American Association of Endodontists

By John A. Mitsos, CLU®, CLTC

Dentists and dental specialists turn to search engines for more than clinical questions. They also look for answers about financial security. Phrases like “disability insurance for dentists,” “own-occupation disability,” and “what happens if I can’t practice dentistry” appear frequently in financial and dental-planning content because they reflect real professional concerns.

What those searches reveal is something fundamental: the risk of losing the ability to earn a professional income. For dentists, that risk is unusually concentrated. If injury, illness, or neurological changes affect clinical work, income often stops with it.

The real risk isn’t rare, it’s routine!

When people think about disability, they often picture traumatic accidents. In dentistry, the dominant risks are far less dramatic and far more common. Musculoskeletal disorders, stress-related conditions, autoimmune disorders, and cardiovascular events represent sources of long-term disability among healthcare professionals.

Across the general working population, roughly one in four people will experience a disability long enough to interrupt their career before retirement age. That probability is high enough to be treated as a planning assumption rather than a remote possibility, particularly in a profession as physically demanding as dentistry.

Why dentists are financially exposed

Dentists’ income is not only high; it is directly tied to physical capability and technical precision. If that capacity is reduced, income declines immediately.

Unlike many corporate professionals, dentists typically cannot pivot into a new role that pays anything close to chairside earnings. Even part-time or limited clinical work often results in a substantial income drop. Meanwhile, financial obligations such as student or practice loans, payroll, and family and lifestyle expenses do not stop.

Without disability income insurance, a prolonged illness or injury can become a liquidity crisis far faster than expected. Even well-funded savings and investment portfolios can erode quickly when high fixed expenses collide with reduced income. Losing the ability to practice dentistry is not just a health issue, it can be a career-defining financial event.

Social Security is not a dentist’s safety net.

Social Security Disability Insurance (SSDI) pays benefits only if you are unable to work in any occupation, not just dentistry. If you could theoretically earn income in another field—teaching, consulting, or administrative work—you may be denied. Approval rates are low, the process is slow, and benefit amounts are modest relative to a dentist’s earnings. From a planning standpoint, SSDI is not income replacement; it is a last-resort public program.

Why “own-occupation” coverage matters

Dentists do not search for just any disability policy: they search for own-occupation coverage. That distinction is critical.

A true own-occupation policy pays benefits if you cannot perform the duties of dentistry, even if you could earn income in another profession. Without it, a policy may deny a claim if you are capable of doing non-clinical work, regardless of the income gap.

Dentists should also consider:

Residual or partial disability benefits, which pay when work capacity is reduced
Future purchase options, which allow coverage to increase as income grows
Cost-of-living adjustments, which help preserve benefit value during long claims

These features determine whether a policy truly protects earning power or simply appears adequate on paper.

Practice owners face an added layer of risk.

For practice owners, a prolonged absence due to disability can destabilize the business. Staff salaries, rent, equipment leases, and loan obligations continue regardless of clinical availability. Business overhead expense (BOE) disability insurance can help keep a practice operating, but it does not replace personal income. Dentists who own practices typically need both forms of coverage to protect their professional and personal financial structures.

Cost versus consequence

Disability income insurance is typically a small fraction of a dentist’s income, depending on age, health, and policy design. That cost is tiny relative to the exposure it protects.

One long-term disability claim can represent millions of dollars in lost lifetime earnings. Few financial decisions offer a higher return on risk reduction.

The fact that so many dentists actively search for this coverage tells an important story: income risk feels more real than most people admit. Disability income insurance does not eliminate uncertainty, but it converts fear into something manageable. For a profession built on precision, that stability is worth protecting.

TH-26-004

source: https://www.ssa.gov/oact/NOTES/ran6/an2024-6.pdf

John A. Mitsos, CLU®, CLTC, is Financial Services Professional and Training Specialist, Treloar & Heisel, LLC. He can be reached at jmitsos@treloaronline.com.

Reflections from a President’s Year

Over the past year, I spent a good deal of time in airports and on airplanes—nearly 80 flights in total. Along the way, I began collecting Starbucks mugs from each city I visited. What started as a simple travel souvenir quickly became something more meaningful. Each mug represents a place, a conversation, and a connection with colleagues who share a common commitment to our profession.

Those experiences reinforced something both simple and profound: the true strength of the American Association of Endodontists is not measured by the size of our membership, the reach of our programs, or even the impact of our initiatives.

The strength of the AAE is its people.

With more than 8,000 members, the AAE is far more than a professional association—it is a community. It is a community of clinicians dedicated to preserving natural teeth, educators advancing scientific knowledge, volunteers who generously give their time and expertise, and a professional staff whose commitment allows the Association to operate at an exceptional level. Throughout the past year, every conversation and every encounter reaffirmed the shared mission that unites endodontists everywhere: saving teeth, relieving pain, and improving lives.

Engagement Across the Profession

Throughout the year, I had many opportunities to connect with students, colleagues and leaders across dentistry. These conversations consistently highlighted the growing recognition of the AAE’s leadership in advancing endodontics and promoting the value of saving natural teeth.

Education remains central to that mission. Programs such as APICES, the Educators Workshop and Corporate Conference—collectively known as Endopalooza—and Insight Track continue to provide meaningful opportunities for learning, mentorship, and collaboration.

Endopalooza brings together residents, educators, corporate partners, and organizational leaders in a uniquely collaborative environment. The open dialogue and professional connections created there strengthen the bridge between academic training and clinical practice while helping prepare the next generation of endodontists.

Insight Track likewise remains one of the AAE’s premier educational programs, offering an immersive focus on critical topics presented by world-class faculty. The enthusiasm surrounding these programs reflects the deep commitment of AAE members to lifelong learning and clinical excellence.

Strengthening Global Partnerships

International engagement also expanded significantly this year. Meetings with colleagues and organizations across Canada, Europe, South America, and Africa reinforced the global respect for the AAE’s leadership.

These interactions highlight the importance of collaboration in advancing research, education, and clinical practice in endodontics. Increasingly, the international endodontic community looks to the AAE for guidance in promoting the preservation of natural teeth and advancing the science of endodontics worldwide.

Expanding Public Awareness

Public awareness remains an essential part of the AAE’s mission. Over the past year, the Association expanded its media outreach to help educate the public about the value of endodontic care and the importance of preserving natural teeth.

Through satellite media tours, television appearances, radio interviews, and national publications, the AAE reached a broad audience and reinforced a message that sits at the very core of our profession: Nothing looks, functions, or feels like your natural teeth.

Public education initiatives such as Save Your Tooth Month continue to highlight the important role endodontists play in relieving pain, preserving natural dentition, and improving patients’ quality of life.

Advocacy and Protecting the Specialty

Advocacy remains one of the AAE’s most important responsibilities. Over the past year, the Association pursued a proactive agenda focused on protecting the specialty, preserving endodontists’ ability to practice, and safeguarding patient care.

At the state level, the AAE worked to oppose legislation that would have weakened specialty advertising standards and blurred the definition of endodontic care. These efforts helped protect both patients and the integrity of specialty recognition.

Nationally, the AAE continued its leadership in dental benefits reform, advocating for greater transparency, fair contracting practices, and reduced administrative burdens so endodontists can focus on patient care rather than navigating insurance obstacles.

Workforce sustainability also remained a key priority. The Association supported initiatives designed to address the financial barriers associated with advanced dental education, including protection of Graduate PLUS loan programs, loan forgiveness opportunities, and support for the REDI Act.

At the federal level, the AAE led the largest grassroots advocacy effort in its history to protect the financial stability of endodontic practices nationwide. Through coordinated engagement and strong member participation, the Association successfully defended tax provisions critical to dental practices.

The AAE also continued to champion science-based public health policy, including support for community water fluoridation and initiatives that promote oral health nationwide.

Strategic Direction for the Future

The AAE entered 2026 with a new Strategic Plan for 2026–2028. Developed through thoughtful deliberation by the Board of Directors and refined through collaboration with staff, the plan provides a clear framework to guide the Association’s priorities in the years ahead.

At its core is a simple but powerful objective: The public should prioritize saving their natural teeth and seek endodontists as their trusted choice for endodontic care.

Achieving this vision requires continued leadership from AAE members in advancing the science and practice of endodontics. The strategic plan emphasizes strengthening clinical resources, modernizing guidelines and position statements, and ensuring that clinical tools reflect the highest level of evidence-based care. Advocacy remains a central pillar of this strategy.

Advancing Science and Clinical Excellence

Several important initiatives advanced the scientific foundation of endodontics during the past year.

A major milestone was the publication in the Journal of Endodontics of five articles describing the development of a Core Outcomes Set for Endodontics. First authorized by the Board of Directors in 2017, this landmark initiative represents years of collaborative work and provides a roadmap for standardizing outcomes research and advancing patient-centered care.

Collaboration across the dental profession also expanded. A special issue produced jointly with the Academy of General Dentistry highlighted evidence-based endodontic practices and strengthened interdisciplinary understanding between general dentists and specialists.

The AAE also continued its collaboration with the European Society of Endodontology on the development of standardized diagnostic terminology.

Additional milestones included approval of updated clinical guidance documents, including the joint AAE/AAOMR CBCT Position Statement and the updated Trauma Guidelines.

Recognizing the rapid evolution of technology in healthcare, the AAE also convened its first Artificial Intelligence Think Tank, which will help guide the responsible and ethical integration of artificial intelligence into endodontic practice, education, and research.

Looking Ahead

Taken together, these efforts represent more than a year of activity—they represent meaningful momentum for the future of the specialty.

The AAE continues to grow as a leader in education, advocacy, scientific advancement, and public awareness. None of this progress would be possible without an engaged membership, dedicated volunteers, and professional staff committed to excellence.

This past year reinforced something I have long believed: the AAE does not belong to any one leader or any one Board. It belongs to all of us. Its future will be shaped by members who mentor the next generation, advocate for the specialty, contribute to research and education, and remain committed to the mission we share.

As we look ahead, I encourage each of you to stay involved. Mentor a resident. Volunteer your time. Teach. Support the Foundation. Advocate for our specialty. Continue advancing the science and practice of endodontics. The future of the AAE depends on the willingness of its members to step forward and lead.

In the end, the work of endodontists is both simple and profound. We save teeth. We relieve pain. We improve lives. And we do it together.

Serving as President of the American Association of Endodontists has been the most meaningful and rewarding year of my professional life. Representing this extraordinary community has been an honor I will carry with me for the rest of my career.

I leave this role deeply grateful—for the trust placed in me, for the friendships formed along the way, and for the opportunity to serve a profession that improves lives every day.

The future of endodontics is bright—and the best days for the AAE and our specialty are still ahead.

See you in Salt Lake City, April 15-18, 2026.

By Drs. Antonis Chaniotis, Anastasia Chanioti, and Ronald Ordinola Zapata

Introduction

Successful root canal preparation begins with negotiation and establishment of a smooth radicular tunnel from the canal orifice to the physiologic terminus—the glide path (1). Although a natural glide path usually exists in most roots, its dimensions, geometry, and content often make it difficult to negotiate, particularly in canals that are abruptly curved and constricted (2).

Contemporary martensitic engine-driven nickel-titanium (NiTi) instruments are extremely flexible and capable of following established canal anatomy (3). However, their safe use generally requires a reproducible glide path at least equivalent to an ISO 10 file with a .02 taper. When the anatomy prevents a size 10 K-file from reaching the radiographic terminus, because of abruptly curved and constricted canals, the clinician is confronted with what may be defined as a challenging glide path (1). In these situations, conventional instrumentation strategies may lead to procedural errors such as ledging, transportation, or instrument separation (4).

Establishing and enlarging a glide path in complex anatomy therefore remains one of the most critical steps in endodontic treatment (Fig 1).

Figure 1. A-D. Challenging splitting and double curved apical glidepath negotiation in a second maxillary premolar, E-I. Challenging splitting highly curved anatomical glidepath negotiation in a second maxillary premolar, K & L. 1 year and 15 years follow up radiographs.

Challenges in Initial Canal Negotiation

Small stainless steel hand files remain the primary instruments for initial canal exploration. Their flexibility allows them to follow narrow pathways; however, they frequently lack the rigidity required to negotiate constricted or calcified canals (5). Under apically directed watch-winding motion, these instruments may buckle or distort.

Conversely, tapered hand files possess greater stiffness but are often too bulky to pass through constricted regions of the canal system. To address this limitation, several manufacturers have introduced specialized glide-pathfinding instruments (e.g., C- files, D-finders) designed to enhance penetration through calcified pathways (5). These instruments typically feature modified tip geometries, heat-treated stainless steel for increased rigidity, or carbon steel alloys that enhance cutting efficiency.

Various design modifications—including alterations in taper, cross-section, and metallurgy—have attempted to balance three critical factors: small tip size, sufficient rigidity, and resistance to deformation (6). Despite these advances, severe canal curvature combined with calcification continues to present a significant clinical challenge.

Negotiation and “Follow” Strategy

Once a canal orifice is identified, initial exploration can begin with a slightly pre-curved ISO size 10 K-file (.02 taper). The file tip is gently introduced into the orifice and allowed to passively follow the canal trajectory. Using delicate watch-winding movements with minimal apical pressure, the file is allowed to “slide” within the canal until resistance is encountered (1).

If the file reaches working length without obstruction, engine-driven instrumentation may begin. However, when the file becomes blocked short of the radiographic terminus—often at an abrupt curvature—the clinician must adopt strategies to secure the glide path (1).

When curvature prevents further negotiation, both the radius and position of the curvature must be estimated and replicated on the scouting file (Fig. 2). Pre-curving the apical portion of the file allows the instrument tip to be oriented toward the inner wall of the curvature (Fig.3). In canals with abrupt curvatures, coronal pre-flaring may be necessary to allow the pre-curved file to enter the canal.

Figure 2. A. Double curved transparent 3D printed tooth for practicing and teaching challenging root canal negotiation (drsk.com, Sweden), B. Radiographic evaluation of the curvatures and measurement of the radius of the middle and apical third curvatures, C. Replication of the different radius of the curvatures in a 15 k-file by using the Endo Bender tool (Sybron endodontics)

The pre-curved file is then gently guided to the point of obstruction with watch-winding movements and no apical force. At the curvature, the instrument is rotated so that the tip faces the inner aspect of the curve, enabling it to negotiate beyond the blockage.

A notched silicone stop on the file can help control the spatial orientation of the pre-curve. In some cases, introducing a secondary apical curve in a different plane facilitates negotiation of complex three-dimensional anatomy (1).

Once the tip negotiates beyond the curvature, the envelope of motion technique can be applied. In this maneuver, the file is rotated clockwise while maintaining slight coronal resistance to prevent apical screwing-in (Fig 3). This movement selectively removes dentin from the coronal aspect of the curvature, slightly increasing the curvature radius and smoothing the pathway (7).

Figure 3. A. Preoperative periapical radiograph revealing apical anatomic complexity in the second maxillary premolar, B. Intraoperative Periapical Radiograph revealing the blocked glidepath in the level of the first curvature, C. Intraoperative periapical radiograph revealing the negotiation result around the first curvatures after applying the negotiation and follow strategy, D. Postoperative periapical radiograph after TCA instrumentation and obturation procedures

Gradually, the canal becomes easier to negotiate, and the file may advance to the radiographic terminus using gentle watch-winding movements. Once working length is achieved, short amplitude “smoothing” motions (<0.5 mm) help loosen the file and refine the glide path.

At this stage, when a size 10 K-file becomes extremely loose and reproducible, engine-driven NiTi instrumentation may be initiated.

Glide Path Enlargement with the Tactile Controlled Activation (TCA) Technique

In canals with severe curvature, conventional rotary instrumentation can generate significant torsional and cyclic stresses. To reduce these stresses, Tactile Controlled Activation (TCA) instrumentation was introduced (8).

TCA is defined as single-stroke activation of a stationary engine-driven file only after passive engagement within a patent canal provides tactile feedback regarding canal anatomy. The concept is based on maximizing passive engagement below the curvature before file activation, thereby minimizing torsional stress.

The technique consists of three phases: stationary, in-stroke, and out-stroke (2).

Stationary Phase

After access preparation and canal location, technical patency and a glide path to at least size 10/.02 are established. The first rotary instrument selected should have a tip size smaller than the dimensions of the patent glide path at the level of the abrupt curvature, with a taper preferably ≤4%.

The file is mounted in the endodontic motor but introduced into the canal without rotation, passively advancing until frictional resistance is encountered. In difficult access situations, the file may be inserted manually before connecting the motor intraorally.

In-Stroke Phase

Before activation, the clinician must confirm that the file tip is positioned below the first curvature, not above it. This may be verified radiographically or by precise measurement of the curvature depth.

Once the correct position is confirmed, the file is activated and passively left to advance apically until the first point of resistance is encountered beneath the curvature.

Out-Stroke Phase

When resistance is reached, the instrument is withdrawn from the canal without further apical pressure. During withdrawal, the file may be directed toward the bulkier root structure—away from the thin “danger zone”—in an anti-curvature motion.

This single in-stroke/out-stroke movement allows dentin removal while reducing the risk of torsional failure. The file transitions from maximum passive engagement (stationary) to minimal engagement during activation, reducing stress accumulation.

After removal, the file flutes are cleaned and inspected for deformation. Irrigation is performed and patency is reconfirmed. During the next stationary phase, the same instrument will typically bind slightly deeper in the canal.

The cycle is repeated in a crown-down progression until the file reaches working length with single TCA strokes. Once a file can reach working length without activation during insertion, its shaping task is considered complete. Subsequent instruments enlarge the preparation to the desired apical diameter and taper using the same controlled approach. The combination of the glidepath securing technique with the single stroke Tactile Activation Technique (TCA) will ensure the safe and uneventful instrumentation of challenging abruptly curved canal trajectories allowing the preservation of the original anatomy (Fig 4, 5).

Figure 4. A. Panoramic CBCT view of a second mandibular molar with buccally oriented abrupt curvature (Bull’s eye), B. The Sagittal CBCT view revealing the parameters of the abrupt curvature (topography, length, radius and angle of curvature), C. Pre-operative 2 dimensional radiograph of the same tooth, D. Postoperative radiograph after following the glidepath negotiation and TCA instrumentation strategy.

Figure 5. A. Panoramic CBCT view of a second maxillary molar with complicated highly curved apical anatomy suggesting a challenging glidepath, B &C. The axial CBCT views of the same tooth revealing fusion of the roots, C. Pre-operative 2-dimensional radiograph of the same tooth, D. Postoperative radiograph after following the glidepath negotiation and TCA instrumentation strategy.

Flexible martensitic NiTi instruments with non-cutting tips are best suited for TCA. Instruments with strong restoring forces or cutting tips may increase the risk of ledging when activated within a curvature and are contraindicated to be used with this technique (2).

Clinical Considerations

The TCA technique aims to deliver adequate apical preparation in severely curved canals while minimizing the duration of active engagement around curvatures. By emphasizing tactile feedback and controlled activation, the approach seeks to reduce torsional stress and procedural errors.

Although clinical experience suggests that the method may be particularly advantageous in complex anatomies—including constricted and abruptly curved canals—independent investigations evaluating its limits remain limited. As with all advanced instrumentation techniques, careful case selection and clinician judgment remain essential.

References

West JD. The endodontic Glidepath: ‘‘secret to rotary safety.’’ Dent Today 2010;29: 90-93.
Chaniotis A, Ordinola-Zapata R. Present status and future directions: Management of curved and calcified root canals. Int Endod J. 2022 May;55
Peters OA. Current challenges and concepts in the preparation of root canal systems. J Endod. 2004.
Bürklein S, Werneke M, Schaefer E. Impact of glide path preparation on the incidence of dentinal defects after preparation of severely curved root canals. Quintessence international 2018;49(8):607-613
Allen, M. J., Glickman, G. N., & Griggs, J. A. (2007). Comparative analysis of endodontic pathfinders. Journal of endodontics, 33(6), 723–726.
Cormier, C. J., von Fraunhofer, J. A., & Chamberlain, J. H. (1988). A comparison of endodontic file quality and file dimensions. Journal of endodontics, 14(3), 138–142.
Yu DC, Tam A, Schilder H (2009). Patency and envelope of motion–two essential procedures for cleaning and shaping the root canal systems. General dentistry 57, 616–621.
Chaniotis A, Filippatos C (2017) Root canal treatment of a dilacerated mandibular premolar using a novel instrumentation approach. A case report. International Endodontic Journal 50, 202–211

Dr. Chaniotis Antonis is in private practice and a clinical fellow teacher, National and Kapodistrian University of Athens, Dental School, Department of Endodontics, and Chair, Clinical Committee of the European Society of Endodontology. Orcid: https://orcid.org/0000-0003-2844-5338

Dr. Anastasia Chanioti is clinical fellow teacher, National and Kapodistrian University of Athens, Dental School, Department of Endodontics. Orcid: https://orcid.org/0000-0003-3535-1655

Dr. Ronald Ordinola Zapata is from the Endodontic Division, Department of Restorative Sciences. University of Minnesota School of Dentistry, Minn. Orcid: https://orcid.org/0000-0001-9738-0828

The authors can be reached at chaniotisantonis@gmail.com.

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.

The New Mexico Legislature is considering Senate Bill 151, a broad tax package that introduces new deductions and credits aimed at supporting healthcare practitioners, affordable housing development, local journalism, and corporate tax alignment. While the bill includes provisions designed to strengthen the healthcare workforce, it does not clearly include oral health care professionals within its eligibility framework.

SB 151 establishes tax deductions for certain healthcare-related in-office equipment and medication sales, along with tax credits intended to support providers delivering care within the state. These incentives recognize the financial realities facing healthcare professionals and seek to promote workforce sustainability and patient access. However, without explicit inclusion of dentists and dental specialists, oral health providers may be excluded from these benefits.

Oral health is essential health. Endodontists—specialized dental professionals trained to diagnose and treat dental pain and infection—provide medically necessary care that often must be delivered urgently to prevent systemic complications. Their practices rely on advanced diagnostic imaging, surgical equipment, and in-office medications that are integral to patient treatment. Excluding oral health care professionals from healthcare-focused tax relief measures creates inequitable treatment across disciplines and reinforces the outdated separation of dental care from overall healthcare policy.

In response, the AAE submitted a formal letter requesting that SB 151 be amended to explicitly include licensed dentists and dental specialists within the definition of eligible healthcare practitioners. Our advocacy emphasized the importance of parity in tax policy and the need to ensure that oral health professionals are treated equitably alongside other healthcare providers.

By seeking this amendment, the AAE is working to protect practice sustainability, promote workforce stability, and safeguard patient access to specialty dental care in New Mexico. We will continue engaging with lawmakers to ensure oral health is recognized as an essential component of the healthcare system.

Across multiple states, lawmakers are introducing legislation to regulate the use of virtual credit cards in health and dental insurance reimbursement. These measures address a growing concern among providers: insurers issuing payment via single-use virtual credit cards that may carry processing fees, often without clear advance disclosure or provider consent.

Virtual credit card payments can impose transaction fees that reduce reimbursement for services already rendered. In many cases, providers are automatically enrolled in these payment methods without meaningful notice or are not offered a no-fee alternative. For endodontists providing urgent, medically necessary treatment, reduced reimbursement and administrative complexity can create barriers to delivering timely care.

The legislation under consideration would prohibit insurers from requiring virtual credit card payments as the sole reimbursement method, mandate disclosure of any associated fees, and ensure that providers have the option to select alternative payment methods. Some measures also prohibit transmission fees unless the provider affirmatively consents.

The AAE submitted formal letters of support for these bills, highlighting the importance of payment transparency and provider choice. Our advocacy emphasized that reimbursement practices must be fair, predictable, and free from hidden administrative costs that diminish compensation for patient care.

By promoting transparency and consent-based payment systems, these reforms strengthen practice sustainability and reduce unnecessary administrative burdens. The AAE will continue to advocate for policies that protect providers from unfair reimbursement practices and preserve patient access to specialty dental care.

The Massachusetts Legislature is considering legislation to increase transparency in the practice of dental leased networks—commonly associated with “silent PPO” arrangements. These practices occur when a dental plan leases its contracted provider network to third-party entities without the provider’s clear knowledge or consent. The result can be reduced reimbursement, altered contractual terms, and confusion for both providers and patients.

Under the proposed legislation, provider network entities would be required to disclose third-party health plans that access their networks, identify applicable fee schedules, and notify dentists of any material changes affecting reimbursement. The bill also strengthens oversight of these arrangements and ensures that providers are aware of which entities are accessing their contracted rates.

Silent PPO arrangements undermine the integrity of provider contracts. When dentists agree to participate in a network, they do so with an understanding of the reimbursement terms and administrative obligations. Network leasing without transparent disclosure can lead to reduced payments under unfamiliar plans, administrative confusion, and difficulty resolving disputes. For endodontists delivering specialized and often urgent care, unexpected reimbursement reductions can directly affect practice sustainability and patient access.

The AAE submitted a formal letter of support for this legislation, emphasizing that transparency and contractual integrity are essential to maintaining fair relationships between insurers and dental professionals. We underscored that providers must have clear notice of which entities are accessing their networks and must be protected from reimbursement reductions that occur without consent.

By strengthening disclosure requirements and ensuring accountability in network leasing practices, this bill protects providers from hidden contracting practices and supports stable, predictable reimbursement structures. The AAE remains committed to advancing policies that promote fairness, transparency, and high standards of patient care.

State legislatures across the country are advancing dental loss ratio (DLR) legislation intended to improve transparency and accountability in dental benefit plans. At its core, a dental loss ratio establishes the percentage of premium dollars that insurers must spend on patient care rather than administrative expenses, marketing, or executive compensation. Without enforceable DLR standards, a substantial portion of premium revenue may never reach the patients it was intended to serve. For endodontists and the patients who rely on timely, medically necessary treatment, these policies directly affect access to care and fairness in the dental marketplace.

In recent years, policymakers have increasingly looked to the federal medical loss ratio model under the Affordable Care Act as a framework for reform. That model requires health insurers to devote a defined percentage of premium dollars to clinical care or issue rebates to policyholders. Similar guardrails in the dental market would ensure that premium spending is directed toward treatment—not overhead. However, not all DLR proposals include the strong enforcement mechanisms necessary to deliver meaningful reform. Transparency alone is not enough. Without a clearly defined minimum threshold and annual rebate requirement, reporting measures risk becoming administrative exercises rather than patient protections.

The AAE has taken clear positions on several DLR proposals this legislative cycle.

Where AAE Supports Strong Reform

The AAE supports legislation that establishes a specific minimum dental loss ratio of 85 percent and requires insurers to provide annual rebates if they fail to meet that benchmark.

We have submitted formal support for:

Missouri – SB 1596
West Virginia – HB 4810 / SB 548
Washington – HB 1535

These bills pair transparency with enforceable standards. By requiring dental plans to dedicate the majority of premium dollars to patient care and refund excess administrative retention, they prioritize patients and introduce real accountability into the marketplace. This approach reflects the balanced, proven model that has protected medical insurance consumers for more than a decade.

Where AAE Opposes Reporting-Only Measures

The AAE has also expressed opposition to proposals that focus primarily on reporting requirements without establishing enforceable minimum thresholds.

We oppose:

Mississippi – HB 1117 / SB 2479
New York – A 3919 (A/B versions)

While transparency is an important component of reform, reporting alone does not prevent harmful insurer practices, reduce administrative burdens, or ensure that premium dollars are directed toward care. Without a mandatory minimum loss ratio and automatic rebate mechanism, these bills may fall short of meaningfully improving patient access. The AAE continues to urge lawmakers in these states to adopt stronger, enforceable protections.

Where AAE Urges Amendments to Strengthen Protections

In several states, legislation moves in the right direction but requires strengthening to fully protect patients.

We are urging amendments to:

Alabama – SB 81
Hawaii – SB 2132
Nebraska – LB 639

Although these bills establish loss ratio requirements, they lack sufficiently robust enforcement mechanisms or clearly defined rebate structures to ensure consistent compliance. Without clear standards and annual accountability, insurers may retain flexibility that weakens the intended patient protections. The AAE is working with lawmakers to refine these proposals so that they deliver meaningful, enforceable reform.

Protecting Patients and the Integrity of Care

For endodontists, dental loss ratio reform is not an abstract policy debate. Administrative denials, delayed reimbursements, and coverage limitations affect real patients seeking urgent care. When premium dollars are diverted away from treatment, patient access suffers.

Our message to legislators nationwide is consistent: dental loss ratio legislation must include strong, enforceable standards that ensure premium dollars support patient care. Through direct engagement, formal comment letters, and ongoing collaboration with policymakers, the AAE continues to advocate for reforms that protect patients and uphold the integrity of specialty dental care.

This work reflects the AAE’s ongoing commitment to advancing policies that promote transparency, fairness, and access to high-quality endodontic treatment.

Artificial intelligence is not new. The concept emerged in the early 1950s and has progressed through multiple stages of development. However, beginning in 2022–2023, large language models, powered by advances in computing power, big data, and neural networks, significantly accelerated its capabilities, producing breakthroughs in image recognition, speech processing, and natural language understanding.

AI is no longer theoretical in healthcare either. It is actively influencing how we diagnose, communicate, and deliver care.

As endodontists, specialists who have long embraced precision, innovation, and advanced technology, we are uniquely positioned to lead in this space.

Across healthcare, and particularly within dentistry, AI is being applied to imaging interpretation, predictive analytics, treatment planning, education, quality assurance, and even regulatory and payer decision-making. Some developments are promising. Others raise important questions. And many are unfolding around us rather than being shaped by us.

That reality prompted a fundamental question at the AAE:

If AI is going to shape the future of endodontics, who should help shape AI?

The answer, we believe, is the AAE.

Who Should Help Shape AI?

From enhanced imaging analysis and CBCT interpretation to predictive analytics and workflow automation, artificial intelligence has the potential to strengthen diagnostic accuracy, improve efficiency, and support better patient outcomes. In endodontics specifically, AI tools are being developed to assist in identifying periapical pathosis, detecting missed canals, assessing fracture patterns, and supporting treatment planning decisions. In the future, augmented robotics may even assist in performing portions of endodontic procedures.

But while the technology is powerful, our responsibility remains clear: AI must enhance clinical judgment—not replace it. The art and science of endodontics rely on training, experience, and critical thinking. AI can generate data and insights, but it is the endodontist who interprets that information within the full clinical context of the patient in the chair.

That balance, innovation guided by expertise, is precisely where the American Association of Endodontists is focused.

Over the past year, your Board of Directors supported the formation of a dedicated initiative to examine the implications of AI for our specialty. This formally launched with the Artificial Intelligence in Endodontics Think Tank, a strategic advisory body reporting directly to the Board through a designated liaison. The Think Tank was intentionally structured to bring together leaders in clinical endodontics, research, education, advocacy, technology, and organized dentistry, alongside senior AAE and Foundation staff.

Its charge is forward-looking and clear: to explore, evaluate, and develop a comprehensive framework for the responsible integration of AI in endodontics.

During its inaugural meeting, participants reviewed the rapidly evolving AI landscape, identified priority areas, and began outlining measurable next steps for how the AAE can guide the specialty responsibly.

Priorities

Priority areas under consideration include:

Enabling responsible clinical adoption while preserving professional judgment and patient safety
Preparing the future workforce by integrating AI concepts into education and lifelong learning
Translating insights from medicine and broader dentistry into specialty-specific applications
Defining the role of the AAE Foundation in supporting AI-related research
Developing advocacy principles regarding regulation, payer decision-making, and utilization review
Clarifying terminology, including the distinction between “artificial” and “augmented” intelligence
Establishing clear guardrails and standards that define appropriate use and boundaries

In short, this initiative is about stewardship.

It is about ensuring that endodontists lead the conversation, shape policy, and define standards, so that artificial intelligence strengthens patient care, supports clinical excellence, and advances our specialty rather than undermines it.

AEO

Just as importantly, we are advancing the AEO (Answer Engine Optimization) initiative—our strategic effort to optimize the AAE’s patient website so that accurate, evidence-based endodontic information is accessible not only to patients directly, but also through large language models and AI-driven search tools. As more people turn to AI platforms for health information, it is critical that the content being surfaced reflects the expertise of endodontists. Through enhanced structure, expanded FAQs, clear data points on outcomes and longevity, and carefully developed educational copy, AEO ensures that when patients ask AI about root canals, tooth pain or saving their natural teeth, the answers are grounded in science and aligned with our specialty’s standards of care.

Another visible example of our dedication to AI is our Save Your Tooth Month AI agent. Designed to help patients access credible, science-based information about endodontic care, this tool reflects our commitment to combating misinformation while leveraging emerging technology for public education. I am proud to share that the AI agent has already received multiple awards and is currently a finalist for PRWeek’s Best AI Healthcare Innovation award, with formal recognition to be announced in May. As a finalist, the AAE will receive national industry acknowledgment for this groundbreaking work.

This achievement underscores an important point: AI is not just a clinical tool. It is also a communications tool, an educational tool and a platform for extending our mission to save natural teeth.

Education

Education, of course, remains at the core of everything we do. At AAE26, we are offering a robust slate of AI-focused programming designed to move beyond theory and into practical application. Dedicated sessions explore the current AI landscape in endodontics, real-world clinical integration, ethical considerations and the evolving regulatory environment. In addition, hands-on workshops provide members the opportunity to examine AI-driven imaging analysis, diagnostic support technologies and workflow tools in a structured learning environment. These sessions are designed not simply to demonstrate innovation, but to help clinicians critically evaluate emerging tools—asking what problem they solve, how their outputs should be validated and where the boundaries of appropriate use must remain firmly in the hands of the endodontist.

Our goal is not to encourage adoption for adoption’s sake. Rather, it is to ensure that endodontists are equipped to evaluate AI tools critically, integrate them responsibly and maintain the highest standards of patient care.

As we look ahead, several guiding principles remain paramount:

First, patient trust must always come first. Transparency about how AI is used in diagnosis or treatment planning is essential.

Second, data integrity and privacy cannot be compromised. Safeguarding patient information is a professional and ethical obligation.

Third, continuing education is vital. The technology will evolve; so must we.

Endodontics has always been a specialty grounded in precision and driven by progress—from the adoption of the operating microscope to advances in rotary instrumentation and 3D imaging. Artificial intelligence represents another chapter in that tradition. If approached thoughtfully, it can enhance our ability to diagnose earlier, treat more effectively and communicate more clearly with patients and referring colleagues.

The AAE will continue to serve as your trusted resource in navigating this rapidly changing landscape. Through structured Think Tank oversight, strategic initiatives like AEO, comprehensive educational programming at AAE26 and award-winning public outreach, we are committed to ensuring that AI strengthens—not disrupts—the standard of excellence that defines our specialty.

I encourage you to explore the AI offerings at AAE26, engage in the conversation and consider how these tools may support your practice and your patients. Together, we can lead dentistry forward—responsibly, ethically and confidently.

Thank you for your dedication to saving natural teeth and for your continued commitment to innovation in endodontics.

It is with great sadness that we announce the passing of Mbachan Collins Okwen, DDS, MBA, MSD, endodontist, educator, and leader, who died on January 21, 2026, in Conroe, Texas. A former Board member of the AAE (District V Director), Dr. Okwen was known for his contributions to endodontic education in Africa, his deep commitment to patient care, and his unwavering spirit of service that touched many lives across continents.

Dr. Okwen was born on June 29, 1972, in Bamenda, Northwest Region of Cameroon. From an early age, he demonstrated a blend of intellect, humility, creativity, and compassion for others.

He began his primary education at G.S. Batibo, laying the academic foundation that would define his life. He later attended the prestigious Sacred Heart College Mankon, where he excelled and obtained both his Ordinary and Advanced Level certificates. Even in his youth, he stood out—not only for his intelligence, but for his discipline, curiosity, and emerging leadership qualities.

He went on to pursue dentistry at the University of Benin, Nigeria, where he earned a Bachelor of Dental Surgery and a Doctor of Dental Surgery. His commitment to excellence was evident in his studies and in his dedication to mastering his profession.

Driven by a desire to expand his knowledge and global opportunities, Dr. Okwen later moved to the United States, where he earned a Master of Business Administration, MBA, further demonstrating his remarkable intellectual range and versatility. Yet dentistry remained his calling.

In 2014, eager to return fully to dentistry and elevate his specialty training, he was accepted into a preceptorship at UT Health Houston. He pursued graduate training in endodontics while simultaneously carrying a bold vision: to initiate and develop a formal endodontic training program in Africa. He completed his graduate endodontic training at UT Health Houston in 2016, earning his Master of Science in Dentistry, MSD.

During his preceptorship, Dr. Okwen purchased used microscopes and endodontic instruments from the university at auction and transported them to Nigeria. With these tools, he helped establish the first endodontic training program in western central Africa at the University of Benin. His mission was clear and uncompromising.

“The goal was to get them to do exactly what we do here and nothing less,” he had said. “Of course, there’s always tons of patients…”

He later became a Diplomate of the American Board of Endodontics and served as a Clinical Assistant Professor in Endodontics, mentoring the next generation of specialists.

Dr. Okwen founded 1488 Dental in The Woodlands, Texas, where he served the greater Houston community with exceptional dedication. His patients were not merely clients; they were family. Known for his availability and commitment, he devoted himself fully to his craft.

His leadership extended to the AAE, where he served on the Board of Directors from 2022 to 2025. He also served on the AAE Nominating Committee and was actively involved with the AAE Foundation for Endodontics, championing mentorship and professional responsibility.

His commitment to giving back was further reflected in the founding of the Ralph Okwen Foundation, a family trust established to support excellence in science at Sacred Heart College Mankon, Bamenda, and to expand access to high-quality endodontic care in Africa, relieve suffering, and inspire others to give back so that people everywhere could experience the joy of being free from dental pain.

Beyond dentistry, Dr. Okwen was a musician. He also held certifications in Cisco networking and server maintenance and maintained a strong interest in artificial intelligence, particularly systems that could empower Africa. Developing children’s stories was another passion he carried.

“During my many conversations with him over the two years I served as his District Co-Director, it became abundantly clear that he was an exceptionally devoted father,” said AAE Treasurer Dr. Brad Gettleman. “I truly cannot recall a single conversation that did not, at some point, circle back to his children, whom he loved more than anything in the world.”

Dr. Okwen was known to be humble, generous, and deeply grounded. He believed material possessions were tools for meaningful impact. He confronted challenges directly and pursued excellence relentlessly. He will be missed.

Further reading: Learn more about Dr. Okwen’s incredible passion for endodontics in this Foundation for Endodontics article.

By Feng-Ming Wang, DDS, PhD

Deroofing of the jaw cyst (the original strategy of decompression) was first suggested by Partsch in the German literature in 1892 (1). In 1964, Patterson reported a successful decompression by using a polyethylene tube and stint for drainage on a large periapical lesion associated with the left central and lateral incisors on a 26-year-old patient (2). This was right after endodontics being formally approved as the 8th dental specialty by the American Dental Association House of Delegates in 1963. After many years, decompression appears to be an overlooked alternative approach for managing large cystic periapical lesions (3).

Nonsurgical root canal treatment on anterior teeth has a success rate of 74% in a 2004 study (4) and 59% in a 2024 study (5). In the latter study, if the outcome was evaluated by Cone-Beam Computed Tomography (CBCT), the success rate dropped to 20% (5). Endodontists have seen that despite the advancement of the knowledge of endodontics and modern technology, there are lesions that do not heal after nonsurgical root canal treatments. Often, periapical surgery is chosen to address the situation of non-healing periapical lesions following nonsurgical treatments and retreatments. But challenges exist due to the pitfalls of periapical surgery. Most common ones include jeopardizing the osseous support of adjacent teeth, damage to the blood vessels, nerves of adjacent teeth, and anatomic structures like canalis sinuosus in the anterior maxilla (6), and occurrence of a surgical defect. Sometimes patients cannot tolerate the procedure well because of their age and/or health conditions. Thus, it is important to know that decompression can be a great substitute of periapical surgery when such dilemma presents.

Understanding the pathogenesis of periapical cyst would help us understand the decompression technique so that we could use it comfortably to manage large cystic periapical lesions. There are at least three popular theories regarding the formation of periapical cyst. First, in the nutritional deficiency theory, as islands of epithelium expand, more central epithelial cells are distanced from their nutritional supply and undergo necrosis. A cystic cavity results in the center of the cell mass as liquefaction necrosis occurs (7). Second, in the immunological reaction theory, inflammatory mediators from the immune reactions stimulate epithelial cell rests of Malassez (ERM) to proliferate, resulting in cystic lined lumen formation (8). Third, in the abscess theory, cavity comes into existence and starts to be lined by the epithelium from the proliferating ERM led by inflammatory mediators; cavity enlarges due to osmotic pressure with the lack of lymphatic circulation and pressure-induced resorption of the surrounding bone (9-11). The degenerative characteristics of epithelial linings continues enhancing osmolality of the cyst contents till pressure is relieved. Although the pathogenesis of the periapical cyst remains to be elucidated, clinical cases evidenced that irrigation after aspiration with or sometimes even without long-term decompression can achieve optimal outcomes. The possible explanation of treatment efficacy could include the following: 1) diminishment of osmotic pressure after the integrity of the lesion wall is disrupted; 2) reduction the impact of inflammatory mediators on epithelial cells after the lesion content is aspirated and rinsed; 3) introduction of bleeding and blot clotting followed by new blood vessel formation and then tissue regeneration, especially bone formation as a wound healing process. Further, it has been proposed that the epithelial cells would experience programmed cell death (apoptosis) in response to the lack of the inflammatory mediators (12).

According to Glossary of Endodontic Terms, decompression aims to reduce the size of a large cystic periapical lesion using two primary techniques: 1) the surgical incision through a wall and insertion of a drain; 2) the penetration of the cyst in two locations with two large gauge needles and flushing with sterile saline (13). There are several types of drain technique described in the literature (3). Manjarrés and colleagues developed a 3D-printed educational model for decompression and nicely showcased its application clinically (14). The author of this Communiqué article has recently successfully used Penrose drain in treating several cases of large cystic periapical lesion. One of the author’s publications showed that decompression using the Penrose drain significantly induced bone regeneration and reduced lesion size before periapical surgery was performed later (15). Penrose drain was named after Charles B. Penrose (1862-1925) physician specializing in gynecology. Penrose drain is soft, radiopaque, and inert, with minimal foreign body reaction. It provides patients with comfort and can be located radiographically. The length of drainage in literature ranged from 2 days (16) to 5 years (17). The author found that 4-week period had worked well in all their cases. Hoen and colleagues reported that aspiration followed by irrigation without further placement of drain achieved great results as well (18). As shown in Figure 1, the healing of large cystic lesion associated with teeth #7 and #8 in an 85-year-old female was demonstrated by CBCT imaging following aspiration and irrigation only. Nevertheless, the author recommends that clinicians should determine the length of drainage case by case. Of note, it appears unnecessary or sometimes impractical for patients to perform self-irrigation of the lesion with saline or some type of antibacterial agent.

Figure 1 – Management of large periapical lesion by decompression. An 85-year-old female presented with pain and swelling in the anterior palate. A-D) Preoperative limited field of view CBCT scan. A) Axial view. B) Coronal view of teeth #7 and #8. C) Sagittal view of tooth #7. D) Sagittal view of tooth #8. E) Decompression by aspiration using an 18-gauge needle. F) Irrigation of the lesion with saline using 2 needles. G-J) Three-year follow-up CBCT scan. G) Axial view. H) Coronal view of teeth #7 and #8. I) Sagittal view of tooth #7. J) Sagittal view of tooth #8. (This work was done by Dr. Wang together with his former resident Dr. Ghazaleh Rezaei, who currently practices at Las Vegas Endodontics. CBCT scans were kindly provided by Dr. Matthew Massey at Heart of Texas Endodontics.)

It is worth mentioning that a large periapical lesion does not automatically mean a cyst. The proportion of periapical cysts increases when lesion increases in size (19). But some very large lesions have been confirmed to be granulomas through biopsy. Provisionally, a periapical lesion could be diagnosed as a cystic lesion when it involved one nonvital tooth and the straw-colored fluid was aspirated from the lesion (20).

In general, decompression may be considered in cases involving nonvital teeth or teeth associated with a large radiolucent lesion (more than 200 mm²) when needle aspiration demonstrates a straw-colored fluid or copious drainage from the canal during root canal therapy. The cystic cavity should allow free placement of a tube or drain within the lesion. Decompression should not be recommended for lesions with a chronic sinus tract. If upon attempting aspiration, the clinician is unable to remove fluid from the bony cavity, this would indicate the presence of granulomatous lesion which is unsuitable for decompression. Like any other surgical procedures, it is always important to review medical and dental history and evaluate risks thoroughly prior to decompression of large periapical lesions.

In summary, decompression is a preservative and minimally invasive approach to manage large cystic periapical lesions. Endodontists should be aware of this treatment option and may offer it to understanding and motivated patients before more aggressive surgical procedures are selected.

Dr. Feng-Ming Wang is a Clinical Associate Professor of Endodontics in Texas A&M University College of Dentistry and maintains a private practice at Precision Endodontics in Plano, Texas. The author would like to thank Dr. James L. Gutmann for kindly reviewing the article.

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