Julian Webber – specialist at the Harley Street centre for Endodontics, international lecturer, former President of the British Endodontic Society, active member of the European Society of Endodontology, and a full member of the American Association of Endodontists. In last month’s issue we featured an interview with Michael Norton on the implant/endo debate,
here Julian gives his perspective on when to save teeth and the principles of endodontics. We talk generally about endodontics first.
What drew you to become an endodontist?
JW: I qualified as a dentist and due to various connections and people that I knew who had done post graduate training in the USA; I decided to do something similar. After discussion with colleagues I applied to Northwestern University Dental School, Chicago and returned in 1978 as the first UK dentist to receive a Masters’s degree in endodontics from a US university. Back in the UK I worked together with Fred Harty and Chris Stock, and set up the Lister House Endodontic Practice which became the household name in endodontics for many years. Finally I decided to leave and set up here in Harley Street in 2002.
What has been the biggest development most in endodontics since you qualified?
JW: The number one thing that has developed in endodontics would be the use of the microscope. It enables us to treat more complex cases successfully because we can see clearly what we are doing. It enables us to find canals that previously we would never have been able to, and it allows us to carry out endodontic retreatment and surgery with a greater degree of predictability. Endodontists see many endodontic failures, and with the microscope we can retreat many cases which previously would have seemed untreatable and the tooth would have been extracted.
Are patients aware of, and do they understand endodontics?
JW: I think as far as the UK is concerned, there is a real lack of understanding of what endodontics is and what it can do for you. When done correctly it is pain free even though patients often think root canal treatment equals pain. So, when patients are first presented with the proposition that they need endodontic treatment, they face it with fear and trepidation. We have our own website, www.roottreatmentuk.com which clearly explains the nature of our work to both patients and referring dentists. In addition we set up the Saving Teeth Awareness Campaign, www.savingteeth.co.uk to improve public awareness of the benefits of endodontic treatment and the solutions available should someone be faced with the possibility of tooth loss
Is cost of treatment an important factor for patients?
JW: Whilst all our patients are seen on a private basis, cost is certainly an issue. However I usually express my fee in terms of the alternative. Should the patient lose the tooth they are faced with having an implant or a bridge. If you look at the cost of these treatments they are very much more expensive (especially the implant) than saving the tooth with good root
treatment followed by the restoration. If I was a patient I think I’d know what I’d want.
What criteria do you use when deciding whether endodontics is appropriate or not?
JW: There are only two real questions to answer. Firstly, can the tooth be restored after the root treatment and secondly is the periodontal condition reasonably sound and can be maintained? As an endodontist I make the assessment that the tooth can be root treated and then it’s up to the restorative dentist to restore the tooth after with a good crown and maintain periodontal support. There should be no other criteria. However, there are of course always endodontic situations which really are insurmountable, but if a tooth can be, it should be saved at all costs.
What are the success rates of endodontics?
JW: You can measure success in two ways. Traditionally you measure endodontic success in terms of healing and resolution of infection, but you can also measure endodontic success in terms of survival of the tooth - if I do the root canal today and the tooth is still there in 10 years’ time we can say that tooth has survived in the mouth. Dental implant success is measured
in terms of survival so you can’t compare implant and endodontic success unless you use the same parameters of success to determine long term outcome. Indeed if you look at the literature on long term survival, the restored endodonticaly treated tooth has the same high survival rates as the implant retained restoration. In addition, if we look at the healing rates in terms of resolution of infection when root canal treatment is done properly we also see very high success rates, especially when the treatment is carried out by an endodontist. I personally have thousands of cases going back 25-30 years which have survived in function and are infection free. I recall all may patients annually for as many years as I feel necessary to assess healing
Moving on to the recent debate with Michael Norton on the subject of endodontic treatment and implants, when is it right to save the tooth and when is it right to replace
it?
JW: The implant/endodontic debate between Michael and myself I think was very well received. We gave colleagues who came along that evening a lot to think about. Michael and I are very much on the same wavelength. Both of us would always encourage patients to save a tooth where possible. Yes, there are always certain situations where that is not possible and then an implant should be considered. Let’s not forget that implants replace missing teeth and are not substitutes for them. I think many of the attendees on the evening were surprised at the scope of modern endodontic treatment and what endodontists can achieve. Admittedly, there may be a grey area when it comes to endodontic surgery, especially second time around. If so little tooth remains and there is so little support with considerable infection, an extraction may be indicated. For Michael the big issue was the teeth that had been brutally or poorly root treated and terribly restored. I was in total agreement with him that in these cases no further intervention would be of benefit to the patient. Sometimes, you just have to “hold up your hands” and say enough is enough and the only way forward is an extraction and implant
Does it ever feel like a competition between endodontics and implants?
JW: Implantology is a branch of dentistry as is endodontics and there are specific indications for both treatments. It is as unethical to remove a tooth and place an implant when it could be root treated and restored as it is to carry out endodontics on a hopeless tooth that cannot be root treated and restored. I have nothing bad to say about implants, they are excellent at
replacing missing teeth, and excellent for teeth that simply cannot be rebuilt and restored. I’m not in competition with implant specialists and they are not in competition with us; there are specific circumstances where endodontics is needed and there are specific circumstances where implants are needed. We all need to work together as a team to come up
with the best treatment plan for the patient.
What would you like to see in the future for endodontics?
JW: We’ve progressed a long way in endodontics over the past 20 years, we’ve seen some huge advances in materials and instruments and techniques. What I’d like to see in the future, is further education for general dentists in modern endodontic technique and to simplify the root treatment procedure. All dentists should be able to negotiate complex curvatures in canals, have the ability to get all the way to the end of the canal, fill them dimensionally and provide a good restoration after. When dentists have these skills more teeth will be saved and patients will benefit.