Continuing Education

Volume 33 No. 4 Page 80

The Role of Endodontics in

Interdisciplinary Dentistry:
Are You Making the Right Decisions?
Authored by John West, DDS, MSD

Upon successful completion of this CE activity 2 CE credit hours will be awarded

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Continuing Education

The Role of Endodontics in

Interdisciplinary Dentistry:

text Interdisciplinary Treatment Planning Volume II:

Comprehensive Case Studies and is lead author
of Esthetic Management of Endodontically Treated
Teeth in Ronald Goldsteins third edition of Esthetics
in Dentistry. Dr. West has presented unrivaled endodontic
continuing education in North America, South America,
Europe, and Asia while maintaining a private
practice in Tacoma, Wash. He can be reached at
(800) 900-7668 (ROOT), johnwest@centerforendodontics.com,
or centerforendodontics.com.

Are You Making the Right Decisions?

Effective Date: 4/1/2014

Expiration Date: 4/1/2017

ABOUT THE AUTHOR

Dr. West is the founder and director of
the Center for Endodontics and
continues to be recognized as one of
worlds premier educators in clinical and
interdisciplinary
endodontics.
He
received his DDS from the University of
Washington in 1971 where he is an affiliate associate
professor. He then earned his MSD in endodontics at
Boston University Henry M. Goldman School of Dental
Medicine in 1975, where he is a clinical instructor and has
been awarded the Distinguished Alumni Award. Dr. Wests
memberships include: 2009 president and Fellow of the
American Academy of Esthetic Dentistry and 2010
president of the Academy of Microscope Enhanced
Dentistry, the Northwest Network for Dental Excellence,
and the International College of Dentists. He is a 2010
consultant for the ADAs prestigious board of trustees
and is a consultant to the ADA Council on Dental Practice.
Dr. West further serves on the Henry M. Goldman School
of Dental Medicines Boston University Alumni Board. He is
a Thought Leader for Carestream Digital Dental Systems
and serves on the editorial advisory boards for The
Journal of Esthetic and Restorative Dentistry, Practical
Procedures and Aesthetic Dentistry, and The Journal of
Microscope Enhanced Dentistry. He co-authored
Obturation of the Radicular Space with Dr. John Ingle in
Ingles 1994 and 2002 editions of Endodontics and
was senior author of Cleaning and Shaping the Root Canal
System in Cohen and Burns 1994 and 1998 Pathways
of the Pulp. He has authored Endodontic Predictability
in Dr. Michael Cohens 2008 Quintessence text
Interdisciplinary Treatment Planning: Principles, Design,
Implementation, and Michael Cohens 2010 Quintessence

Disclosure: Dr. West is the co-inventor of ProTaper,

WaveOne, and Calamus Endodontic Systems (DENTSPLY
Tulsa Dental Specialties).

INTRODUCTION
The mere subject of endodontics evokes tunnel vision
diagnosis, thinking, and treatment planning. By its very
nature, endodontics focuses on single-tooth dentistry.
Sometimes, endodontics is reduced to a single canal and,
at other times, endodontics is even defined as a single
millimeter (such as an underfilled lateral portal of exit [POE]
or historically, and perhaps more commonly, known as a
lateral canal). And yet, that single endodontic tooth can be
the missing, strongest, or weakest link in the decision
process, sequence, and treatment plan influencing or being
dependent on the predictability of treating endodontically
diseased teeth.1
This article will discuss the relationship of endodontic
interdisciplinary success and the 3 critically essential
determinants of endodontic predictability: (1) biology, (2)
structure, and (3) aesthetics. By increasing the thought
process awareness, options, and choices, dentists can
experience better control of their interdisciplinary
endodontic outcomes and the role endodontics plays in
predictable comprehensive dentistry.

BIOLOGY
The biology of endodontic disease and its rationale for
treatment are simple, and have been the basis for successful
clinical endodontics for half a century that has produced
successes for 20 to 50 years and beyond (Figures 1a to 1d).2,3
The rationale for endodontics is that any endodontically
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Continuing Education

The Role of Endodontics in Interdisciplinary Dentistry: Are You Making the Right Decisions?
diseased tooth can be predictably
a
c
b
d
treated if the root canal system
can be sealed either nonsurgically
or surgically, and, if the periodontal condition is healthy or can
As
be
made
healthy.4
endodontists, we are often asked
the question, Do you think this
tooth should be saved? The right
question is, Is this tooth Figures 1a to 1d. Biology: When endodontics is performed diligently with skill, knowledge, and willingness
for patience and precision, long-term predictable results are not only possible but probable. (a) Pretreatstructurally restorable? From an ment of endodontic failure. (b) Periapical radiograph at time of treatment. (c) The 32-year post-treatment
endodontic perspective, our success. (d) Shows healthy gingival and attachment apparatus while no sign of the original sinus tract.
Tooth is fully functional.
question or your question as a
dentist to see small details by viewing a huge screen image
restorative dentist performing endodontics should be, Can
versus a dental periapical radiograph. Three-dimensional
we produce the Endodontic Seal?5 If the role of
digital imaging can be a valuable road map for finding and
endodontics is to prevent lesions of endodontic origin
tracing the root canal path. Knowledge of the average
(LEOs) where they do not exist and heal LEOs where they
number of canals that are in each tooth can be helpful for the
do exist, then the 3-D treatment and ultimately elimination of
dentist who performs an occasional endodontic procedure.6
the cause of endodontic disease (contents of the root canal
system) is key. Of course, as I discuss later, the tooth must
3. Follow all canals. The mastery of this skill is the single
also be restorable and aesthetically valued.
most significant skill in endodontics short of correct and
Endodontics has become more precise with improved
proper diagnosis. Manual files must be curved and often in
technology that continues at a breakthrough pace:
multiple planes in order to successfully follow to their
microscopes, Ni-Ti shaping, 3-D cleaning devices and
termini. Clinicians must be mindful of collagen or dentin
solutions of the root canal system, digital and 3-D imaging,
mudthe fatal flaws of successful endodontic following.
microinstruments including ultrasonics and delivery
There are 3 other situations that prevent the successful skill
systems, and predictable 3-D obturation. But all the newest
of following to the canal radiographic terminus (some
technology does not help the biologic outcome unless the
distance from the physiologic terminus), and they are: (1)
dentist understands endodontic principles and knows
the curved file does not sufficiently mimic the canal 3-D
when, why, and how to use the latest tools. The clinician
path, (2) the tip of the chosen file is too wide apically, or (3)
remains the greatest determinant of all! The role of
the shaft of the file is too wide coronally (coronal restrictive
endodontics in interdisciplinary dentistry still comes down
dentin). Knowledge, skill, and willingness are required to
to knowing what the biology wants, and what that comes
solve each of these situations, or combination of
down to is doing predictable endodontics.
situations.7
How can dentists do predictable endodontics? The
4. Shape the canals into the continuously tapering
recipe is simple. You only need the following 10 ingredients:
funnel using ethylenediaminetetraacetic acid (EDTA) as
1. Design a successful access cavity with no restrictive
irrigant. EDTA momentarily softens the radicular walls,
dentinal triangles and yet full respect and protection of the
making Ni-Ti shaping theoretically safer and, at the same
ferrule (see Structure below).
time, removes the smear layer as it is being created. In
2. Find all canals. In order to do this time after time,
other words, the desired shape preparation connects the
magnification and illumination are essential. The best form
dots between the minimal apical constriction and one third
of magnification and illumination is the operating
the width of the tooths mesial-distal width as measured at
microscope. Period. In addition, digital imaging allows the
the cemento-enamel junction. This optimal shape provides
2

Continuing Education

The Role of Endodontics in Interdisciplinary Dentistry: Are You Making the Right Decisions?
for sufficient obturation hydraulics while preserving precious
ferrule not only in the mesial-distal dimension but also the
more critical facial-lingual dimension. Shaping also
facilitates 3-D cleaning.
5. Clean the root canal system by constant chamber and
canal flooding and exchanging with sodium hypochlorite. The
use of mechanical cleaning devices such as the
EndoActivator (DENTSPLY Tulsa Dental Specialties) can
improve removal of detached pulp, necrotic debris, and
bacteria through agitation.
6. Conefit. When is shaping finished? In these Ni-Ti
times, magnified evidence of dentin in the files apical flutes
validates that that files shape has been prepared. The
successful conefit for vertical compaction of warm guttapercha or size verifier for carrier-based obturation further
confirms that proper shaping is finished.
7. Remove smear layer prior to oburation pack. Agitate
an EDTA product (such as QMix [DENTSPLY Tulsa Dental
Specialties]) in order to remove any remaining smear layer,
capable of blocking portals of exit and then dry the canals.
8. Obturate the canals with preferred sealer with a
vertical compaction technique such as warm gutta-percha. (I
use Kerr Pulp Canal Sealer [SybronEndo] because of its
sealing longevity and radiopacity, plus it is bactericidal.)
Carrier-based obturations (GuttaCore [DENTSPLY Tulsa
Dental Specialties]) are preferred using root canal sealer
(ThermaSeal [DENTSPLY Tulsa Dental Specialties]).
9. Back-pack 1.0 mm short of chamber entrance, etch,
bond, and seal the canal orifice and chamber floor to the
depth of 2 mm (OptiBond [Kerr] and a flowable composite).
10. Restore coronal seal (access) with SonicFill (Kerr).

Figure 2. Structure:
Producing and
protecting sufficient
restorative tooth
sometimes requires
creative thinking and
treatment planning.
The endodontic,
periodontal, and
aesthetic determinants are revealed in
this single-line
diagram. (Original
image used with
permission from
Dr. Frank Spear.)

The acoustic wave produced with the SonicFill device

predictably generates solid foundations. Check occlusion and
take final images. Schedule or proceed with onlay or crown.
Finally, if coronal leakage is present (see Carestream
Logicon technology), coronal caries must be removed,
followed by the endodontics and new restorative. Therefore,
there are 2 parts of correcting a structural (leakage) of an
endodontically diseased tooth: endododontic treatment or
retreatment and structural retreatment. Even so, correcting
both the endodontics and the restorative remain financially
competitive with an implant while, at the same time, having
the advantage of retaining and restoring natural tooth parts,
if needed!

STRUCTURE
Endodontic treatment can render a tooth unrestorable when
the radicular preparation weakens the root or minimizes or
eliminates the retentive ferrule. In endodontics, there is a fine

Figures 3a to 3c. Aesthetics: Gingival discoloration for uncleaned root canal system chamber can degrade smile aesthetics. (a) Pretreatment clinical of discoloration along gingival contours. (b) Pretreatment image followed by image of safe bleach barrier that appears like a
bobsled outline from the facial. (c) Bleached and restoration placed with aesthetic result.

Continuing Education

The Role of Endodontics in Interdisciplinary Dentistry: Are You Making the Right Decisions?
a

Figures 4a to 4d. Aesthetics: Patient wanted aesthetic tooth No. 9 for a wedding in 2 weeks. (a) Following the restorative dentists image, the
patient was referred to the endodontist because this was not a simple crown; the root had been severely resorbed. (b) Images of before and
after a safe bleach barrier was placed and a solution of sodium and perborate mixed with water was placed in the access. (c) Satisfactory
aesthetic result for the wedding. (d) Periapical image of subsequently restored access.

line between overshaping and undershaping. There is also a

fine line between the new buzzword minimally invasive
endodontic canal preparations and a preparation that is so
minimal that it cannot be properly cleaned or obturated in 3-D.
In the 1950s, silver cone biologic underpreparations
prevented 3-D cleaning, shaping, and obturation; therefore
preventing long-term success, particularly when the coronal
seal was given enough cyclic fatigue to structurally break
down at the cavosurface margins producing coronal
microleakage.
Ferrule must be present facially and lingually after
endodontic preparation that also ideally preserves the mesial
and distal ferrule as well. In summary, the desired 4.0 mm
from the height of bone to height of ferrule is the minimum
restorative determinant identified in the restorative literature.
In addition, the outline form of the access preparation should
not be too small or too big...it should be just right!
There is also the importance of predictability regarding
the size of the access cavity, the largest POE of all! With the
advent of the microscope, most endodontists have been
able to reduce the size of their access by up to 50% while
still maintaining the desired straight-line access.8 Magnification and coaxial lighting allow the clinician to pinpoint
orifice locations without having to search around and
discover orifices by feeling them. There is a balance here,
however. For example, if you cannot predictably reach a
21.0-mm rotary or reciprocation file into the MB of a
maxillary second molar because of lack of oral access, then
you may need to lean the mesial wall (more mesial than
otherwise ideal) in order to slip over the mesial cavosurface
and slide into the MB without breaking a file. The angle of

access and incidence sometimes does not coincide where

patient openings are limited.
Even more toward the minimally invasive extreme,
there are some endodontists suggesting leaving the roof of
the pulp chamber intact and drilling holes where,
hopefully, the dentist can then slide files into the canals. The
first problem is that some canal entrances will not be seen
and therefore missed due to aberrantly located canals
obscured by the chamber roof. Secondly, because of this
peep hole, the dentist will not be in control of the delicate
Glidepath management with subsequent rotary or
reciprocation shaping and precision obturation. In addition,
the now impossible-to-clean chamber and its pulp horns
remain as culs-de-sac for colonies of bacteria and pulp
tissue (dead or alive) that are inaccessible. Perhaps worse,
anterior teeth would often become discolored and an
aesthetic disaster requiring a crown. And finally, where is
the literature that supports the tooth is stronger with
portions of the usual fragile roof in place? Sometimes, the
role of endodontics in interdisciplinary dentistry is to
discover and unravel steps that take dentistry backward in
time.
Structure preservation is an essential consideration in
endodontic retreatments, since an endodontic preparation
already exists and may have already compromised or
violated the minimum 1.5 to 2.0 mm vertical height and 1.0
mm ferrule thickness (Figure 2). In considering nonsurgical
retreatment, further coronal shaping, while intended to
improve funnel preparation, could compromise coronal
tooth structure even further. Consequently, the lack of
structure could make surgical retreatment a better,
4

Continuing Education

The Role of Endodontics in Interdisciplinary Dentistry: Are You Making the Right Decisions?
a

Figures 5a to 5e. Aesthetics: Unraveling the dilemma of correcting aesthetics in the calcific metamorphosis tooth. (a) Pretreatment image after
unsuccessful external custom tray bleaching. Pretreatment image had remained the same for a decade. (b) Pulp was and still is vital. (c) A CBCT 3-D
image reveals depth that pulp chamber begins in order to prevent pulp exposure. (d) Protective bleach barrier and walking bleach placed.
(e) Approaching proper color with one more walking bleach and aesthetic access repair.

Figures 6a to 6d. Aesthetics: Patient presents with sinus tract due to underfilled root canal system. (a) Gutta-percha cone is tracing sinus tract.
(b) Gingival levels noted dissimilar and referred for periodontal and orthodontic consultation. (c) Endodontic nonsurgical retreatment has been
successful for more than 16 years (right image). (d) Orthodontics immediately followed the initial endodontic success. Happy with her smile, the
patients improved self-esteem allowed her to risk going from a flight attendant to pilot. You never know what the role of an endodontically treated
tooth can play in the interdisciplinary treatment plan.

the culprit bite source, an orthodontic band is cemented to

the tooth. If the bite pain is eliminated and pulp remains vital
and asymptomatic, then restore with crown or cuspal
coverage. Excellent predictability can be expected if the bite
pain is gone after ortho band placement but pulp symptoms
persist if the dentist now performs endodontics and places
a crown or full coverage. If the ortho band solves the pulp
pain but not the bite pain, this tooth has a guarded longterm prognosis.
As a rule of thumb, steps for CTS include the following:
1. Place band and still painful to chew. If patient wants a
guarantee, then recommend removal and replacement.
2. If no pain to chew, but pulp is symptomatic, then do endo
and restore.
3. If band and no bite pain and no pulp pain and vital,
then restore with confidence.

minimally invasive patient option. And while a surgical

option may protect tooth structure, the surgery could
compromise the aesthetic outcome by resulting again in an
attached gingival scar or a black triangle at the site of the
interproximal papilla.9 And so it goes, biology versus
structure versus aesthetics are collaborative treatment
planning determinants and considerations.
Another destructive structure condition that involves the
pulp is the silent cracked tooth syndrome (CTS).
Considerable misconception surrounds the diagnosis and
treatment plan for CTS. This patient will present with a tooth
that hurts to bite on, and yet the pulp tests vital. The
symptom of bite and pulpal pain typically do not occur in the
same tooth since pulp necrosis occurs in a coronal-apical
direction. If the tooth has periapical symptoms, the pulp
should test nonvital, but the CTS tooth has, by definition, a
vital pulp. The Class I CTS does not affect the pulp. The
Class II CTS involves the pulp. How do you diagnose which
is which? The most accurate test is the cotton wad test (a
damp portion torn off of a cotton roll) where the patient tests
himself or herself. Once the patient personally duplicates

AESTHETICS
The role of endodontics determinant in interdisciplinary
dental aesthetics can be the weakest link.10 The color of the
endodontic tooth may not match the aesthetic adjacent or
5

Continuing Education

The Role of Endodontics in Interdisciplinary Dentistry: Are You Making the Right Decisions?
contralateral tooth (Figures 3a to 4d). For example, if the pulp
horns of an endodontically diseased tooth are not sufficiently
cleaned, remaining necrotic pulp horns can be filled with
discoloring tissue, bacteria, and blood bilirubins. Special
attention must also be made to improve the existing color of a
discolored tooth due to necrosis and gangrene using special
endodontic ultrasonics and ideally microscope quality
magnification and light. While an off-color endodontic access
repair may not noticeably affect the color, an off color can
affect a positive patient outcome when the access is far less
than invisible. If the patient can see a discolored access
material especially in a new crown, it appears like a mistake.
Another endodontic/aesthetic continuum is revealed in
degeneration of calcific metamorphosis, which has long
been a dilemma for the interdisciplinary team. When pulps
become calcified, it can make endodontics treacherous
when finding the canal or when overpreparing the structural
dentin in order to find the canal. Pulps die and calcify in a
crown-to-apex direction and therefore the canal can most
often be located by penetrating deeper but often not without
destruction of the ferrule and remaining coronal tooth
structure. In addition, light transmission is prevented in
calcified crowns adding to an aesthetic dilemma. The teeth
appear dark. Where calcific metamorphosis teeth have
nonvital pulps, endodontics must be attempted. With
knowledge, skill, and training, these patients can, however,
experience successful treatment.
What if the pulp tests vital, and the patient wants to correct
the tooth (or teeth)? The treatment options are crown(s),
veneer(s), endodontics and bleaching, external bleaching, or
implant(s). There is yet another treatment option, particularly in
the case of chamber calcific degeneration: a walking bleach
procedure with no endodontics can be noninvasive, safe, and
aesthetically predictable and pleasing (Figures 5a to 5e). The
interdisciplinary treatment of our patients smiles, by changing
previously distracting endodontically discolored teeth, can
truly change lives (Figures 6a to 6d).
A final area of the endodontic role in biologic, structural, and
aesthetic dentistry is repair of the enododontic access cavity.
Access finishing requires skill, care, attention, and time to do it
right. For the clinician who simply wants to get the treatment
over, it is important to remember that optimal predictability
requires the same level of energy, attention to detail, and

Table. Ten Action Steps to Increase Your

Education in The Role of Endodontics in
Interdisciplinary Dentistry
1. Start your own interdisciplinary study club modeled
after the Northwest Network for Dental Excellence.
Send inquires via e-mail to
johnwest@centerforendodontics.com.
2. Attend Interdisciplinary Dental Education Academy.
Visit the Web site at ideausa.net.
3. Join the Seattle Study Club. Send inquirers to
info@seattlestudyclub.com.
4. Join Spear Education and Spear Digital Spear
Education. Visit speareducation.com.
5. Purchase the following book: Cohen M, ed.
Interdisciplinary Treatment Planning: Principles,
Design, Implementation. Chicago, IL: Quintessence
Publishing Co; 2008.
6. Purchase the new Dr. Ron Goldstein book: Goldstein
RE, ed. Esthetics in Dentistry. 3rd ed. Shelton, CT:
PMPH-USA; 2014: In press.
7. Visit endoruddle.com.
8. Visit endopro.net.
9. Subscribe to Endodontic Practice US. Visit the Web
site endopracticeus.com.
10. Subscribe to Journal of Esthetic and Restorative
Dentistry. Visit the Web site
onlinelibrary.wiley.com/journal/10.1111/(ISSN)1708-8240.

patience at the end of a procedure as it did in the beginning.

Often, this is the difference that makes the difference.

CLOSING COMMENTS
Are you still confused about the role of endodontics in
interdisciplinary dentistry? Most cases are obvious, but
more and more gray areas are facing dentists today in their
treatment planning. A good question is to look in the mirror
and ask, What would I do if it were me? Therein lies the
answer for your patient as well.
6

Continuing Education

The Role of Endodontics in Interdisciplinary Dentistry: Are You Making the Right Decisions?
REFERENCES
1. West JD. Implants versus endodontics: As the
pendulum swings. Dent Today. 2014;33:10-12.
2. Schilder H. Cleaning and shaping the root canal. Dent
Clin North Am. 1974;18:269-296.
3. Schilder H. Vertical compaction of warm gutta-percha.
In: Gerstein H, ed. Techniques in Clinical Endodontics.
Philadelphia, Pa: WB Saunders Co; 1982: 84-90.
4. West JD. Endodontic predictability: What matters?
Dent Today. 2013;32:108-113.
5. West J. Endodontic update 2006. J Esthet Restor
Dent. 2006;18:280-300.
6. West JD. Endodontic predictabilityRestore or
remove: how do I choose? In: Cohen M, ed.
Interdisciplinary Treatment Planning: Principles,
Design, Implementation. Chicago, IL: Quintessence
Publishing Co; 2008: 123-164.
7. West J. Anatomy Matters. Could it all simply be a
coincidence? Part 8. Endodontic Practice US.
2013;6(5):52-55.
8. West JD. The role of the microscope in 21st century
endodontics: Visions of a new frontier. Dent Today.
2000;19:62-69.
9. Tarnow DP, Magner AW, Fletcher P. The effect of the
distance from the contact point to the crest of the bone
on the presence or absence of the interproximal dental
papilla. J Periodontol. 1992;63:995-996.
10. West JD, Chivian N, Arens D, et al Esthetic
management of endodontically treated teeth. In: Goldstein RE, ed. Esthetics in Dentistry. 3rd ed. Shelton,
CT: PMPH-USA; 2014: In press.

Continuing Education

The Role of Endodontics in Interdisciplinary Dentistry: Are You Making the Right Decisions?
POST EXAMINATION INFORMATION

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1. The rationale for endodontics is that any

endodontically diseased tooth can be predictably
treated if the root canal system can be sealed either
nonsurgically or surgically, and, if the periodontal
condition is healthy or can be made healthy.

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a. True

b. False

2. The 3-dimensional treatment and ultimately

elimination of the cause of endodontic disease,
contents of the root canal system, is key.
a. True

b. False

3. Knowledge of average number of canals that are in

each tooth is interesting but not really helpful for the
dentist that performs an occasional endodontic
procedure.

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a. True

b. False

4. The use of mechanical cleaning devices does not

significantly improve removal of detached pulp,
necrotic debris, and bacteria through agitation.
a. True

b. False

5. The acoustic wave produced with the SonicFill

device predictably generates solid foundations.
a. True

b. False

6. With the advent of the microscope, most

endodontists have been able to reduce the size of
their access by up to 90% while still maintaining the
desired straight-line access.

General Program Information:

Online users may log in to dentalcetoday.com any time in
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view or print letters of completion and results.

a. True

b. False

7. Another destructive structure condition that involves

the pulp is the silent cracked tooth syndrome (CTS).
a. True

This CE activity was not developed in accordance with

AGD PACE or ADA CERP standards.
CEUs for this activity will not be accepted by the AGD
for MAGD/FAGD credit.

b. False

8. The most accurate test for CTS is the cotton wad

test (a damp portion torn off of a cotton roll) where
the patient tests himself or herself.
a. True

b. False

Continuing Education

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