truth.” If clinicians labeling the data disagree with one another or practice with different diagnostic philosophies, those biases become embedded into the algorithm itself.
A study reporting 92% sensitivity for periapical lesion detection only matters if we understand who labeled the data, how consistently they agreed, and whether the system was validated on imaging systems and patient populations similar to our own. If an AI system consistently disagrees with your interpretation, that disagreement may reflect differences in training data, imaging parameters, or diagnostic philosophy. In that situation, AI may undermine rather than support clinical judgement.
The regulatory landscape adds another layer of nuance. Most dental imaging AI products enter the market through the FDA’s 510(k) pathway, which requires demonstrating substantial equivalence to a prior device rather than proving improved patient outcomes. Manufacturers largely submit their own performance data, and independent external validation is not required. Additionally, algorithms evolve after clearance and without mandatory oversight of post-market changes.
That does not mean these tools lack value, it means they should be critically evaluated rather than accepted as infallible black boxes where we input an image and receive an answer without knowing how it was trained, the ground truth, whether it altered data (which AI can do), etc. Because any lack of transparency can lead to over-trusting the interpretation.
Automation Bias Is the Real Clinical Risk
One of the greatest dangers with AI is not incorrect output but instead overreliance and automation bias. Automation bias is the tendency to favor suggestions from an automated system even when contradictory evidence exists. In healthcare, this can quietly influence clinical decision-making.
Imagine driving in an unfamiliar city toward the airport when you see a sign that says, “Airport 1 mile.” However, your GPS says, “no, keep going.” Soon, another sign says, “Airport next exit.” But your GPS says “no, don’t take that exit with the giant airplane symbol, keep driving.” Would you listen to the signs or the GPS? If you say you would trust the AI then you fell victim to automation bias and probably missed your flight.
The same phenomenon occurs in radiology. A radiographic overlay may confidently flag a region as pathology, and a newer clinician may hesitate to challenge it even when the evidence does not fit.
Our Curriculum Has Not Caught Up
Most dental schools still provide little formal education on AI evaluation, implementation, or ethics. At the same time, many faculty members were trained before AI tools entered clinical workflows and may feel uncomfortable teaching concepts they themselves are still learning. Today’s students are entering a professional environment fundamentally different from the one many educators are trained in. Additionally, students are accustomed to immediate answers from technology and are more likely to trust those answers without questioning them. We have all experienced this ourselves: asking AI or the internet a question and accepting the response at face value.
General-purpose AI systems can produce inaccurate information, unsupported conclusions, or fabricated citations. More specialized medical AI systems may perform significantly better, but clinicians must be able to critically evaluate what they are using, how it was trained, and whether it is appropriate for clinical decision-making. As educators, we cannot simply teach students to use AI; we must teach them how to question it.
Data Bias: Who Trained it and on Whom?
AI systems are only as good as the data used to train them. If a model is trained predominantly on one demographic population, imaging system, or diagnostic philosophy, performance will decline outside those conditions.
For example, will an AI system correctly distinguish periapical cemento-osseous dysplasia (PCOD) from inflammatory periapical disease in populations where PCOD is more prevalent? Was the model trained on ideal CBCT scans from academic centers, and will it perform equally well on scans acquired with poorly calibrated equipment or inconsistent imaging protocols? Equipment bias, population bias, and training bias all matter.
Even image acquisition settings influence outcomes. Differences in kVp, resolution, calibration, artifacts, or reconstruction protocols may affect how an algorithm performs in private practice compared with the environment in which it was developed.
Clinicians should evaluate AI systems using their own previously diagnosed cases and ask an important question: does this system consistently agree with sound clinical judgment in my environment? If not, that discrepancy deserves attention.
The Clinician Remains Responsible
The governing principle should remain simple: the dentist decides; AI suggests.
AI can identify areas of concern, assist with workflows, and improve efficiency. But it does not hold a dental license, cannot appear before a dental board, and cannot assume medicolegal responsibility for irreversible treatment decisions. When AI contributes to a clinical error, liability remains with the clinician. That reality makes documentation increasingly important. If AI is used to help diagnose, clinicians should document that the findings were independently evaluated and clinically correlated. Most importantly, clinicians must resist the temptation to let AI become the primary driver of suspicion. Clinical judgment should originate from examination, interpretation, and reasoning, not from an algorithmic overlay.
What We Owe Our Learners
Students entering practice today will evaluate, purchase, and use AI tools often with little formal training in how to do so. Endodontic education is uniquely positioned to address that gap.
The important questions are practical ones:
- Was it externally validated?
- What is the false positive rate?
- Who established the ground truth?
- Was it trained on imaging systems and patient populations similar to mine?
AI is a reason to deepen clinical expertise, strengthen critical thinking, and reinforce the importance of independent diagnostic judgment. Ultimately, the future of AI in dentistry is not to replace clinical judgement, it is to make good clinicians even better.
Disclosure: The author has no relevant financial relationships with any commercial AI product or company mentioned in this article.
About the Author: Ashley L. Madern, DMD, MS, is a Clinical Assistant Professor and Oral & Maxillofacial Radiologist at Midwestern University College of Dental Medicine, where she teaches oral radiology and oral health sciences.
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.
As the first installment in a new quarterly series on coding and reimbursement, this article explores key strategies for improving claim submission and reimbursement outcomes.
Navigating dental benefits is an important part of practice management. From verifying patient coverage to submitting claims and appealing denials, understanding the process can help endodontists reduce administrative burdens and improve reimbursement outcomes.
Verify Coverage Before Treatment
Before treatment begins, practices should verify a patient’s dental benefits through an online portal, electronic verification service, or by contacting the dental benefits company directly. During verification, it is important to confirm not only that the patient is covered, but also which specific CDT procedure codes are eligible for benefits.
Some practices choose to request a preauthorization before treatment. While preauthorization may provide additional information about coverage, it can also delay care if response times are lengthy. In situations where treatment is urgent, verbal verification of benefits may be the more practical option.
Why CDT Codes Matter
Current Dental Terminology (CDT) codes serve as the standardized language used by providers and payers to communicate dental procedures. Maintained and updated annually by the ADA, CDT codes are required for standardized electronic dental claims under HIPAA.
Accurate coding is essential at two key points in the reimbursement process: when seeking a preauthorization and when submitting the final claim. The fundamental principle remains simple—code for the treatment that was actually performed.
The AAE offers coding resources and guidance to help members understand and apply CDT terminology appropriately.
Strengthening Claims Through Documentation
Correct coding should be supported by clear and complete clinical documentation. High-quality radiographic submissions can make it easier for dental benefits companies to evaluate claims and reduce requests for additional information.
Practices should submit:
- High-quality, dated radiographs
- Properly oriented images
- Clearly identified tooth numbers when appropriate
- Original electronic images whenever possible
Strong documentation helps support the clinical necessity of treatment and can improve the efficiency of claims review.
When Claims Are Denied or Downcoded
One of the most common frustrations for dentists occurs when a claim is submitted correctly, yet the dental benefits company denies the claim or changes the submitted code to one associated with lower reimbursement.
While these situations can be discouraging, providers should first determine whether the issue stems from policy language, contractual provisions, or a claim-specific decision. Understanding the reason for the denial or downcoding can help identify the most effective next step.
Using the Appeals Process
When a claim determination appears incorrect, providers can request a review through the payer’s appeals process. Most dental benefits companies provide detailed instructions in their provider manuals, including contact information for claims questions, appeals, and other administrative matters.
Appeals are generally most effective when submitted in writing and supported with relevant clinical documentation and a clear explanation of why the original claim should be reconsidered.
Although the process can be time-consuming, a well-prepared appeal remains an important tool for ensuring claims receive appropriate review and helping practices advocate for fair reimbursement.
By understanding benefits verification, CDT coding, documentation requirements, and the appeals process, endodontists can better navigate the reimbursement system while continuing to focus on delivering high-quality patient care.
Questions for Our Coding Experts?
The AAE Practice Affairs Code Maintenance Committee welcomes questions from AAE members related to CDT coding and reimbursement education. Members may contact advocacy@aae.org with coding-related questions.
The American Association of Endodontists (AAE) recently submitted a letter of support for New York Assembly Bill 11520 and Senate Bill 10607, legislation designed to improve patient access to medically necessary endodontic services through stronger insurance coverage protections.
The legislation would require dental plans that cover restorative dental services to provide coverage for medically necessary endodontic treatment, including diagnostic examinations, specialist consultations, radiographic imaging, root canal treatment, retreatment procedures, apicoectomies, emergency treatment, and related post-treatment care. The bills would also prohibit insurers from denying coverage solely because treatment is performed by a licensed endodontist rather than a general dentist.
The AAE supports the legislation because it recognizes the critical role endodontists play in diagnosing and treating dental pain, infection, and disease while helping patients preserve their natural teeth. Patients often face barriers to specialty dental care due to inadequate provider networks and restrictive coverage policies that can delay treatment and negatively impact oral health outcomes.
Importantly, the legislation includes network adequacy protections requiring insurers to provide coverage for services rendered by non-participating endodontists at in-network cost-sharing levels when adequate specialist networks are unavailable. The bills would also prevent insurers from imposing annual limitations, frequency limitations, or utilization review requirements for medically necessary endodontic services that are more restrictive than those applied to comparable restorative dental services.
The AAE joined efforts to advocate for these reforms because timely access to endodontic care is essential for preventing the progression of infection, relieving pain, preserving natural dentition, and improving overall health outcomes. By strengthening coverage requirements and expanding access to specialty care, the legislation would help ensure that treatment decisions are guided by clinical necessity rather than insurance barriers.
The AAE remains committed to advocating for policies that improve patient access to quality oral healthcare and support the specialty of endodontics at both the state and federal levels.
The American Association of Endodontists (AAE), alongside organized dentistry and public health advocates, successfully opposed Iowa House File 2395, legislation that sought to prohibit fluoride-based additives in both public and private water systems across the state. The bill would have banned the use of hydrofluorosilicic acid and other fluoride compounds commonly used in community water fluoridation programs aimed at preventing tooth decay and improving oral health outcomes.
The AAE opposed the legislation due to concerns about its potential impact on preventive oral healthcare and patient health. Community water fluoridation has long been recognized by leading healthcare and public health organizations as a safe, effective, and evidence-based method for reducing cavities and improving oral health, particularly among children, seniors, and underserved populations with limited access to dental care.
Through coordinated advocacy efforts with organized dentistry, healthcare stakeholders, and public health advocates, the bill ultimately failed to advance during the legislative session. The outcome represents an important advocacy victory supporting evidence-based dentistry, preventive oral healthcare initiatives, and continued patient access to proven public health measures that improve oral health outcomes.
As legislative sessions conclude across the country, the AAE remains committed to monitoring and advocating on state and federal legislation impacting oral healthcare, patient safety, and the specialty of endodontics.
The American Association of Endodontists (AAE) continues to advocate for policies that protect endodontists, preserve patient access to specialty care, and strengthen the future of the profession. Most recently, the AAE submitted formal support for Ohio House Bill 845, legislation aimed at improving transparency, accountability, and fairness in dental benefit plan administration.
Our advocacy efforts are driven by the experiences and engagement of our members. Across the country, endodontists consistently share concerns about increasing administrative burdens, reimbursement uncertainty, prior authorization challenges, and payment practices that negatively affect the delivery of patient care. These real-world experiences help shape the AAE’s legislative priorities and strengthen our ability to advocate effectively on behalf of the specialty.
Ohio H.B. 845 addresses several issues that directly impact dental providers and patients, including restrictions on mandatory virtual credit card payments that impose unnecessary transaction fees, safeguards surrounding prior authorizations, and increased transparency related to third-party leasing arrangements and provider network access. These reforms are designed to reduce administrative complexity and improve fairness within the dental insurance system.
For endodontists, these issues are particularly important. Endodontic care is often urgent and essential to relieving pain, treating infection, and saving patients’ natural teeth. Delays in treatment, reimbursement uncertainty, and growing administrative obstacles can interfere with timely care and place additional strain on specialty practices.
The AAE believes legislation like H.B. 845 helps protect the integrity and sustainability of specialty dental care. Advocacy at both the state and federal levels plays a critical role in ensuring that endodontists can continue providing high-quality care while navigating an increasingly complex insurance environment.
Equally important is the collaboration between the AAE and its members. Effective advocacy depends on strong member engagement, communication, and grassroots involvement. When members share their experiences and challenges, they help inform policymakers about how insurance practices affect providers and patients alike. Together, these collective efforts strengthen the voice of the specialty and support meaningful reform.
Protecting endodontics means protecting access to care for patients. The AAE remains committed to working alongside members, state dental societies, and legislators to advance policies that support specialty practice, reduce unnecessary burdens, and preserve the ability of patients to receive timely, high-quality endodontic treatment.
As advocacy efforts continue across the country, member involvement remains essential. The AAE encourages all members to stay engaged, share their perspectives, and participate in advocacy initiatives that help shape the future of the profession.
The American Association of Endodontists continues to advance policies that protect patients, strengthen dental practices, and improve transparency in oral healthcare. Through coordinated advocacy efforts alongside state dental societies and coalition partners, several bills supported by the AAE have now been signed into law.
New Mexico SB 151
New Mexico SB 151 expands healthcare-related tax relief and incentives intended to help recruit and retain healthcare providers in the state. During the legislative process, the AAE advocated to ensure oral healthcare providers, including endodontists, were recognized within the bill’s healthcare workforce provisions. This helps support practice sustainability, workforce recruitment, and improved access to specialty dental care in underserved communities.
Mississippi HB 1117
Mississippi HB 1117, the Creating Transparency and Accountability in Dental Services Act, requires dental insurance carriers to annually report their dental loss ratio (DLR), increasing transparency around how premium dollars are spent. The law promotes greater accountability among dental insurers and supports future efforts aimed at fair reimbursement practices and improved patient access to care.
New York S 2105 / S 2105A
New York S 2105A addresses the use of virtual credit cards and electronic payment methods by insurers by requiring carriers to provide fee-free payment alternatives and obtain provider consent before imposing transaction fees. This legislation helps reduce unnecessary administrative costs on endodontic practices and supports more transparent reimbursement processes.
Mississippi HB 1391
Mississippi HB 1391 proposed the creation of a task force to study community water fluoridation, with a particular focus on evaluating potential negative consequences and determining whether those concerns outweigh the established public health benefits of fluoridation. The AAE opposed the legislation, citing the substantial body of scientific evidence supporting community water fluoridation as a safe and effective public health measure for preventing tooth decay. The bill ultimately did not advance during the 2026 legislative session.
These legislative victories demonstrate the continued importance of advocacy at both the state and national levels. The AAE thanks its members, state partners, and advocacy leaders whose engagement helped move these initiatives across the finish line. Continued member involvement remains essential as lawmakers nationwide consider legislation impacting endodontic practice and patient care.
As state legislative sessions begin to wrap up across the country, the AAE will continue monitoring and advocating on legislation impacting endodontists and oral healthcare at both the state and federal levels. The Association remains committed to protecting the specialty, advancing patient access to care, and ensuring the voice of endodontics is represented wherever healthcare policy decisions are being made.
Bjarne Bergheim, President & CEO, Sonendo, Inc.
An engineer’s path into endodontics, the founding question behind the GentleWave® Procedure, and why technology, partnerships, and patient education are converging at the right moment for the specialty.
As Sonendo’s first employee, what initially drew you to the company?
By 2006, I had spent nearly a decade in cardiovascular device development, working on some of the earliest transcatheter heart-valve concepts. I was ready for the next big problem to solve.
Through Fjord Ventures — our family office and life-science accelerator — we began exploring an idea that would eventually become Sonendo and, ultimately, the GentleWave® Procedure.
What drew me in was the scale of the unmet need: root canal therapy is performed more than 15 million times each year in the U.S., yet the fundamental challenge had remained largely unchanged — how do you more effectively remove infection from the dentin without unnecessarily removing the dentin itself?
If we could remove infection from the dentin, we would effectively have the solution for tooth decay, the most prevalent chronic disease in the world. From my perspective, that was an extraordinary problem to solve. From a patient’s perspective, it was an even more meaningful one.
What problem was Sonendo founded to solve?
Sonendo started with a simple “what if.”
The standard approach to root canal treatment had — and still largely has — a mechanical premise: remove the infected dentin. When we founded Sonendo, we asked the question differently: what if, instead of removing the infected dentin, we could remove the infection from the dentin?
Leave the tooth structure intact, and go after the bacteria and necrotic tissue directly — even where a file can’t physically reach. That single inversion of the problem is what created the GentleWave® Procedure.
To solve this problem, we quickly realize we need to degass the fluids we use during the procedure. The presence of air within the root canal system – sometimes termed vapor lock – will prevent proper cleaning and disinfection into the dentin. Put another way, if degassed fluids are not used during the procedure, we found it impossible to properly clean and disinfect a root canal system. Degassing happens automatically in the GentleWave System.
We further created an automated way to 3-dimensionally dissolve tissue and bacteria within the root canal system. Every GentleWave procedure instrument accelerates fluids close to the speed of sound, that in turn creates a cavitation cloud and a broad spectrum of pressure waves throughout the root canal system to gently dissolve tissue and bacteria.
Combining tissue dissolution with degassing enabled exceptional cleaning and disinfection. But one very important challenge remained: we had to do all of this while keeping the entire root canal system under continuous negative pressure. We believe any presence – continuous or intermittent – can be a source of post-op discomfort for the patient. This is why our Procedure Instrument is designed to always provide negative pressure. We take this very fact seriously and this is why every procedure instrument manufactured at Sonendo is manually tested to ensure they consistently create negative pressure.
We believe this continuous negative pressure is the reason why our procedure instrument reduces post-op pain and discomfort. We also believe that the combination of degassed fluids, broad-spectrum cavitation energy, and advanced fluid dynamics allows GentleWave to deliver a multidimensional clean — reaching deep into complex root canal anatomy, including the microscopic isthmuses, fins, and lateral canals where bacteria can hide.
To this day, the original question still drives every decision we make: how do we clean more, while preserving more?
How does technology like GentleWave help endodontists deliver better outcomes?
GentleWave was designed around four vectors at once: clinical, patient, practitioner, and practice.
Clinically, it reaches areas that mechanical instrumentation cannot, while preserving more natural tooth structure. For patients, most report minimal to no post-operative discomfort, with most procedures completed in a single visit. For the practitioner, GentleWave provides reliable and predictable technology that allows the endodontist to focus on diagnosis, judgment, and patient relationships rather than fighting the procedure.
And on the practice side, the AAE’s recent Referral Patterns Survey makes a point endodontists shouldn’t miss: 76% of general dentists rate up-to-date equipment and technology as ‘very’ or ‘extremely’ important when choosing an endodontist to refer to — yet endodontists rank that factor last among the top factors they believe general dentists use when choosing a referral partner. That perception gap matters: technology is not just a clinical investment; it is a referral-relationship and practice-growth signal.
What do patients misunderstand most about root canal treatment today?
Two things, and they are connected.
First, the persistent myth that root canals are painful — a belief inherited from a version of the procedure that is decades out of date. Modern endodontics, performed by a specialist with current technology like GentleWave, is typically comfortable and aimed at relieving pain, not causing it.
Second, the assumption that extraction is a clean, equivalent alternative. “Just pull it and replace it” sounds straightforward, but a natural tooth is genuinely irreplaceable — biologically, emotionally, functionally, and often financially over a lifetime.
Roughly 78% of Americans say they would do almost anything to avoid losing a natural tooth, and yet many still choose extraction because they do not fully understand what saving the tooth involves today.
Closing that knowledge gap is one of the most important things we can do as an industry.
Why was it important for Sonendo to support Save Your Tooth Month?
Save Your Tooth Month is one of the purest expressions of our mission.
Tooth decay is the most prevalent chronic disease in the world — and yet most people still do not frame it as a public-health issue. The AAE has built a national platform around exactly the message we wake up every day to advance: natural teeth are worth saving, and endodontists are the specialists best equipped to save them.
Standing alongside the AAE during May is a way of saying: this is not only a Sonendo message or an AAE message. It is a shared message. And the more voices behind it, the further it travels.
Looking ahead, what excites you most about the future of endodontics?
What excites me most is that the next decade in endodontics is going to be defined by the same forces that have already transformed other areas of medicine: better data, better imaging, better materials, and intelligence built into the workflow.
The trend lines support it. The specialty has grown more than 40% since 2001, making it one of dentistry’s strongest-growth specialty segments.
Sonendo’s role is to keep doing what we set out to do from the beginning: solve the hardest cleaning and disinfection problem in dentistry, while making the GentleWave® Procedure more accessible, more efficient, and more clinically relevant.
Endodontists have treated nearly 2 million patients with GentleWave System to date. Every one of those patients is a person who got to keep something irreplaceable.
That is the part that still gets me out of bed in the morning.
By Ariadne Letra, DDS, MS, PhD
Apical periodontitis (AP) results from the progression of microorganisms within an infected/necrotic root canal system. The localized infection activates the local host immunoinflammatory response, triggering a cascade of events with recruitment of immune cells, release of inflammatory mediators, establishment of local inflammation, hard tissue breakdown, and eventual formation of a periapical lesion1.
Studies in humans and animal models have implicated host factors as critical contributors to AP susceptibility, with host-pathogen interactions suggested to influence disease development and progression1. Host factors involving genetic regulatory mechanisms may affect host physiology, resulting in imbalances in the expression of key pro- and/or anti-inflammatory mediators that integrate the complex biological network underlying AP.
In other words, when an individual’s genetic machinery is disrupted, the consequences may affect how the immune system responds to infection, whether a patient heals, how much pain they experience, and even whether they develop the disease at all2.
Genetic mechanisms such as DNA variation (e.g., single-nucleotide polymorphisms, SNPs) have been proposed as host factors potentially influencing an individual’s risk of AP development, progression, and/or repair. SNPs are the simplest form of genetic variation among people and occur on average about once in every 1,000 nucleotides, which means that each person has roughly 4 to 5 million SNPs in their genome. Most SNPs are neutral, but those located within functionally important genes can alter gene and protein expression, impair cellular function, and thereby influence disease susceptibility or healing capacity2,3.
What the Research Shows
In recent years, emerging evidence has supported AP as a genetically regulated process with overlapping protective and destructive functions. Studies across multiple populations have found that polymorphisms in disease-relevant genes, including pro-inflammatory mediators such as interleukins, matrix metalloproteinases, tumor necrosis factor, heat shock proteins, and others, are associated with AP. The majority of these studies reflect candidate genes selected based on their reported function in the pathogenesis of AP, and revealed the association of many genes, such as IL1B, IL6, IL8, MMP1, MMP3, MMP8, TNFA, TBX21, HSPA1L, WNT3A, among others 2-6. One variant in IL1B (rs1143643) that was significantly associated with AP was also shown to alter gene and protein expression in periapical tissues5. Similarly, the MMP1 promoter variant (-1607 1G/2G) associated with AP was also shown to result in differential gene expression based on individual genotypes; individuals with this polymorphism had increased MMP1 mRNA expression in periapical tissues as compared to healthy tissues obtained from individuals without AP4. Among the more clinically promising findings is the role of the WNT signaling pathway in bone repair. WNT3A variants are associated with AP, and laboratory evidence suggests WNT3A may be a viable therapeutic target for accelerating bone healing after AP-related bone loss6,7, pointing towards targeted treatment possibilities. These findings suggest functional effects of these polymorphisms on cellular functions involved in AP pathogenesis and shed light on how polymorphisms may shape an individual’s risk of AP and how they may be used as targets for treatment strategies.
Genome-Wide Studies
Recently, two genome-wide association studies analyzing over two million genetic variants in thousands of adults with and without AP revealed the association of novel genes with AP, with and without associated pain8,9. Among the newly associated genes are RAP1GAP (RAP1 GTPase activating protein) and SPP1 (osteopontin), both of which are involved in immune cell recruitment, macrophage polarization, and regulation of immune-inflammatory response8. Moreover, these studies found distinct male-only and female-only AP-associated variants, confirming a sexual dimorphism pattern reported in epidemiological studies and animal models of AP, highlighting potential implications for precision AP risk assessment and treatment planning10.
Toward Precision Endodontics
A deeper understanding of the genetic underpinnings in AP is essential for developing precision diagnostic and treatment strategies. That said, the associations identified to date should not be interpreted as causation. Genetic association studies remain limited by sample size, population diversity, and difficulty controlling for environmental confounders such as microbiome variation. Therefore, the most significant advances in the field will be made through unbiased studies with large and diverse populations and functional validation of identified SNPs as potential targets for precision treatment strategies8.
For now, endodontic treatment remains the standard of care, and most patients heal well. But the trajectory of this research points toward a future in which genetic profiling may help clinicians predict a patient’s risk of developing AP, likelihood of treatment success or failure, susceptibility to associated pain, and optimal pharmacological management, enabling more predictable diagnosis, treatment, and prognosis of all endodontic patients. While such precision endodontic approaches are not yet a clinical reality, recent research advances suggest they are within reach.
References
- Cavalla F, Letra A, Silva RM, Garlet GP. Determinants of Periodontal/Periapical Lesion Stability and Progression. J Dent Res. 2021:100:29-36.
- Menezes-Silva R, Khaliq S, Deeley K, Letra A, Vieira AR. Genetic Susceptibility to Periapical Disease: Conditional Contribution of MMP2 and MMP3 Genes to the Development of Periapical Lesions and Healing Response. J Endod. 2012; 38:604-607.
- Letra A, Ghaneh G, Zhao M, Ray H, Francisconi CF, Garlet GP, Silva RM. MMP -7 and TIMP-1, new targets in predicting poor wound healing in apical periodontitis. J Endod 2013; 39:1141-1146.
- Trombone AP, Cavalla F, Silveira EM, Andreo CB, Francisconi CF, Fonseca AC, Letra A, Silva RM, Garlet GP. MMP1-1607 polymorphism increases the risk for periapical lesion development through the upregulation MMP-1 expression in association with pro-inflammatory milieu elements. J Appl Oral Sci. 2016; 24:366-375.
- Dill A, Letra A, Souza LC, Yadlapati M, Garlet GP, Vieira AR, Silva RM. Analysis of multiple cytokine polymorphisms in individuals with untreated deep carious lesions reveals IL1B (rs1143643) as a susceptibility factor for periapical lesions development. J Endod. 2015; 41:197-200.
- Souza LC, Cavalla FC, Maili L, Garlet GP, Vieira AR, Silva RM, Letra A. WNT gene polymorphisms and predisposition to apical periodontitis. Sci Rep. 2019; 9:18980.
- Tang Y, Zhou X, Gao B, Xu X, Sun J, Cheng L, Zhou X, Zheng L. Modulation of Wnt/β-catenin signaling attenuates periapical bone lesions. J Dent Res 2014;93:175-182.
- Petty LE, Silva RM, Souza LC, Vieira AR, Shaw DM, Below JE, Letra A. Genome-wide Association Study Identifies Novel Risk Loci for Apical Periodontitis”. Petty LE, Silva R, de Souza LC, Vieira AR, Shaw DM, Below JE, Letra A. J Endod. 2023;49:1276-1288.
- Salminen A, Hyvärinen K, Ritari J, Leppilahti JM, Palotie U, et al. Genome-wide association study of pulpal and apical diseases. Nat Commun. 2025 Jul 23;16(1):6774.
- Sangalli L, Souza LC, Letra A, Shaddox L, Ioannidou E. Sex as a Biological Variable in Oral Diseases: Current Perspectives and Future Directions. J Dent Res. 2023, 102(13): 1395–1416.
Ariadne Letra, DDS, MS, PhD, is Professor and Assistant Dean for Faculty Affairs, Department of Oral and Craniofacial Sciences, Department of Endodontics, Center for Craniofacial and Dental Genetics, at the University of Pittsburgh. She is also an associate editor of the Journal of Endodontics. Dr. Letra can be reached at AriadneLetra@pitt.edu.
Dr. W. Craig Noblett, AAE President
As I begin my term as your president, Endodontics as a specialty seems to be in a secure position. Public awareness of endodontics is at an all-time high. The message that we are the specialists at preserving natural teeth is definitely resonating with the public, reflected in the high level of demand for specialty endodontic care. Our practices are busier than ever. While it might be tempting to relax and pat ourselves on the back for a job well done, we must resist the urge to rest on our laurels and maintain our vigilance in promoting and protecting our specialty.
We face significant external challenges ranging from attempts to erode specialty recognition and the process by which that occurs, efforts to undermine public health initiatives such as water fluoridation, scope of practice modifications, the curtailment of federal student loan availability, and the capricious and often malicious withholding of research funds. In response to these and other concerns, I am happy to report that our regulatory surveillance and advocacy efforts are at the highest level that I have ever observed. Recent examples of our advocacy activity include a robust campaign in Ohio to preserve and strengthen the regulations governing specialty advertising as well as opposition to anti-fluoridation legislation in Iowa and Kentucky. Happily both anti-fluoridation bills were defeated – a significant victory for public health. We have also been actively supporting legislation aimed at dental plan reform in several states. But not all threats are external.
We are facing a significant existential threat to our specialty, and it is one for which we have yet to come up with any viable definitive solution. The critical shortage of full-time educators. More important than any device, instrument, technique, or material, educators are critical to the survival of our specialty. Without qualified graduate program directors, the future supply of endodontists could start to decline even as the demand continues to increase. Let’s face it –my colleagues and I might love what we do in educating our future endodontists, but we aren’t getting any younger, and as retirements start looming on the horizon, we are going to need people to take our place. This is a topic on which I would like to focus more during this upcoming year. I am hoping we can gather some definitive information as to what creates the barriers to careers in education – beyond the obvious financial considerations, so that we can work toward a meaningful and effective solution. This is not something that we will be able to solve in just a year’s time, but I look forward to collaborating with the Foundation’s Task Force on Endodontic Education to explore the possibilities, and I would welcome any feedback as to your perceptions in this area.
Another significant external challenge that we face is the alarming increase in mis- and disinformation to which the public is exposed. The aggressive nature of this messaging and the shameless exploitation of the public’s fear and lack of knowledge requires a thoughtful and strategic approach in combating this false information. Your AAE leadership is actively engaged in developing strategies and responses to the different false claims regarding endodontic treatment. This effort will also include regulatory messaging for legislators with the approach of protecting the public from inaccurate information that could adversely affect their health. Our extremely successful public awareness campaign will continue as a complementary effort as we continue to present the benefits of preserving natural teeth and portray our specialty in a friendly and favorable light.
I hope at this point, you are wondering what you might do to help with the efforts to secure the future of Endodontics. I learned early on from my dad that members of a profession are responsible for its health and wellbeing. If we don’t care for it, others will step in and attempt to take over and regulate our activities. So what you as a member can do is stay engaged, volunteer your time, either with the AAE or your local component society. Participate in our advocacy efforts, either directly or in a supporting role. If you haven’t already, become Board certified. It is also critical that we all support our Foundation as it promotes not only research, but educators and education. Each of these will contribute to our favorable public image and help to ensure our future as a specialty.
I look forward to a challenging but productive year as your president, and I vow to keep you well informed of our activities on your behalf.
Call to Order
President Steven J. Katz called the 2026 General Assembly of the American Association of Endodontists to order at 8:45 a.m. on April 17, 2026, at the Salt Palace Convention Center in Salt Lake City, Utah. A quorum of voting members was in attendance. President Katz instructed the assembly on voting procedures for the meeting.
Standing Rules for the General Assembly were published online with the General Assembly meeting materials and were reviewed at the outset of the meeting.
President Katz appointed Dr. Mark Desrosiers to serve as parliamentarian for the 2026 General Assembly.
Approval of Minutes
President Katz called for approval of the minutes of the 2025 General Assembly as published in the Communiqué.
GA-1 Moved: That the 2025 General Assembly Minutes be approved as published.
Motion Carried.
Report of the Constitution and Bylaws Committee
Constitution and Bylaws Committee Chair Dr. Natasha M. Flake presented three proposed amendments to the Constitution and Bylaws, published in the February 2026 issue of the Communiqué.
The first proposed amendments provided for an expansion of Educator membership eligibility to include internationally trained endodontists holding full-time faculty positions in CODA-accredited programs.
GA-2 Moved: that the proposed amendments to Chapter I, Section 3 and Chapter III, Section 3 AAE Bylaws, relating to Educator Membership, be approved.
Motion Carried.
The second proposed amendment aimed to clarify the process by which Constitutional amendments may be proposed.
GA-3 Moved: that the proposed amendment to Article XII of the AAE Constitution, relating to Amendments, be approved.
Motion Carried.
The third proposed set of amendments related to the Foundation for Endodontics’ updated governance structure, reflecting a revised composition of the Board of Trustees, term length references, and nomination and election processes.
GA-4 Moved: that the proposed amendments to Articles II and X of the AAE Constitution, relating to Foundation governance, be approved.
Motion Carried.
GA-5 Moved: that the proposed amendments to Chapter IX of the AAE Bylaws, relating to Foundation governance, be approved.
Motion Carried.
All motions amending the Constitution and Bylaws passed with the required 3/4 and 2/3 affirmative votes, respectively.
Reports of Officers
Written reports from the AAE President, Secretary, and Treasurer were made available to members online prior to the meeting.
Treasurer’s Report
AAE Treasurer Dr. Bradley H. Gettleman reported that for the fiscal year that ended on June 30, 2025, the AAE achieved an operating surplus after investment earnings of $228,000. Strategic initiative spending totaled $606,000 resulting in a bottom-line deficit of ($378,000). Strategic initiatives focus on the public, the profession, and membership.
In addition, AAE received a clean audit from its independent auditors, indicating that financial operations not only comply with Generally Accepted Accounting Principles, but also that the association is financially sound and that the Board of Directors has operated responsibly and in the best interest of the AAE and its membership.
Dr. Gettleman reviewed AAE Operating Revenues, Expenses, and Operating Surplus, Strategic Initiatives, and overall financial results for fiscal years ending June 2024 and 2025. For Fiscal year 2026, an operating deficit of ($379,000) and a total deficit of ($932,000) are forecasted. The projected deficit also includes expenses related to strategic initiatives. These projections reflect a prudent and conservative approach, accounting for inflationary pressures and cautious revenue expectations for the annual meeting.
The AAE Investment balance at June 30, 2025 equaled $14.1 million and was 101% of annual expenses. With investment reserves exceeding 90% of one year’s expenses, AAE remains in a very strong financial position.
Dr. Gettleman reported that the Board of Directors approved a Fiscal Year 27 budget projecting revenue of $13.5 million, expenses of $14.3 million, investment earnings of $385,000 with an operating deficit of ($403,000). This deficit is slightly greater than the current year, as we expect AAE to minimize expenses and expand revenues to reduce this conservative estimate.
The Board is advancing the strategic plan which focuses on expanding the public’s awareness of endodontics, developing knowledge to advance the specialty, advocating for quality endodontic care, and supporting members to advance patient care. The Board approved additional funding for the strategic initiatives in the amount of $613,000. This will be funded in Fiscal Year Budget 27 through the use of reserve funds. This strategic spending level is similar to prior years, and AAE’s strong financial position allows the organization the opportunity to invest in new initiatives to strengthen the profession.
Journal of Endodontics Report
JOE Editor-in-Chief, Dr. Kenneth M. Hargreaves, reported continued advances in the Journal of Endodontics.
JOE continues to attract noteworthy papers from researchers and clinicians around the world. There has been a 350% increase in the number of new manuscripts submitted to the JOE from 2003-2025.
This increase in submissions consisted of many manuscripts of good quality. In addition to the 1,392 new manuscripts submitted in 2025, an additional 227 revised manuscripts were submitted in response to a prior review.
With more than 400 endodontists and scientists from more than 25 countries currently serving as members of the Scientific Advisory Board (SAB), the JOE represents a substantial commitment to excellence by AAE members and endodontists around the world.
The JOE has developed an outstanding Impact Factor over the last two decades. Other measures are also strong: in 2024, the JOE generated twice as many citations and published more papers than the IEJ.
The JOE Awards were presented at the JOE Award and Scientific Advisory Board Reception recognizing the best articles in the categories of Basic Research: Biology, Basic Research: Technology, Case Reports and Clinical Techniques, Clinical Research, Regenerative Endodontics, Systematic and Scoping Reviews and Narrative Reviews. In addition, 7 papers published in 2025 received Honorable Mentions. Nominations for next year’s awards will open in the fall and members are encouraged to submit nominations to recognize their peers who are shaping the future of the specialty.
Foundation for Endodontics
Foundation for Endodontics President Dr. Patricia Tordik presented the Foundation report and highlighted the Foundation’s continued commitment to advancing endodontics through research, education, and access to care. Dr. Tordik reported that in 2025, the Foundation invested more than $1.25 million in programs supporting educators, researchers, residents, and practicing endodontists.
Dr. Tordik reviewed several key initiatives, including the Foundation & Dentsply Sirona Freedom Scholarship, the International Access to Care Program serving three Caribbean nations in 2025, and the New Diplomate Award developed in partnership with Cornerstone Dental Specialties.
The Endodontic Educator Fellowship Award was presented to Dr. Rachel Garoufalis, Assistant Clinical Professor and Director of Predoctoral Endodontics at the University of New England College of Dental Medicine, in recognition of her contributions to education and mentorship.
Dr. Tordik also highlighted the Foundation’s Domestic Access to Care initiatives funded in collaboration with Specialized Dental Partners. In 2025, three Domestic Access to Care initiatives were funded. Between 2021 and 2024, the program supported projects in eight states, contributed 2,724 volunteer hours, treated 830 patients, and completed 1,499 procedures.
Corporate partners were recognized for first-time and continued contributions during the 2025–2026 campaign.
Dr. Tordik announced that donations made in honor of Dr. Alan S. Law, 2026 recipient of the Dr. Edgar D. Coolidge Award, established a Full-time Educator Award in his name to be awarded annually. Additional educator development and tribute grant recipients were also recognized.
Dr. Tordik concluded by encouraging continued support of the Foundation’s 2025–2026 fundraising campaign and thanked Foundation Trustees, donors, and volunteers for their commitment to the specialty.
American Board of Endodontics Report
American Board of Endodontics President Dr. Meetu Kohli presented the report of the American Board of Endodontics and reflected on the ABE’s continued commitment to lifelong learning, excellence, and continuous improvement within the specialty.
In 2025, the ABE examined 204 Oral Exam candidates, reviewed 154 Case History Portfolios, and administered the Written Exam to 223 examinees. Additionally, over 100 Diplomates completed their recertification requirements.
Dr. Kohli highlighted several major initiatives completed during the year, including a comprehensive Job Task Analysis for all three examinations to enhance the experience for candidates and examiners. She also reported that the ABE is transitioning to a new database system expected to modernize and streamline processes for candidates and Diplomates by the end of 2026.
Dr. Kohli thanked past Directors who continue to serve as volunteer examiners, recognized the contributions of ABE staff members, and thanked the ABE Directors for their dedication.
Dr. Kohli congratulated the 138 new ABE Diplomates honored at the Grossman Ceremony in Salt Lake City and encouraged members pursuing Board certification to continue through the process, emphasizing the value of certification to both the individual and the specialty.
Diplomates in good standing were encouraged to consider Board service through the ABE self-nomination process. Dr. Kohli concluded her remarks by reflecting on her service as ABE President and expressing confidence in the continued strength and future of the organization.
Presentation of ABE Nominees
ABE President Dr. Meetu Kohli presented the following slate of nominees for ABE Directors:
Scott L. Doyle, Director, Second Term
Emanouela D. Carlson, Director
Qian Xie, Director
Dr. Kohli also announced the ABE’s officers for 2026-2027:
Joseph M. Dutner, President
Garry L. Myers, Vice President
Scott L. Doyle, Secretary
Renato M. Silva, Treasurer
Nominating Committee Report
AAE Nominating Committee Chair, Dr. Stefan I. Zweig, presented the slate of nominees for AAE officers and Foundation for Endodontics Trustees:
American Association of Endodontists
President: W. Craig Noblett
President-elect: Elizabeth Shin Perry
Vice President: Bradley H. Gettleman
Secretary: Kenneth W. Tittle
Treasurer: Mark B. Desrosiers
Immediate Past President: Steven J. Katz
Foundation for Endodontics Trustees
Hossein Moosavi, Trustee
Morgan Celistan, New Practitioner Trustee
Jack Burlison, Public Sector Trustee
Amy Warren-Kimbro, Public Sector Trustee
Judith Forsythe, Public Sector Trustee
Dr. Zweig also announced the 2026-2027 officers for the Foundation for Endodontics:
President: Craig S. Hirschberg
President-elect: Stefan I. Zweig
Treasurer: Robert S. Roda
Secretary: Bruce C. Justman
Immediate Past President: Patricia Tordik
District Director Nominees
President Steven J. Katz presented the slate of nominees for District Director positions:
District I: Tadros M. Tadros
District II: Adrienne Korkosz
District III: Christopher Walker Cain
District VI: Calee C. Clark
District VII: Mike A. Sabeti
Election of Board Members
There being no other nominees, the slate of nominees for Officers and Directors of the AAE, Directors of the American Board of Endodontics, and Trustees of the Foundation for Endodontics were elected for terms beginning in 2026.
New AAE officers and district directors, ABE directors, and AAE Foundation trustees took an oath to abide by the Constitution and Bylaws of the American Association of Endodontists and the Bylaws of the respective organizations to which they have been elected, and to discharge their duties and responsibilities to the best of their abilities.
Outgoing President’s Remarks
Immediate Past President Steven J. Katz thanked the Assembly for the opportunity to serve as AAE President. He reflected on the honor of serving as AAE President, emphasizing leadership through service, collaboration, and advocacy for the specialty. Dr. Katz thanked AAE members, volunteers, Board and committee leaders, and staff for their dedication and contributions to the organization’s success. Highlights of the year included adoption of an updated strategic plan focused on saving natural teeth, advocacy efforts to protect specialty recognition and patient access to care, and continued public education initiatives promoting evidence-based endodontic care. Dr. Katz concluded by expressing gratitude to family and colleagues, confidence in the future of the AAE, and support for incoming President Dr. Craig Noblett.
Incoming President’s Remarks
Incoming President Dr. Craig Noblett reflected on his professional journey from dental school, residency, private practice, Board service, and full-time academia, noting the path that ultimately led him to leadership within the AAE. Dr. Noblett thanked mentors, colleagues, the AAE staff, and members for their support and emphasized his commitment to advancing the interests of endodontics and the Association during his presidency.
He highlighted the AAE’s ongoing advocacy efforts to protect specialty recognition, research funding, and patient access to specialty care. He identified the shortage of full-time endodontic educators as a significant challenge facing the specialty and expressed his intention to focus on educator recruitment and support during the coming year in collaboration with the Foundation’s Task Force on Endodontic Education.
Dr. Noblett encouraged members to remain actively engaged in organized dentistry through volunteerism, advocacy, Board certification, and support of the Foundation. He concluded by inviting members to attend the next Annual Meeting in San Antonio.
New Business
No new business was submitted for consideration by the Assembly.
Adjournment
There being no further business, the 2026 Meeting of the AAE General Assembly was adjourned at 9:50 a.m.