A Tooth-Saving Guide to New Endodontic Technology Every Dentist Should Know About

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It wasn’t all that long ago when endodontists (including myself!) had to rely solely on traditional tools like manual files and 2D imaging. Things were going just fine—or so I thought at the time. I was achieving solid outcomes for my patients, but it was no secret that this limiting technology was holding me back! Nowadays, endodontists have SO MUCH advanced technology at our disposal that makes our lives a thousand times easier, turning good root canals into great ones.

What It Was Like before I Used my Favorite New Endodontic Technology

I’m not talking about the Dark Ages or anything! I just want to share what life was like in my practice in the beginning. 

I was performing root canals daily, and I was getting really good outcomes for my patients. But they weren’t as kickass as the outcomes I’m getting now.

For example, I was having to retreat patients every few months from root canals I’d performed years in the past—and sometimes only months. That’s not a terrible failure rate, but it was obviously tough on the patients. Plus, it hurt my production (and my feelings!), which isn’t great, because I like to protect every minute of my chair time. 

The types of complications my patients were experiencing were normal and expected, based on traditional instrumentation, irrigation, and obturation. When you’re using manual files, for example, you just can’t get into every tiny crevice and crack in a tooth’s root system.

After a little while, these retreatments started to be tough for me, too. Not only was I down on myself for having “failed” these patients and upset by seeing them back in pain (you know, the type of patient who says, “It hurts when I tap on my tooth.”), but it also started to impact my bottom line. Retreatments take up valuable clinical time for myself and my assistants, and they take up space in the schedule where I couldn’t treat a new patient. 

I really believe that dentists should offer to retreat failed root canals, unless they are truly stumped by the case. I encourage you to always do your risk assessment and know your limits. There’s absolutely nothing wrong with referring out to someone else if you worry that you’re in over your head. We’re here for our patients’ well-being, not our own egos. And also, balance that with honoring your promise to perform excellent work via retreatments, when possible. This shows your patient that you really care about them and their healing.

Advanced Endo Tools Redefining the Modern Root Canal

I’m a sucker for new endodontic technology, and I’m always looking out for the best and brightest new tools that improve outcomes, safety, efficiency, and patient experience. But before I dive into the details, there’s one thing I want to emphasize: 

No matter how much cool, shiny, effective technology you have, if you don’t BELIEVE that you can save teeth, the tech won’t serve you or your patients. We have to upgrade our beliefs first and foremost.

With that in mind, let’s talk about the various advanced tools that are completely redefining the modern root canal!

Endodontic Operating Microscope

When I’m preparing dentists to attend my E-School LIVE program—which takes place with live patients at my practice in NC—I give them a packing list.

• Comfy shoes
• Extracted teeth to practice on before we move to real-life patients
• Loupes with a magnification of at LEAST 5.0.

Those of you who practice with low-powered loupes, my hat’s off to you. I honestly have no idea how you do it. I rely SO much on magnification, because it allows me to see details I would otherwise never notice.

I know that general dentists almost never have operating microscopes, and I’m not expecting that to change any time soon. But at the very least, I highly suggest you invest in a pair of loupes that are 5.0x or higher. Trust me when I say that endo becomes so much easier when you can see!

And then practice with them! It’s going to shock you how different everything looks at first. It’s like peering through binoculars, and you’re disoriented, trying to find what you’re looking for. It’s like having Honey, I Shrunk the Kids vision—up close and personal! But also, oh, so powerful.

Enhanced magnification doesn’t just elevate your endodontic game, but your restorative game, too! Don’t think you’ll use your loupes just for endo; you’ll easily get your money’s worth out of them.

Cone Beam Computed Tomography (CBCT)

First and foremost, I’m obsessed with my cone beam. If you’ve spent any time reading my blogs or following me on social media, you know that I talk about CBCT all. the. time. But that’s because it’s so freaking important!

After all, radiographs don’t always tell you the full story. Being able to see what’s going on inside a tooth, in 3-D, that’s everything. I not only use my CBCT to help diagnose and identify where canals are located, I sometimes also use it again during treatment, so I can make sure I’m on the right track. I really can’t overstate how important it is for me in my practice.

Here’s the problem though: Dentists hear how freaking amazing it is, so they invest in the technology. Then, a technician arrives to install it, and then they give the practice staff a training on how to use it. The training includes topics like: How to operate it and change the angles, how to position the patient, how to capture and download images. Unfortunately, what the training does not include is how to actually effectively use the damn thing! 

That means there are thousands of well-meaning dental practices all over this country and beyond where providers aren’t adequately trained on how to read the images the CBCT produces. As a result, no one in the practice feels confident or comfortable with CBCT, and they either leave it to collect dust or use it ineffectively. 

So, while I believe CBCT is a gift that is absolutely worth the investment, it does take some clinical training to get the hang of. Fortunately, I teach an entire module on CBCT in E-School, my award-winning endodontic CE course!

GentleWave

When it comes to irrigation, there’s nothing I love more than my GentleWave. That’s because it gets into and cleans all those tiny, microscopic nooks and crannies inside canals. It doesn’t care that the anatomy is tricky, it just does its thing. As an added bonus, it helps reduce postoperative discomfort for my patients.

The GentleWave is a boss at helping me instrument. I no longer have to struggle with getting to working length or making sure I’m patent in my cases (it helps me get that path). It has significantly decreased my stress levels during instrumentation. It’s a beast of a useful machine, and I have mad respect for it.

But let me use a tooth story to demonstrate exactly why I’m a GentleWave provider, through and through!

A Tale of Two Teeth

This patient has an extensive treatment plan that’s still currently in progress. I performed a root canal retreatment on tooth #30, which was failing at the time and which is still failing now. When I see that a tooth isn’t responding to an orthograde root canal therapy and re-treatment, I consider it time to treat the tooth surgically and to prepare the tooth for an apicoectomy.

This first radiograph is of the patient as he presented to my office a few years ago. He had never experienced any pain, and he had normal probings, palpation, and percussion. Since the tooth had already been treated with a root canal, he obviously didn’t have any response to cold. His diagnosis was Previously Treated and Asymptomatic Apical Periodontitis #30. You can see that #31 was extracted due to some mesial resorption.

Since I don’t know what the previous disinfection protocol was, I decided to re-treat the tooth. I know it doesn’t look like my root canal made much difference, but I hoped that refreshing the insides would do the trick and start to heal the tooth.

You can see it more clearly on the CBCT.

Evidently, it was time for me to pivot and treat the tooth surgically, so we decided on an apicoectomy. However, that part of his treatment wasn’t the priority, since he was symptomatic on the other side of his mouth. 

So let’s shift our focus to tooth #19. You’ll be able to see how the treatment for this tooth (and the endodontic technology I used) impacted treatment for tooth #30!

What the Radiographs Revealed

The patient had a root canal performed on tooth #19 a few years ago (by another provider), and it was tender to percussion. I made no other significant findings, and all his probings were within normal limits. The diagnosis for tooth #19 was simple: Previously Treated and Symptomatic Apical Periodontitis. Look closely… you’ll see a small periapical radiolucency around the mesial root.

This is where things get interesting. The straight angle shows the gutta percha length is right on the money, but the off-angle radiograph shows that the two canals are 1mm away from the radiographic terminus. Your radiograph’s angle can really impact your working length. I’m not sure if this case achieved true patency.

After I finished cleaning and shaping, I took a cone fit to discover I was a bit long on one of my mesial canals. Since it was a mesial angle, I knew from the SLOB rule that I needed to trim both my mesiolingual cone and my distal cone, since they were both long.

Everything in my obturation seemed straightforward until the next radiograph. 

Holy moly! There was a middle mesial canal starting in the middle third of the canal. I didn’t see it or even get a file into it previously. However, I was using my GentleWave (as I do in all retreatment cases), and the machine’s fluid dynamics got the disinfection solution into this tiny canal to clean the area. There’s no way any rotary file could do that.

So what does this mean for tooth #30? Well, I know that most things are bilateral in nature, and so based on my treatment of tooth #19, I’m guessing that there’s a middle mesial canal in tooth #30 as well.  I’ve decided to re-treat tooth #30 again to see if using the GentleWave will improve its prognosis. The patient understands that an apicoectomy is still on the table, but he also knows that I want to avoid surgery or extraction at all costs.

As is so often the case, there was more to this patient’s tooth story than it seemed. Anatomy like this is exactly why some treatments fail, and why so many people think that certain teeth are cracked when they’re really not. I want dentists and endodontists to all be aware that when it comes to root canals, anything is possible!

This story also highlights the importance of using all the endodontic technology available to you. If I hadn’t had my GentleWave, I wouldn’t have been able to tell what was really going on with not just one, but possibly two of this patient’s teeth.

Fotona Laser

The newest acquisition in my practice is a Fotona Laser. I’m still getting used to the technology, but I’m impressed with its ability to zap the bacteria in canals, and even get rid of the bits of tiny debris that can collect during treatment. I love using the laser even before I start instrumenting, especially in a necrotic case. This way, I am already decreasing the bacterial load in the tooth before I instrument, preventing me from packing bacteria into the canal.

The energy from the light does a bomb job of activating the irrigants in my canal, so they can get into all those hard-to-reach places. In addition, it can be used to stimulate the periapical area. I also totally love that it can help me out when I need to re-instrument after I use my GentleWave. I’ll never say no to additional disinfection to keep my patients safe.

EndoActivator

Dentsply Sirona’s EndoActivator is a great stepping stone option for those who aren’t yet in the place to bring GentleWave or a laser into their practice. Perhaps this is because endo isn’t a huge part of their practice, or because they don’t have as many funds to invest right now. However, the EndoActivator is a great option for activating your irrigation, which is such a critical part of endodontics.

Bioceramic Sealers

For example, I’m really enjoying some new bioceramic sealers, like the AH Plus Bioceramic Sealer and the EndoSequence BC Sealer HiFlow by Brasseler. Bioceramics have been on the market for a little while, but they still aren’t widely adopted.

These two particular sealers have good flow, are super biocompatible, expand instead of shrink, and can even be used for warm vertical obturation. The only downside is that they harden afterwards, making retreatment a b****.

Old Standby Endo Technology that Still Does the Trick

I love this part of the post, because sometimes it’s not about new endodontic technology to look out for, it’s tools and technology you already have in your practice that you can be using more effectively. I love it when I can save you money and point you towards resources that have been extensively scientifically tested and proven.

Endo Ice

Nothing has changed, friends: You should be doing an endodontic diagnosis on every single tooth you suspect might need a root canal, an extraction, or even a crown. And that includes a cold test.
Endo Ice* is still my go-to for cold tests. Here are my tips and tricks on how to do an effective cold test that won’t get you false negative results. Don’t forget your other endodontic tests like percussion, bite, and even probing which I personally do a ton. These are tried and true because they work.

Rubber Dams and OpalDam

I cannot stress enough how important it is to use rubber dams when you do root canals. They keep everything sanitary, and they can help ensure a great outcome for your patient. Nobody wants a retreatment! In fact, when I have a patient come in for a retreatment, I often hold up a plastic dummy head with a rubber dam on, and I point to the dam and ask, “Did your provider use this on you?” When they look at me blankly, I know that there’s the problem, right there.

Files

When it comes to instrumentation, people have a lot of questions about which files are the best. Yes, I definitely have my preferences (I’m a ProTaper fangirl), but it’s less about which files are the best, and more about what files you use in which situations. But if you want to know about my favorites, they’re the 10C file to start my cases, S1 Gold once I’ve gotten my working length, ProGlider for curvy canals, and S1 Universal if I need to find and get into tiny canals.

Apex Locators

If you ever thought that your apex locator is messed up, chances are, it’s actually user error. Much like files, it doesn’t matter which apex locator you use, so much as how you use it. Ultimately, you need to get to 0.0 (which your apex locator will alert you to) in order to get patent in your canal, so you know you’re at your proper working length, and you can shape and clean like a boss.

How to Implement New Endodontic Technology in the Workplace

By now, I hope you can see how modern technology has completely revolutionized the way we do endodontics. From operating microscopes, to cone beam technology, to canal-cleaning instruments like the GentleWave System and the dental laser, we now have so many tools at our disposal that make doing root canals easier, safer, and more comfortable than ever before.

That said, adopting new technology in your practice isn’t exactly an easy process. It’s an investment of not just money, but also time and energy, which can feel like such a huge barrier that you don’t even want to get started in the first place. Rest assured, however, that the journey is well worth the benefits you’ll experience in your practice for many years to come!

Understanding how to implement new technology in the workplace really comes down to knowing what to expect throughout the process, so let’s review what I see as the three primary phases of integrating new technology into your practice.

Phase 1: Confronting Your Limiting Beliefs

The first phase of bringing any new technology into your practice is having to confront your limiting beliefs about the value of the tool itself. Even after you’ve made the financial investment, there are often lingering doubts about whether it was a worthy purchase and whether you can justify charging your patients for it. This is usually true no matter how many good things you’ve heard about the technology!

When I first got my cone beam (CBCT), I was NOT sold on its value to my practice. Even though I had made the purchase and was one of the first endodontists in my community to adopt it, I was afraid to charge my patients for it because I didn’t really understand the impact it could have on my diagnosis, treatment, and follow-up with patients.

What’s important to understand is that this part of implementing new technology in the workplace is entirely normal, and it’s a product of simply being new to the equipment. When you lack experience using the tool and don’t yet fully understand how to leverage it, it’s natural for you to feel as if you can’t charge more for it—or even doubt that it was a good purchase at all! How could you possibly put a price tag on the benefits when you aren’t able to see them yet? 

Rest assured that, as you start using the technology and integrating it into your workflow, you will begin to recognize its full value to your practice and patients and gain confidence in raising your prices to match it.

Phase 2: Dealing with Workflow Disruption

Speaking of your workflow, the second phase of implementing new technology into the workplace is dealing with workflow disruption. Like anything new, adding a microscope, rotary file system, cone beam, or GentleWave to your practice is going to come with a bit of a learning curve. It doesn’t have to be a big piece of equipment to make a big impact!

To some extent, that’s par for the course, right? You can’t expect to be an expert in a tool you’ve hardly, if ever, used! But don’t underestimate the domino effect of bottlenecks and schedule disturbances that ensue because of it. If we’re being honest, it does take a while before you start to get the hang of things and find a new flow that works for you and your team.

That said, please don’t let that discourage you from adopting the technology. I know it can feel daunting to march into chaos that’s guaranteed to happen, but it’s crucial to remember that this phase is temporary. After some time, you WILL work out the kinks, and the technology-boosted workflow that emerges on the other time will not only better support you, but also your patients!

Phase 3: Finding New Uses and Revenue Streams

If you can hang on through the first couple of phases, your reward is that you’ll finally enter the third, final, and most exciting phase of implementing new technology in the workplace: finding new uses and revenue streams! That’s the benefit of sticking it out and investing time in fully learning how to use your new technology—you begin to understand exactly how to leverage it to benefit your practice and patients.

Let me return to my cone beam as an example. Early on in my adoption of the CBCT, I would primarily use it for diagnosis, keeping the images to myself because I thought I was the only one who could benefit from seeing them. But as I continued to use the technology in my practice, I started to see the advantages of reviewing the images alongside my patient and using it as a tool to both facilitate communication and educate the patient on what was going on inside their mouth. From there, it wasn’t hard at all to justify charging more for the technology, as it was clearly bringing so much value to my patients.

Here’s another example: When I first started using the GentleWave System, I thought its only function would be to help me clean out canals. Boy was I wrong. With time, I discovered that it could not only get canals squeaky clean, but also help me find them in the first place! Not only that, but the power of the GentleWave also helped me reduce my chair time, decrease the number of visits needed for treatment, and even bring down patients’ post-op sensitivity. That’s a heck of a lot of value that I would have never uncovered had I let the technology sit in the corner collecting dust.

Our Teeth Are Precious—Technology Can Save Them

Let’s wrap all of this up with a little metaphor. Have you ever played chess? When you’re a beginner, it’s easy to think that your pawns are dispensable. After all, you have eight of them! But the more you play, the more you realize that every single pawn serves an important purpose, and they’re just as important as any other piece on the board.

It’s the same with our teeth. Because we have 32 permanent teeth, it’s easy to think, “Hey, let’s just pull that tooth. I can extract and implant in-house, and the patient doesn’t even need to worry about a root canal.” But if you take this path, it’s imprinting our own beliefs and goals onto the patient. Maybe that patient wants to worry about a root canal, because they’re committed to saving their tooth. Maybe they don’t want to lose any more bone, or they know that the cost of extraction and implant will be higher than a root canal.

Yes, we’re the doctors, and we’re here to provide expertise and guidance for our patients. But also, it’s their bodies, so I really think it’s important to empower them to make informed decisions about their own care.

At the end of the day, you can have all of the modern endodontic technology in the world at your fingertips, but the most important technology to update is our own beliefs. When we believe in our power as tooth savers, we can do miraculous things.

This is why I sign off my emails with the words, “empower yourself.” Empower yourself, my friend, to upgrade your beliefs, step into a deeper understanding of what you’re capable of, and give teeth a chance!

If you’re ready to take that challenge, I invite you to apply for E-School LIVE, my 4-day live, hands-on endodontic CE course, where you’ll perform root canals on real patients with me there to help guide you in real-time. You’ll be amazed at the results you see in your practice—and within yourself!

– Sonia