Tuesday, April 01, 2008

Digital Convergence - The Need for a Standardized Report Format for Endodontic Treatment

It has been said that endodontics is like making love - no two people do it exactly the same way - each of us has a technique that obtains our desired end result. There may be some generalized concepts that are shared with regards to instrumentation and obturation but the variations are many.

Part of the difficulty with the "science" of endodontics is that for many years the specialty was "personality" or "guru" driven. The N. Americans had one philosophy the Europeans had another. One particular school had one treatment concept because of the Department Head; another University had a different treatment model based upon canal "sterility". The "warm vertical " advocates battled with the "cold lateral" proponents. The patency advocates saw no problem with an apical puff while others half way around the world worried about getting sued for exactly the same "violation of the biologic space". Compounding this further is the obvious disparity in fees for these same procedures. In some of the poorer nations (and even some developed nations where government has taken hold of dental fees) the compensation for endodontic treatment is laughable. No North American endodontist would treat a case for what the UK pays with its national health plan. In places such as India and the Ex-Soviet satellites, the idea that rotary Ni-Ti instruments could be affordable (never mind disposable after one use!) is simply not financially feasible.

There are currently many areas where there is disagreement, such as single appointment vs. multiple appointment endodontics. New polyester based obturating materials are supposed to bind to the canal walls yet allow us to retreat the case if necessary. Fiber posts now are reputed to strengthen roots when bonded in the canal space. Sealing the coronal access with composite is supposed to keep canals from being contaminated and should increase long-term success. Many products continue to be released to Dentistry even though the producers readily acknowledge that the only tests that have been performed on these products are by individuals with a financial interest in the product or those that have been funded by the manufacturer. In the rush to be the "first out of the gate" we have dispensed with unbiased testing because it takes too long to do or to get published. Dentists buy the product, use it and hope that eventually unbiased research shows that it works as specified. Sometimes it doesn't, ergo Hydron of the 1980s. It especially disquieting when paid advocates jump from manufacturer to manufacturer looking for the best endorsement or lecture deal.

As the world moves to a more digital format, the time has come for endodontics to seriously look at a report format that allows rudimentary comparison of the results of treatment. Dr. Shimon Friedman's analysis of 40 years of endodontics (presented at this year's Schilder Symposium Boston March 2004) shows that although we believe that we are doing a better job in Endodontics, the statistics simply are not there. Success rates have surprisingly remained relatively static during that time. When he reviewed the literature, very few studies could qualify for "proper" consideration. The biggest problem with many of the "better" studies is that the sample sizes were simply too small, calling into question the validity of the conclusions.

And therein lies the "Catch-22". Serious researchers will never take clinicians seriously because of the lack of "controls" that by nature cannot occur in private practice. Private practitioners will continue to regard serious research with a jaundiced eye because most of the research is not done "in the trenches, is done by part time academics/clinicians or by students or in many cases is paid for with manufacturer's grant monies". Private practitioners say "Get real, I do it every day. " and researchers respond with "You need evidence based studies. You don't know what is real. Without proper studies your perceptions mean nothing. Your experiences are statistically valueless". Until we can bridge this gap, there will forever be a disparity between the two groups that cannot be resolved. Neither will take the other seriously and a fog will continue over the efficacy of clinical endodontics.

As clincial practice becomes increasingly digitized, perhaps it is time to use the Nexus and develop a "standardized" report format that would address this problem. The form would include a way to include digitized pre, post op and recall images. The basic information would be included such as:

1. Initial Diagnosis_______
2. LEO present Y/N
3. Number of treatment appointments_____
4. Ca OH used inter-appointment? Applied with___________
5. Instrumentation technique - e.g./ Hand files with step back, Rotary Ni-Ti crown down etc.
6. Method of WL confirmation - Film/EAL/Paper points etc.
7. Irrigants used & %s.
8. Obturation Method
9. Obturation material & Sealer type
10. Obturation location - ie/ short/RT/Long
11. Orifice Bonded?
12. Restored at time of treatment or temporized
13. Recalls performed?

I am sure that other areas could be included. The form should be limited in size (to maybe 25 categories to encourage its use) and available on the www at a central database. We could even leave room for notes at the end, should someone wish to explain complications. We need to make it easy as possible for Dentists to enter their cases. (Maybe even have it known as the standard "ROOTS" format!)

The idea would be to provide an easy way for clinicians to tell "how" the case was done, to provide radiography to allow others to examine the case and to create a database of cases that allow rudimentary comparisons. (Yes, I know that many films will be lousy, descriptions may be incomplete, techniques may not be familiar, etc. But at least it is a start. )

I believe that this is exactly what Gary Carr had in mind when he invented TDO- the need create an evidence based, private practice database. Although I have nothing but the highest admiration and respect for Dr. Carr, I think that even he would acknowledge that the $17,500 US price tag of his TDO software (along with the language barriers present when dealing with clinicians of many different countries, the need for the software to handle proprietary insurance submissions, etc.) makes it unlikely that the fully blown TDO program will be in general use the world over.

To those serious researchers who say this is "junk research, not evidence based", I say "maybe so". But until an easy way can be found to recognize the contributions of practicing clinicians in analysis of endodontic results, there will always be a distance that will be present between "pure science" and "practical clinical practice". This distance will continue to act as an impediment to learning, create biases in results and prevent communication between the groups. By providing a standardized report format, we may be able to get decent sample sizes (maybe in the tens of thousands) that allow us to answer some of the more basic questions related to treatment of the root canal system. There still may be subtleties that prevent intimate comparisons and these areas should be studied using evidence-based techniques.

By using the reports of thousands of dentists the world over, we may be able to answer the most basic Endodontic questions such as those of 1 vs. 2 appt. treatment, CaOH use, efficacy of different obturation materials, success rates of cases with pre-op LEOS, influence of WL and location of fill termination, influence of orifice bonding on success etc. In that way, we may need to rely less upon the word of the manufacturers, their paid advocates and sponsored research - and more on the practical experiences of our fellow clinicians.

By : Robert Kaufmann DMD MS (Endo)