The Transformation of Endodontics
in the 21st Century
Stephen Cohen
MA, DDS, FICD, FACD
Diplomate, American Board of
Endodontics
Author: “Pathways of the Pulp”
Private practice, California, USA
scohen@cohenendodontics.com
Kenneth Hargreaves
DDS, PhD
Editor-in-Chief: “Journal of
Endodontics”
Private practice, Texas, USA
hargreaves@uthscsa.edu
Louis Berman
DDS, FACD
Diplomate, American Board of
Endodontics
Private practice, USA
Berman@annapolisendodontics.com
| 6 | Smile Dental Journal | Volume 5, Issue 3 - 2010
Abstract
During this 21st century endodontics is being reinvented and redefined as a result
of advances in cellular biology, microscopy and digital technology along with
reconceptualization of how to clean and shape root canals. Due to space limitations it would
not be possible to explore all the changes in endodontics that are taking place; rather we
will touch on just a few which are already in practice.
Keywords: Regenerative endodontics, Endoscopic endodontics, CBCT, SAF.
Regenerative Endodontics
The primary purpose of endodontic therapy is the prevention or treatment of apical
periodontitis. Although traditional endodontic procedures treat apical periodontitis
by disinfection of the root canal system followed by placing an intracanal restoration
(obturation), a biologically based procedure would instead focus on regenerating a
functional pulp-dentin complex.1,2 This approach offers the advantage of maintaining
normal pulpal function with appropriate formation of secondary or tertiary dentin, and
continued immunological and neuronal surveillance of tissue status.3 Thus, biologically-
based regenerative endodontic procedures offer the potential for saving natural teeth that
otherwise might be doomed to extraction.
The concept of regenerating the pulp-dentin complex is not new. Indeed, more than 50
years ago, Nygaard-Ostby reported several case series of tissue evascularization that were
based on the concept of the initial healing event (revascularization) of surgical wounds.4,5
Although a fibrous connective tissue was found in many of his preclinical and clinical
endodontic cases, the tissue did not renew the pulp-dentin complex. This is not a surprising
outcome given the level of knowledge, materials and instruments available to investigators
many years ago.
In the intervening decades, several critical advances have occurred that greatly improve
the potential for developing regenerative endodontic procedures. For example, the entire
field of tissue engineering was only established in the 1990s.6 In contrast to the mechanical
philosophy of “revascularization”, where tissue bleeding is thought to be sufficient for
healing, the concept of tissue engineering focuses on the three dimensional assembly of
the appropriate combination of cells, growth factors and scaffolds to achieve the desired
regeneration of a functional pulp-dentin complex. These concepts have been systematically
evaluated in the endodontic literature, with studies focused on stem cells,7-10 growth
factors11,12 and scaffolds13-15 capable of promoting the differentiation of odontoblast-
like cells. This has led to the regeneration of dentin-like structures in some,16 but not all
preclinical studies.17 The great challenge going forward is the development and validation
of tissue engineering concepts into effective and predictable endodontic therapeutic
procedures.
Although the full application of tissue engineering principles for clinical regenerative
endodontic procedures remains an active area of research, several clinical case studies
have already reported success in treating the immature permanent tooth with a necrotic
pulp. These teeth often have a very poor prognosis due to the thin dentinal walls and
incomplete stage of root development (Figure 1). In these regenerative cases, “success”
is defined as restoration of continued root development, lack of signs or symptoms and
closure of sinus tracts, if previously present.1 In general, these procedures are conducted
in children who present with a diagnosis of pulpal
necrosis of a permanent tooth that shows radiographic
evidence of partial development. Following informed
consent, anesthesia and rubber dam isolation, the tooth
is accessed, and generally irrigated with NaOCl and
medicated with an antimicrobial agent consisting of
either a combination of a triple antibiotic (ciprofloxacin,
metronidazole, minocycline)18-22 or Ca(OH)2.23,24 Little
to no instrumentation is performed due to the risk of
fracturing the very thin dentinal walls. Instead, the
disinfection protocol relies on the chemical actions of the
irrigants and medicaments. The tooth is then sealed with
a temporary restoration and the patient is discharged.
The patient is recalled about 3-4 weeks later and the
tooth is re-anesthetized, isolated and accessed. At this
appointment, a file is inserted a small distance beyond
the root length and rotated to stimulate bleeding into the
root canal system up to the CEJ; a local anesthetic that
does not contain a vasoconstrictor is often used since
this facilitates the bleeding step. The tooth is then sealed
with mineral trioxide aggregate (MTA) followed by a
permanent restoration.
In general, these regenerative endodontic procedures
are well tolerated. However, some adverse events and
technical challenges have been discussed.19, 20, 26 First,
the triple antibiotic paste may cause staining of the
crown, possibly due to the minocycline component.
Although this can be managed clinically using a walking
bleach procedure, it is important to minimize this
potential problem by careful placement below the CEJ.
Second, the MTA barrier is placed over the immature
blood clot and this can lead to diffusion of the material
into the root canal system, particularly given the long
setting time of MTA. This can be prevented by placing
a collagen plug over the blood clot prior to placement
of the MTA. Third, as discussed above, the use of a
local anesthetic that does not contain a vasoconstrictor
greatly facilitates the ability to stimulate bleeding into
the root canal system. Fourth, even with this anesthetic,
it is occasionally quite difficult to stimulate bleeding
into the root canal system. Interestingly, radiographic

The bleeding step reported in these clinical procedures

partially addresses the three precepts of tissue
engineering since the apical papilla of the developing
tooth has a high concentrations of post-natal
mesenchymal stem cells10, 25 permitting delivery of the
stem cells into the root canal system. In addition, the
blood clot (fibin polymer) serves as a scaffold and both
dentin and platelets provide sources of certain growth
factors. Although this clinical procedure at least partially
addresses the concepts of tissue engineering, the explicit
application of cells, growth factors and scaffolds will
likely be required to predictably regenerate a pulp-dentin
complex in somewhat more mature teeth.
(Fig. 1-a) Radiographic image showing an incompletely
developed apex and a periradicular radiolucency of tooth
A recent retrospective study compared the radiographic
#29. Note the gutta percha cone in the sinus tract that
outcomes (dentinal wall thickness at the apical third and
traces to the apex of tooth #29.
root length) of 48 regenerative endodontic cases to 40
control cases consisting of either MTA apexification or
conventional non-surgical root canal treatment.21 The
data were analyzed as the percent increase in dentinal
wall thickness (or root length) by comparing pre-
operative values to the post-operative recall values. The
results (Figure 2) indicate that antimicrobial treatment
consisting of either the triple antibiotic paste and the
Ca(OH)2 treatment lead to continued radiographic
development of the immature tooth. In contrast, the
results do not support the use of formocresol for this
treatment. Secondary analyses of these data indicated
that the follow-up time should be at least 12-18 months
before an interpretation of clinical success can be made
(and 36 months provides even stronger evidence for
clinical interpretation) and that the level of placement
of Ca(OH)2 is critical; this material should be retained
within the coronal half of the root canal system since (Fig. 1-b) Photograph of a purulent hemorrhagic exudate
placement into the apical half greatly reduces clinical discharged from tooth #29.
success.

Smile Dental Journal | Volume 5, Issue 3 - 2010 | 7 |

 success has been reported in cases that were disinfected
but without generation of clinical bleeding into the
root canal system26 and even in a case where the root
canal system was obturated by conventional endodontic
procedures.10 This suggests that the disinfection of the
root canal system is critically important and that a stem

(Fig. 1-c) Radiograph showing the placement of MTA over a

collagen plug.

(Fig. 2-a) Percentage change in root length from

preoperative image to postoperative image, measured
from the CEJ to the root apex. ***P < .001 versus MTA
apexification control group (n = 20) and NSRCT control
group (n = 20). (1) P < .05 versus MTA control group only.
Median values for each group are depicted by horizontal
line, and individual cases are indicated by the corresponding
symbol.

(Fig. 1-d) 3-month recall. A slight increase of the thickness of

the root canal wall and continued development of the apex
are observed.

(Fig. 2-b) Percentage change in dentinal wall thickness from

(Fig. 1-e) Two years later showing continued root
development. Reproduced with permission from Jung, Lee
and Hargreaves, J Endod 34:876, 2008.
preoperative image to postoperative image, measured at the
apical third of the root (position of apical third defined in the
preoperative image). ***P < .001 versus MTA apexification
control group and NSRCT control group. (2) P < .05 versus
NSRCT control group only. (3) P < .05 versus Ca(OH)2 and
formocresol groups. (4) P < .05 versus NSRCT control group
only. Reproduced with permission from Bose, Nummikoski
and Hargreaves, J Endod 35:1343, 2009.

| 8 | Smile Dental Journal | Volume 5, Issue 3 - 2010

cell source in the periradicular tissues are critical for root
development.

Clearly, regenerative endodontics is a field of active

research that is dynamically growing in both basic
research and clinical applications. Future developments
have potential to revolutionize the practice of
endodontics, possibly saving many teeth that would
otherwise have a poor to hopeless prognosis. Although
current case reports focus on applying these methods
to the immature teeth with a necrotic pulp, it will be
particularly interesting to apply the best lessons learned
to the future application of regenerative endodontic
procedures on the fully formed permanent tooth.

Endoscopy Endodontics (Fig. 3-a) Endoscopic probe with light-transmitting and

Successful surgical and non-surgical endodontics have image-transmitting elements incorporated into a flexible
one important concept in common: visualization is protective sleeve attached to a handle.
essential. For non-surgical endodontics, canals orifices,
many of which are often less than .1mm in diameter,
need to be visualized and negotiated through an
access opening that may be less than 3mm in width or
length. For surgical endodontics, visual differentiation
between bone and root is imperative with apical root
preparation and restoration often being a visualization
challenge. Historically, loupes on eyeglasses allowed
for magnification of 3-4 power. In the early 1990s,
surgical operating microscopes (SOM) were introduced
to endodontics, and presently all specialty programs
certified by the American Dental Association require
advanced training in the use of surgical operating
microscopes. Magnification, with a directed light
source, typically can be as low as 4X and as high as
25X. This outstanding visualization allows for better
canal negotiation with less tooth structure removal as
well as the visualization of cracks, fractures, restorative (Fig. 3-b) Endoscopic probe with light-transmitting and
and resorption defects. For surgical endodontics, image-transmitting elements incorporated into a flexible
more precision is offered allowing for better location protective sleeve attached to a handle.
of key anatomic structures. When evaluating the
success of surgical endodontic procedures using more
contemporary techniques, including the use of surgical
microscopy, a recent investigation yielded almost 50%
greater success over using more traditional techniques.27

There are several problems that the clinician has to

overcome when using a dental operating microscope.
Specifically, the DOM is large and often cumbersome
over the patient. It must be mounted on the ceiling or on
an adjacent wall; there are also portable DOMs, which
can occupy an excessive amount of floor space. For the
dental assistant viewing during procedures, a separate
ocular is required; when the clinician needs to reposition
the microscope for better visualization, the position of
the assistant’s ocular will also be changed. The DOM
often has difficulty visualizing areas lateral to the long
axis of the tooth, especially during surgical procedures, (Fig. 4) The light source emanates from a central source and
often requiring the patient to reposition their head or to the images are directed from the probe to the central source
have the DOM positioned in a direction that might be for viewing and storing.

Smile Dental Journal | Volume 5, Issue 3 - 2010 | 9 |

 uncomfortable for the surgeon. In addition, the depth
of field is fixed; requiring repeated re-focusing when
attempting to visualize objects inside or outside the field
of view.
The advent of endoscopy as an adjunct for endodontic
diagnosis began in the early 1970s.28-31 Endoscopy
facilitates the use of a fiber optic probe to explore
internal and external components of the root canal
and adjacent structures. Images taken via the hand-
held probe are projected onto a video monitor for
imaging purposes. Besides superb visualization with
no issue of depth of field focusing, the images can be
archived and reviewed as single images or videos.
The endoscopic probe can be maneuvered into areas
that would otherwise not be practical with a surgical
microscope, which would be especially useful during
endodontic surgery or for finding canals during non-
surgical endodontic treatment. Besides aiding the
clinician in diagnosis and procedures, there is enhanced
communication between the doctor and patient because
the patient can see what the doctor can image.
The configuration of the endoscope involves an
endoscopic probe with light-transmitting and image-
transmitting elements incorporated into a flexible
protective sleeve attached to a handle (Figure 3). The
light source emanates from a central source and the
images are directed from the probe to the central
source for viewing and storing (Figure 4). For certain
applications, an empty micro-lumen channel is present
in the handle and probe for the integration of forceps
and other devices for operating use. Therefore, the
endodontic endoscope permits to visualize, irrigate, and
clean and shape the root canal at the same time.
Presently, the dental operating microscope is considered
by most endodontists to be the standard for visualization
for surgical and non-surgical endodontics. However,
newer technology involving endoscopic visualization
might change how endodontic procedures are
performed and ultimately increase overall clinical
success.32
Cone Beam Computerized Tomography
Dental radiography provides extensive information
necessary for endodontic diagnosis and treatment
planning. The useful information obtained typically
relates to irregularities in hard tissues such as root and
bone resorption, root configurations, canal morphology,
presence of caries and restorations, and the assessment
of associated alveolar bone and root fractures.
Traditionally, two-dimensional dental radiography,
using either film based or digital imaging, has been
utilized for these examinations. Although the diagnostic
value is indisputable, unfortunately there are many
limitations with traditional dental radiography such as
the obstruction from associated anatomic structures and
| 10 | Smile Dental Journal | Volume 5, Issue 3 - 2010
an inability to visualize pathoses three dimensionally. In
addition, bony lesions are often not visible if they are
only confined to cancellous bone. They might not be
radiographically detected until the bone loss extends
into the internal junction of the cancellous and cortical
bone.33,34 Therefore, three dimensional imaging can
often provide an earlier detection of lesions in the bone.
Three dimensional radiography has been used in
medicine for about 30 years using a large field of vision
imaging with computerized axial tomography scans
known as CAT scans.35 More recently, as computer
and radiographic technology have become more
advanced and affordable, this technology has entered
the dental market as CBCT (cone beam computerized
tomography).36 These devices are similar to conventional
panoramic radiography whereby a cone shape
radiographic beam is directed to a target area and
the image is captured on a reciprocating sensor on
the opposite side of the target. The captured digital
information is digitally interpreted and displayed as
either slices of the targeted area or reconstructed to
provide a three dimensional image.
In an investigation37 which examined “endodontic
problems” in 48 teeth, radiographic evidence of pathosis
was detected in 32 of these teeth using convention
radiography; but when evaluated with CBCT, the
radiologists were able to find demonstrable lesions in
42 of the teeth. In a series of case reports, Cotton et
al.38 presented situations whereby CBCT was essential is
making diagnoses when anatomic structures mimicked
endodontic pathosis, like an enlarged incisive canal.
Using CBCT, they were also able to better visualize the
extent of root fractures, internal resorption, invasive
cervical resorption, a failed implant, and an assessment
of critical anatomy associated with the apex of a tooth
that had paresthesia following endodontic treatment.
Although Simon et al.39 attempted to correlate the
radiographic findings of CBCT when comparing cysts
and granulomas to histologic findings, a more recent
investigation found CBCT imaging not reliable in
differentiating radicular cysts from granulomas. Surgical
biopsy with histopathological evaluation still remains
the only way to differentiate a radicular cyst from
granuloma.40
CBCT should not be seen as a substitute for traditional
dental radiographs. Periapical radiographs have the
advantage for allowing the visualization of a given area
in one image. Although CBCT can give outstanding
visualization without the superimposition of any anatomic
structures, it also gives us this information only as a
“slice” of the area which may not give all of the pertinent
details if the “slice” is not where the pathosis presents.
The future for CBCT is very promising in dentistry and
especially for endodontic diagnosis and appropriate
treatment.
The SAF Instrument™, a New Concept in
Cleaning and Shaping Root Canals
Traditionally, root canals are cleaned and shaped by
alternating between irrigating (usually with sodium
hypochlorite) and then hand and/or rotary filing with
a stainless steel hand file or a NiTi (nickel-titanium)
rotary instrument. Until now this has been the Standard
of Care. Hand files and rotary instruments have two
things in common: 1- they have a central core of metal;
2- they occasionally break inside the canal! Additionally
the clinician has to alternate between putting down the
irrigating syringe to place the shaping instruments, and
then back to the irrigating syringe, etc. Imagine if these
functions could be combined into a single instrument
that could irrigate the canal, shape the canal…………
and not break! Is this possible? Yes!
(Fig. 5) SAF instrument™
The SAF instrument™ officially debuted at the 2010
annual session of the American Association of
Endodontists. This unique instrument has no central
core, rather it consists of a hollow thin cylindrical nickel-
titanium lattice that adapts to the cross-section of the
root canal (Figure 5) regardless of its cross-sectional
shape.
After the canal has been opened initially to a #20 file,
the SAF is inserted into the canal and, with an up-
and-down reciprocal motion, the coarse-filing threads
expand to fill the entire canal while simultaneously
irrigating the entire length of the canal with the irrigating
solution (Figure 6).
(Fig. 6) Reservoir with the irrigating solution attached to the
SAF system.
Conclution
The introduction of newer technologies and concepts
briefly described here will dramatically improve how we
provide endodontic therapy. Indeed, the application of
regenerative treatment will ultimately require that we
even redefine the specialty of Endodontics requiring
clinicians to acquire new skills through continuing
education.
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