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Endodontics Goes Digital

By Lt Col Jarom Ray
Associate Professor, USU Postgraduate Dental College
Program Director, Air Force Endodontics, Lackland Air Force Base, Texas

It’s 2019 and “digital dentistry” provides state-of-the art digital solutions, remarkable innovations, and advanced technologies. Digital dentistry has made dental procedures more effective and efficient, and more and more technologies are being discovered that make dentistry easier, faster, and better.

The field of endodontics, most notably, has seen vast improvements in technology and techniques over the past few years (e.g., digital radiography, cone beam computed tomography [CBCT] used in diagnosis and treatment planning, three-dimensional [3D] printing, rapid prototyping, etc.). In fact, endodontic surgery has currently evolved into endodontic microsurgery (EMS), which uses ultrasonic technology, state-of-the-art microsurgical instruments, new and improved biocompatible materials, as well as the surgical operating microscope. All of the advances in EMS result in its widespread use, greater efficiency, and improved outcomes.

The Air Force Postgraduate Dental School (AFPDS), a part of the Postgraduate Dental College (PDC) of the Uniformed Services University (USU), is at the forefront of EMS research.

The PDC is also composed of the Army and Navy Postgraduate Dental Schools. According to retired Air Force Col. Thomas R. Schneid, DMD, MS, and executive dean of the PDC, “The primary mission of the PDC is to support the military services with a Master of Science degree program that educates, trains, and comprehensively prepares military dental officers to support the needs of the Military Health System. Currently, the PDC consists of 20 Army, Navy, and Air Force residencies that are enrolled in the Master of Science degree program and 10 Air Force one-year general dentistry certificate programs. These programs are located at 17 different military installations throughout the United States.”

The goal of the USU-affiliated military postgraduate dental education programs has always been to train master clinical specialists. However, research directly contributes to making a better clinician. The research component of the program, aligned with knowledge gaps that are important to the Military Health System, prepares graduates to critically evaluate the professional literature and to incorporate scientifically valid information into cost-effective, evidence-based practice in support of improved health and readiness for our warfighters.

Thus, military clinician-educators in the Endodontics Residency Program at AFPDS are effectively pioneering new pathways. Their research has led to the development of a new, innovative, patent-pending surgical technique known as Targeted EMS that uses CBCT imaging, implant planning software, software-designed 3D-printed surgical guides, and trephine burs to define perforation site, diameter, angulation, and depth to achieve osteotomy, root-end resection, and biopsy in a single step. Previously inaccessible sites can now be safely accessed because vital structures can be avoided and protected with precisely defined surgical access.

First targeted endodontic microsurgery design and stent. First treatment was completed June 12, 2017 by 
Air Force Lt. Col. Jarom Ray.
[Image credit: Air Force Postgraduate Dental School]

AFPDS clinician-educators work on a wide variety of projects and produce various research articles for publication and national exposure. A research article by 2018 AFPDS graduate and principal author Maj. Christin Michelle Giacomino, DDS, titled “Targeted Endodontic Microsurgery: A Novel Approach to Anatomically Challenging Scenarios Using 3-Dimensional- Printed Guides and Trephine Burs—A Report of 3 Cases” was featured on the cover of the April 2018 issue of the Journal of Endodontics.

A review paper from AFPDS endodontic resident and principal author Capt. Julie Anderson, DMD, titled “Endodontic Applications of 3D Printing” was highlighted in the September 2018 issue of the International Endodontic Journal.

The Endodontics Residency Program also has four other active 3D printing-based research protocols currently being conducted by Master of Science degree residents: (1) Clinician-centered assessment of 3D-printed stents for Targeted EMS, (2) Targeted EMS vs. EMS: a surgical simulation comparison, (3) Targeted EMS: Implications of the greater palatine artery, and (4) A micro-CT (computed tomography) and stereomicroscopic comparison of porcine root ends resected with EMS and Targeted EMS. In the future, cost-effective 3D printers available throughout the Department of Defense dental clinics could provide precisely guided EMS, thus preventing morbidity associated with the loss of thousands of previously unserviceable teeth.

Within the AFPDS Endodontics Residency Program, valuable research is being conducted in other areas as well. For example, a research study with direct readiness implications—run by 2017 graduate Capt. Darrell Curtis, DDS—consists of reviewing the current paradigm for endodontic outcomes assessment and dental readiness classification. Both of these areas are partially based on follow-up periapical radiography by looking at how outcomes change when CBCT postoperative imagery is utilized. The end result should be more accurate diagnosis and treatment directly leading to enhanced dental readiness.

Results of this research study indicated that conventional radiographs alone had a 35% false-negative rate in detecting apical pathosis twelve to forty-one months after endodontic retreatment and apical surgery. CBCT was much more sensitive and specific for detection of refractory disease. The Air Force, as well as other military branches, has a technological advantage in this regard because most clinics can assess deployable military members with CBCT. However, many civilian dental offices do not have this capability, and they would not be likely to use CBCT for outcomes assessment. When caring for our joint active duty members, they must be adequately assessed so that commanders at various operational and/or deployed locations know that they have a ready force.

Still another AFPDS Endodontics research study, conducted by 2018 graduate Capt. David Weyh, DDS, focused on more cost-effective use of endodontic instruments. At a time when single endodontic file use is increasingly required by the manufacturer’s instructions, the Endodontics Residency Program is investigating the properties of more affordable alternatives to the prominent file brands. Additional program research also conducted by Maj. Giacomino has shown enhanced osteogenic potential (ability to stimulate bone growth) of bioceramic endodontic sealers that has implications for healing of apical periodontitis and dental readiness.

Much of the exciting work of AFPDS research represents the enormous possibilities in this field. Ground-breaking research has produced many innovations and resourceful technologies. The AFPDS Endodontics Residency Program is strategically targeting gaps in knowledge that will lead to cost-effective joint dental readiness. 

Digital dentistry is the way of the future. Focusing research on current technology, such as digital dentistry—while aligning our efforts with knowledge gaps and readiness—hits all of our targets: training master clinicians, satisfying accreditation requirements, creating lifelong learners, and adding greatly to the value of our programs.