The Spiraling Costs of Endodontic Innovations: Is it Worth It?

?When I first came upon the endodontic scene in the very early 70’s endodontic instrumentation was pretty much about the manual use of K-files employed with either a watch-winding or a twist and pull motion depending upon the resistance encountered. The coronal portion of the canal might at some point be straightened to the outer wall with a thin peeso reamer or gates glidden. These tools pretty much represented the armamentarium available and were certainly the dominant way to perform instrumentation. Inexpensive, time consuming and hand fatiguing with occasional instrument separation when the K-files were employed in rotation in curved canals too zealously. Another drawback was the tendency to impact debris in the apical third of the canals losing length and at times producing apical transportations in attempting to regain that length. The goal was to enlarge the canal space a few sizes beyond the original dimensions of an instrument that first encountered resistance, thus assuming such a preparation would leave a canal space large enough for efficient irrigation that would only add to the cleanliness being attained mechanically. All in all, the K-files, peeso reamers, gates gliddens, gutta percha points and the cement (typically zinc oxide eugenol based) were inexpensive and not a financial consideration when considering their use. Indeed, the K-files were used multiple times until they either showed signs of over-twisting or unwinding.

?The first big innovation that impacted endodontic instrumentation was the introduction of rotary NiTi. Nickel-titanium has far more flexibility than stainless steel allowing for greater tapered instrumentation and their use in an engine-driven rotary handpiece. By employing these systems, dentists could produce a shape that at least in the mesio-distal plane corresponded to a similarly sized gutta percha point producing radiographic results that often looked far more impressive than the manual results that had preceded it. It also reduced the amount of hand preparation reducing hand fatigue and in many instances procedural time.?

Unlike the manual conditions that had previously dominated endodontic instrumentation, the new systems come with a stiff price tag. The engines and the hand pieces can cost thousands of dollars and the instruments themselves had prices that were well over 10 times the cost of the original manually used K-files, peeso reamers and gates gliddens. Due to their vulnerability to separation the manufacturers and their advocates strongly recommended single usage further compounding their costs.?

Turning endodontics into a greater profit center is the goal of any endodontic manufacturer and the immense increase in those potential profits made a major investment in marketing a worthwhile task. By convincing dentists that they were producing superior results, that they now had the right to charge higher fees for their services while at the same time reducing the time it takes to perform the service the manufacturers learned that they could sway a good portion of dentists and endodontists into purchasing these systems. Given their vulnerability to separation, marketing was an ongoing task. They had to convince the dentists that separation would be overcome as they attained greater expertize in their usage and at the same time an evolution in the metallurgy of the original products were making them less vulnerable to breakage. At the heart of the marketing is the goal of convincing the dentist that he/she is doing better work because they are employing this new technology and consequently, it is well worth the increased prices they are paying. The evolving technology also gives the manufacturers an increasing array of choices that the dentist can purchase to enhance a technique that had the shortcomings of separation and the requirement in many situations of the need to employ a large number of these expensive single use instruments. In short, the profits from rotary instrumentation, soon to include its modified form of reciprocation offered the dentist an array of options that would give us the sense that the industry was attentive to our needs. To date this has been an effective marketing approach with the prices slowly receding in the face of increasing competition and a market that has matured to the point of reduced growth. For those of us who are old enough to have lived through this evolution of endodontic instrumentation, we should clearly note the dramatic increase in costs and critically determine whether or not given the many other options that are present today, are they worth it? Is this the road we want to continue to go down?

And naturally, given the goal of ever increasing profits a new industry of laser enhanced cleansing tools are the latest innovation introduced into the market.??Their hook is the inadequate cleansing that is rendered after rotary instrumentation that often leaves as much as 35-50% of the original pulpal tissue intact. With their laser induced cavitation using a variety of irrigants they claim that a good portion of the tissue rotary leaves behind is now removed providing a better result. A major weakness in their claims is the lack of any study that shows a higher success rate using their techniques. Now unlike the introduction of rotary that increased the procedural costs to the dentist about 10 to 15 fold, these laser tools costs upwards of $60,000 to $80,000 requiring a new hand piece that costs anywhere from $66 to $100 per tooth. Given the high profits from selling these units, marketing has become personal, constant and intense attempting to market their product by differentiating those who purchase it from those who don’t as inferior and suggesting that any endodontist that doesn’t employ their systems are not worthy of referrals. This approach is bordering on intimidation and is simply not right. While the pursuit of profits is understandable, decency should still count for something and an attempt to pit professionals against each other is an appeal to our worst instincts.

It’s not like the introduction of laser technology is a clear path to superior results. The use of these high-powered instruments have limitations. They cannot be used where open apices are present, should not be used in areas close to sinuses, cannot be used where no coronal dentin is present. They have been shown to produce apical hemorrhage after their usage suggesting precautions that should be taken if one is treating a mandibular molar in close proximity to the inferior alveolar nerve. I spoke to endodontists who bought the system and they refer to it as an adjunct. For $60,000 to $80,000 I want more than an adjunct particularly given the alternative tools I use that appear to produce results that are at least comparable if not superior.?

Continuing to practice throughout this entire time span has taught me the value of independent thinking, the advantages of having a skeptical nature and then using common sense to evaluate what is being introduced. No one can challenge the fact that 30o oscillation is the safest approach from the perspective of the safety of the instruments, that it is virtually impossible to separate them when used in this mode. It follows from this undeniable observation that the thin highly flexible stainless steel twisted reamers both unrelieved and relieved can be used most vigorously against all the canal walls producing a form of internal routing that cleanses and shapes the canals in three dimensions that reflects the original canal anatomy in larger form preserving dentin while at the same time producing better cleansing. This approach bypasses rotary to a large extent if not altogether, allows the multiple use of the instruments where instruments are replaced because they become dull and not because of fear of separation. Most importantly and totally out of context with the goals of the major manufacturers, these alternative methods are inexpensive. The thrust is on safety, of the instruments, of the tooth and on reducing the procedural stress for the dentist.

Regards, Barry