Endodontics vs Implants with Omar Ikram – PDP238

Teaser:
They look at you like, really? I thought implant would last till I was a hundred. How long anyone’s gonna last on this planet? But in my planning, I plan to age 100. So I see everyone as living to age 100. And so my planning, I don’t think this will make it, therefore–

Your health is within your own control. Also, it might be only 50%, 25%, but some of it’s within your own control. I want the patient to go on holiday and not be sitting there worrying about whether their tooth might be bothering and they have to go to a dentist and take antibiotics–

Jaz’s Introduction:
Endodontics versus Implants: is this even a worthy battle? Let’s be honest, right. Any implant dentist worth their salt would agree that for themselves or their family member where an Endo is feasible and you have a good prognosis, that that is the obvious choice first before having an implant, because an implant will still be an option for the future. And that’s pretty much easy and unanimous in dentistry. Unless of course your patient suffers from titanium deficiency disease.

Now where this becomes more pertinent is those dubious scenarios, lack of tooth structure, those nasty cracks we’ve particularly discussed these two scenarios. Whereby perhaps we should be considering implants. But wait, Dr. Omar Ikram may have a few things to say about that and why we should be considering perhaps root filling, retained roots, root burials, amputation, and a term I introduced called Palliative Endodontics. Why that might have a growing role so that we can defer implants because we know implants do not last forever, Endo doesn’t last forever, nothing lasts forever. So important about seeing the bigger picture when it comes to longevity.

Dental Pearl
Hello, Protruserati I’m Jaz Gulati. Welcome back to your favorite Dental podcast. Every PDP episode, I’ll give you a Protrusive Dental Pearl. Now, there is a theme in this podcast where we discuss about the age of the patient. We all know it’s better to have an implant when you are 60 or 70, than when you’re 40. And one thing I always did is when I communicate to patients, I was inspired by a consultant in Restorative Dentistry Dr Chander used a line to a patient. 

He said, “Look, I don’t know how long anyone’s going to live for, but I always plan my dentistry to age 100.” And I’ve been using this line to my patients, and yeah, it’s okay it works well, they get to see the bigger picture. But a lot of patients can’t relate to that. A lot of my patients, their 60’s, 70’s, and 80’s they just can’t relate to that.

They immediately start thinking off topic and thinking, oh, I probably won’t make it. So one of the changes I’ve made in communication based on what Omar discussed with me today, and really the pearl I want to pass on to you is instead of saying to age 100 for everyone, look at your patient. Let’s say they’re in their 70’s and then you wanted to say, “Look, I want this to last well into your 80’s maybe into your 90’s. 

Now, they may still think, “Oh, I probably won’t make it.” But it’s just a bit more relatable than putting a number age 100, because chances are most people don’t know a 100-year-old, but they might have friends in their 80’s and 90’s. Do you see what I mean? Obviously, it’s a very niche scenario. But me personally, I have a very age population that I look after my patients on average are 60.

And so this change in terminology in the way I communicate to patients in terms of longevity of treatment. I think’s gonna really help me to get the point across well into your 70’s well into your 80’s. And you’ll hear this again in this episode being a big part of today in this episode with specialist ended on Dr. Omar Ikram. 

Before we join the main episode, have you downloaded the app yet? The best way to do it, if you haven’t already, is visit the website www.protrusive.app. Once you’re there, make your account. Then once you’ve made your account, you could download the iOS or Android app and log in to find the nicest and geekiest community of dentists in the world.

What I’ve found is that dentists join the app for the content. The premium notes, the transcripts, the Protrusive Vault, our Mini Master Classes and Courses, just a better overall listening and watching experience. But what they stay for is the community. What they find is that they fall in love with dentistry all over again because dentistry can feel so lonely and isolated. 

And on some of these social media groups, you get shot down when you ask for opinions. But really, we’ve brewed a culture very hard to brew, a culture of kindness, being considerate and selflessly sharing information. So remember, the website is protrusive.app. The app is called Protrusive Guidance, I would love to see you on there. Let’s join the main episode with Dr. Omar Aram and at the end, of course, you can answer the quiz to get your CE credits on the app.

Main Episode:
Omar, welcome back to the show. I just saw you post on Instagram, so you are on the bike doing a marathon. Tell me more about that.

[Omar]
Oh no, it was just one of those big days at work and I was doing an extra bit of punishment for exercise. I tend to do this to myself when things get tough, I think what’s something I can do for 20 more minutes? You’ve had that big day, you think I can’t do it anymore. And it’s like, you can, and by doing that, what you’re doing is you’re just pushing yourself that extra bit and saying, “You know what? Even those hard days in clinic, I can still do a bit more. “

[Jaz]
I love that. It reminds me of a book. The David Goggins book? Can’t Hurt me. 

[Omar]
Yes, yes, yes. Have 

[Jaz]
You read that one? 

[Omar]
Yep. That’s a favorite of mine. That’s a good one. 

[Jaz]
I mean, exactly what you’re saying. It reminds me so much of that. So I like your life philosophy.

[Omar]
Yeah, and it’s a good one. I mean, basically he talks about callousing the mind, doesn’t he? That’s it. Making yourself more [inaudible] and thinking you can push yourself a little bit further all the time. And what you do is then you grow. Because if you just sit back and take things easy, you basically don’t grow. You just stay static, and we all know many people who have done this in our lives. There are people I know who are still working, like when the day that they graduated from dental school, and that might be fine for those people. I’m not saying anything wrong, but they haven’t grown.

And sometimes those people aren’t enjoying dentistry as well. And I think to myself, but you haven’t given it a chance. And it’s just little incremental growth. I’ve been graduated now for 27 years as a dentist and it feels like forever, but if you do those 5% growth in 27 years, there’s a lot of growth. 

[Jaz]
Well said. It’s a theme I cover a lot on this podcast. How do we figure out those very engaged bunch in dentistry who say that, “Yeah, they absolutely love dentistry.” And then those who are disengaged and not enjoying it, and I think of the several factors. One is your mindset, but in a way that you have that growth mindset. You have that abundance mindset, okay, you want to keep giving back to profession. There’s more to learn. I think if you see it in that way, then you don’t stay stagnant. 

[Omar]
That’s right. I think that you have to think to yourself sometimes dentistry is a long haul. Like it’s a long game. Yeah, we all graduate, we all want to get busy. I see it a lot with younger dentists. “I want to do what Omar’s doing.” It’s like that’s took 27 years. Just be enjoying where you are and you will get there if you keep enjoying, you will do far more than me. But you will do lots more than anyone. But you do have to keep doing those, you know, 5% growth per year, six or 7% growth. You’ll have to be committed to that.

And I know life will get in the way. I sometimes talk to my friends and I say, life will get in the way of your dentistry. And this is where your team around you, the people around you who are supportive, maybe your parents, maybe your partners, maybe your children are part of that progress. Because if they hold you back, then you won’t progress. 

There are a lot of people I know again, who have seriously big commitments with their family and things like that, and that will just stop them progressing as dentists. I’m not to say that they won’t be great parents or great partners or whatever, but it will hold them back in their dentistry and that’s something we have to all be thankful for. 

I mean, sometimes I think to myself, you and I are in the place we are because of not only what we do, but what our partners and kids and family will allow us to do. And fortune, we caring for people as sick, we will be less involved in dentistry. And also the generations that went before us, that didn’t muck it up for us.

You know, they laid a platform for me to go to university. If I didn’t have that platform, I wouldn’t have been able to do it, and I wouldn’t have been able to do what I’m doing now. And you have to be really, really thankful for that. People that you even met decades, I’m talking 50, 60, 70 years ago, people will have been doing things the right way to enable you to have the platform and the start that enabled you then to go to university.

Also they set almost from the grave or from the past, they set you a benchmark, like for example, I have a grandfather who is heavily involved in partition India and Pakistan. And for me, I never met him. And I look at his picture with one of the people who came up with the concept of Pakistan and I think, “Wow, this guy was right there when they created Pakistan. 

And he was involved with the people who doing all that.” And I think to myself, I never met him, but I would’ve liked to have made him proud. And that is something quite amazing when you look at past generations, even though you never met them and think, and they laid the platform for me to be able to do it.

And then you should pay that forward as well for other people. It might be your kids and your partner, of course it might be your patients, of course it’s your patients. But sometimes, I think to myself “And what else? And what about colleagues? What about that dentist who came to me on the course on Wednesday and said, I’ve got serious depression.” I’m like in a really bad place. And I said, “Look, if you can get the grades to get into dentistry now, and you can battle with that and you can enjoy dentistry, you will actually be able to do anything you like. 

It’s just a matter of you being able to see that. You might not be able to see it now, but if you keep going, you will be better, and then the sky’s the limit.” You’ll get to a point where the obstacles that we all come up against the costs of living, making your practice, you can list a hundred barriers will all come up against the ones that you able to break through a leap are the ones that many others won’t.

And every time you come up against the barrier, if you can leap it in style or gracefully leap it or whatever, then you will become better for it. And many others won’t be able to do that. And then you’ll get to a place where you’ll realize that the sky’s the limit. Like after that, you are definitely there with this podcast, I’m sure. 

But I’m just getting to the stage where I’m thinking to myself what I want to last, what is it? 20 years or so of my career I don’t know how many years I’ve got working in dentistry, but I’d love to keep going as long as possible. But there was a time where I wanted to retire early because I thought dentistry was really hard. But now I don’t have that thought at all. I think to myself, let’s keep going with this positivity and fun it’s a massive part of my life now. 

[Jaz]
Like I said, it’s a mindset like the philosophical start that we’ve had, Omar to his podcast, I mean, 3 little reflections of based on what we said is the book Outliers argues exactly what he said that actually it’s not just ranks to riches in terms of hard work and determination. 

You need so much more to go in your favor. There’s a reason why both Steve Jobs and Bill Gates were born in 1955. There’s a reason for that because when they were 17, 18, they weren’t old enough to be like married commitments. They were young enough, enthused enough, and they both were early adopters of having being lucky to be in a home that had a computer kind of thing.

And then you paid homage to your grandfather. So that’s great. So Outliers, that book then reminds me of Mark Twain quote, “It took me 20 years to become an overnight success.” And then the last one to point out is “Everyone’s got a plan until they get punched in the face.” And if you get punched in the face, you may need an Endo. 

And therefore we’re talking about Endo or an Implant. Because we’re talking Endo versus Implant, right? So this is like a big debate . On one side of the ring, we have orthodontics on the other side we have implants. And quite commonly in conferences, I see this as a very popular lecture title. And it’s great, and I think there’s space to discuss more about it. And I guess the elephant in the room, Omar, first excuse this little monologue is there is a bias, right? You are an endodontist. Okay? So we kind of know what the ding, ding, ding, when there will be at the end. However, I don’t know a single implantologist worth their salt.

If Endo is on the table as a viable option, A single end is worth their salt. Who would opt for the implant when the tooth is still a viable option on themselves, on their patients, on their daughter. And I think some of the themes I wanna discuss with you is feasibility. Why endo for an implant, but then what makes it unfeasible? What are the red flags that we should be thinking? 

Actually this Endo will not be predictable and we should be then going for an implant. So I guess where I want to start is what are the complications of extractions and implant that we want to veer away for? And we’ll build on, “Okay, well how can we do more endo and when is endo appropriate?”

[Omar]
That’s a really great start. Because I had this down and I think the biggest thing we have to think about with regards, I’m gonna start with what I say to patients now. I used to say like we all did. You’ve got an infection in your root canals, you could take the tooth out or you could replace it. That’s not the right thing to do at all. 

That’s what they teach you at dental school is totally not the right way because every patient is different, and every tooth is different, and every scenario is different. The smart clinician will actually be able to work out what’s right for that patient because of certain factors. So what I say to patients is, our teeth are supposed to last for about 24, and everyone says, what are you talking about? 

Teeth are supposed to last for 80 and 90 years, but this first molar comes through when you’re six years old, the second molar comes through around 12 years old, and the third molar comes through around 18 years of age. So you add six years that’s 24, 24 is also the years where we look at implants as maybe an option because the patient’s stopping growth. And 24 is probably about the life expectancy of a human being.

In a world where we don’t have tribes and we don’t have farming and we don’t have roads and all those things we have now. So in order to keep your teeth going way longer than 24, because people live in the developed world to about 85 in Australia. 83, 85, depending on gender, women last longer. 

They live a longer life apparently. And basically, if we are going to keep people’s teeth going instead of just 24 or so to 85, we are going to have to create something that’s not normal. And we’ve done that with longevity, with heart bypass surgery and valve replacement and brain surgery. And you can list all the medical advances which aren’t supposed to be done to people that’s kept them alive.

We have to do the same in dentistry. We are keeping a tooth around longer. So that’s gonna involve things like root canal treatment possibly. And that’s gonna extend the life, not keep it till you’re 95 years old necessarily. So to get back to your question is to say implants, the biggest difference between implants and retaining the tooth through root canal treatment is that implants don’t have a periodontal ligament. 

That’s the big difference. And then patients, someone look at me like, “Why is that an issue?” And I say, Look, when you bite on a tooth, the ligament moves like it does in any ligament of any muscle when you are lifting weights or whatever to tell you that the bone has to remain there. You don’t have a ligament, you don’t have that connection with the body, you don’t have bone retention. 

The tension and the ligament keeps the alveolar bone present. If you have a denture on the ridge pushing down, after you take the tooth out, then the denture will actually resorb bone because it’s like your wetting ring on your finger. It compression will resorb bone. The implant won’t prevent food pressing on the ridge, so that will prevent the bone resorption being fast, but the bone resorption will happen because there is no ligament.

And so sometimes I’m saying to patients, “Look, implants last between 15 to 25 years, that’s a really good implant.” Obviously they can fail straight away and all those things that, something that can happen. But if the patients say under 60, I say to them, you’ll generally be dealing with an implant failure in your lifetime if you take the tooth out and replace it. If the patient’s 65 or 70, sometimes I’m saying to them, “Look, an implant will last you into your sort of mid to late 70’s 80’s it’s a possibility. 

You might replace it sometimes, like depending on the tooth, of course, as you said before, if a tooth is restorable, it would have a root canal treatment. But then what is restorable is what’s possible, and it’s based on your skill of not only endo, but restoring teeth. And the problem is many, many endodontists aren’t amazing restorative dentists necessarily, although I think you’ve got some really great ones there in the UK for sure.

And also many general dentists don’t wanna do the Endo. So it’s that kind of new kind of situation where we have restorative endodontists who do good Endo, and then they do good core and restoration of the tooth because restoration of the tooth has the most impact on survival of the tooth and longevity. So if you do a great Endo and chuck a temp, and it’s going to be way worse than if you can restore the tooth and then set the crown up for the general practitioner or whoever’s doing the crown or the cuspal coverage.

So what we’re saying here is really the periodontal ligament is really the main factor. And so I’m talking to patients now more and more about this. But also other things that you’ve got to bear in mind with implants, so just to get you started on a few of these. So the obvious ones, the ligament’s gonna be lost and it won’t last forever. It’ll probably last between 15 and 25 years, and that’s good enough for some patients. 

Some patients, as I said, if they’re 70 and the tooth’s really in a bad state, well it’ll probably last 85 or 90 with the implant. Maybe if the other thing just mention is that I never, ever now say take the tooth out and replace it with an implant. I go to someone for an opinion. Unless the tooth’s like cracked down the middle. There’s a few probably get to this red flags, but there are a few situations where you really cannot do endodonic because the tooth is structure is totally destroyed and that’s red flag. 

But if the tooth is half viable for anything, I often say, “Look, I wouldn’t opt for root canal treatment as the first option here. The tooth structure is bad or you’re in that age group where an implant may last your entire life into your late 80’s 90’s etc. depending on the patient. I mean, if the patient’s well and healthier, they’ve got a good family history. 

Sometimes I’m talking about family history of longevity and they’re saying, “Oh, but my mother lived to a hundred,” and I go, “Well, maybe we keep the tooth, maybe it won’t last your whole life. Things like that, you have to be a clinician. You have to talk about these things. Doctors talk about it and why not dentists? 

Then the other thing we’re looking at here is medical history. Again, some of the antidepressants have like four times the failure rate. You’d be surprised about four times failure rate with implants. 

[Jaz]
Do we know the mechanism of antidepressants and implant failure? Do you understand the mechanisms of that yet? 

[Omar]
Well, there is some theory on this. It’s got to do with basically the bone interactions with the medication. It’s not really well understood but basically there’s this research showing that it’s the SSRI or the Serotonin–

[Jaz]
Selectively uptake Inhibitors.

[Omar]
Correct. Those ones. They’re basically the worst ones. So if a patient’s taking that, talk to them about not having an implant because there’s problems with that. You know the obvious ones come up–

[Jaz]
Bisphosphonates.

[Omar]
Yep correct, bisphosphonates. And also not only bisphosphonates, but are you in that category of patient who may need to take  bisphosphonates? Have you got osteoporosis that’s early and things like this–

[Jaz] Or in the family? 

[Omar]
Yep, in the family, are they female patient who get osteoporosis maybe a bit more than males because of the physiology. Smoking, obviously diabetes, the obvious ones, oral hygiene, those sort of factors. So things like bisphosphonates, again, very important to say. And if you’re about to start bisphosphonates, well we need to start maybe doing the implant or not. Again, an opinion before we do anything.

I’m doing that a lot nowadays go for an opinion. If he says, or she says, what you want the specialist or the dentist to say regarding longevity and it’s going to be wonderful, then do that. But I can do something for you but I’m not saying it’s the first option all the time. So I almost never say, just take the tooth out it’d be rare. 

[Jaz]
But this is the conversation that the general dentist has, right? You’re putting yourself in the shoes of the general dentist and the message you’re giving to listeners is try and get an opinion just in that middle category, and you’re unsure from the person who’s going to be doing the more complex job, the implant, or be the Endo.

[Omar]
Yeah. So what happens is the patients often come to me from a general practitioner, you know, the classic one is external cervical resorption, central incisor, can you save it? And the answer is, well, I can sometimes and sometimes I can’t. And again, we’ll talk about that maybe in a few minutes about the red flags for endo. 

But I’m often going, well if you are under 60, we need to keep this tooth going until you are into your 60’s. That’s often say, well into your 60’s and beyond will be wonderful, but into your 60’s is where we want this tooth to last till then an implant lasts 15 or 20 years and you’re sort of nearing 80’s and then you have the fixed bridge option.

The bridge option should be the last option because they use the teeth either side to hold it in. You’re going to damage those teeth and maybe if you’re 90, that’s not an issue. Certainly it is an issue if you’re in your 40’s having a bridge because we know that’s going to fail the abutment teeth will fail. You’ll have root canal treatment on teeth just because they were there prepped to hold the teeth in to pontic again, all that sort of stuff. 

So you do not want bridges in young patients, but in an older patient maybe it’s fine. So this is the sort of way I go is like implant that fails if you were in sort of late 80’s and that failed then a bridge and that should keep you going well into your late 90’s. And then we’ve done the things that I was talking about that extend the life of having a fixed tooth there. 

And I think that’s the key is like, look for that fixed option to last forever. Sometimes when you say to patients, you’ll be dealing with an implant failure in your lifetime, they look at you like, really? I thought implant would last like till I was a hundred. And it’s like, no–

[Jaz]
Everyone thinks that, right? Spend that money and they expect it to last forever. And so we need to give them that dose of reality and expectation management. But you’re saying that specific case of let’s say the Cervical resorption and you could save it, but then who else’s opinion would you seek?

[Omar]
Yeah, so if the external cervical resorption is really severe, then I’ll often get the patient to go for an implant consult or opinion. And again, I say, look, if you are in a situation with a person who is going to do the implant, so this is going to be a great result and it’s going to last for 20 years, maybe you’ll take that one because what I can offer you sometimes isn’t 20 years. 

What I can offer you might be like five to 10 years maybe. It depends on the severity. External cervical resorption is one of those really difficult ones where it’s like could be just a restoration and it could be like completely gone. By the time the patient gets to us, often it is completely gone. 

They’ve had external cervical resorption for many months or years, and the tooth is asymptomatic because as I explained to patients, your immune system is removing your tooth and we have no inflammatory reaction against our own immune system. And basically the immune system is bowing into your tooth and actually protecting your tooth from the bacteria in your mouth.

So the immune systems in the cavity predicting your tooth from the bugs so you don’t get bugs using the hole in your tooth as we do with caries or cracks because the immune system’s removing the tooth but protecting it at the same time. But you get to that point where it’s symptomatic and it’s like the hole is so big now the bacteria can gain access and that’s when you have the problems. And it’s like, so now the tooth’s like really in a bad state, I have to say.

If I have a tooth with external cervical resorption, with pulp necrosis, it’s usually not looking too good. That’s how I generally would judge cases like that. If it has a vital pulp, even if the structure is quite compromised, I’m usually more keen on saving those teeth. 

But it’s a sliding scale with external resorption and thankfully we have CBCT, which is such a good tool for showing the patient “Look, half your tooth’s gone.” It’s not, there’s a 2D radiograph. So I’ve been doing a few cases like this recently, but holding onto teeth with externals cervical resorption is very difficult. Quite often they need crown lengthening and surgical treatment of the resorption as well as root canal treatment. 

And it just kind of adds to the cost. And again, you need to justify the cost for the patient because if you’re spending the same or more than an implant in private practice in England, I’m sure, and the implant is the same as a crown and root canal treatment, and if you chuck a surgery for the external cervical resorption, then it’s possibly more.

But if you can say to the patient, and the reason why we want to keep this tooth is the implant will fail in your lifetime, then they’re all more on board with what you are doing. I found this a change, my messaging from when I was a new grad going. 

Yeah, it’ll last like, 15 years and you have no experience to tell the patient that, because that’s what some of the papers say. They say it last eight, 15 years, 10 year survival’s very good, even 20 years survival. The Eckerbom paper is like in the sort of 74%. You’ll be using these kind of stats, but actually what you need to do is work out if that patient doesn’t need the tooth for that long, then you’re looking at the patient. 

An 85-year-old doesn’t need the tooth for 15 to 20 years. That’s generally how it goes. And as patients age, different things come up like. You know, maybe they can function with just premolars and there’s a whole heap of things that come up as you get older that totally change how–

[Jaz]
Do deliver that message gracefully, Omar? Usually if I say to an 80-year-old patient that, Hey, I’m going to do this, and I’m usually the first one to say, “Okay, I think this has a really good success rate, 15, 20 years I can expect from this intervention. And I usually wait for them say they laugh at opposite I probably won’t be here at that point, I’ll take that option kind of thing. So rather than me saying, you probably won’t be here at that point, therefore is a graceful way to communicate that. 

[Omar]
Yes, I totally learn the hard way as everyone does. I never say you won’t be needing it. You say. It’ll last you well into your nineties, and as you said, the patient usually says, but I’m not gonna probably live till I’m 90. And I go, well, that’ll last you a long time then. But conversely, what you’re often doing, I find nowadays is I’m taking patients who are under 60 and they say, you’re 55 years old in my books that’s a young patient. And they look at me and go, “What do you mean?” I go, ” Because most people live till 85, 83, whatever it is.”

You’ve got many years chewing ahead of you. I mean, I know you don’t think that way, but, but realistic, you do. That’s the way the average life expectancy works in this country. And so by retaining– 

[Jaz]
One thing I learned, Omar is, sorry, if you don’t mind saying, is one of the consultants I work with, Satinder Chander, he said to patients, I can’t predict how long anyone’s going to last on this planet, but in my planning I plan to age 100. So I see everyone as living to age 100. And so my planning, I don’t think this will make it, therefore, to get you to age 100, here’s my plan, plan A, plan B. And I just feel like that’s a really nice way. Look, you can’t predict anything, but I’m going to plan to age 100. 

[Omar]
That’s a tough one. Being an ended on to supply to the age a hundred because a lot of the time we are dealing with such broken down teeth, cracks and things like that. It can be difficult. I usually say around, 80, 85, I don’t actually say that. I sort of say if we can get the tooth to last well into your 60’s and beyond, that’s what we’re aiming for in an implant would then last year. 

[Jaz]
I think that’s more realistic. A lot of time when I said that a hundred line patients raise their eyebrow, I was like, well I can’t relate to that. Do you see what I mean? So I quite like your way more like depending on the age of patient into your 60’s into your 70’s into your age. I think that just has a bit more realism. So I actually like that more. So let’s talk about the red flags, right? So for example, one question I had is.

Let’s say you have a lower molar, let’s say a lower second molar, classically split tooth or a crack tooth going from the mesial marginal ridge all the way to distal marginal ridge. You start exploring the crack let’s say it has an MOD amalgam, you remove the amalgam, and then before you access into the pulp chamber, you already have a crack that you can see running from mesial to distal, but it’s above the pulp chamber. You haven’t actually gone to the pulp chamber yet at this point are you committing to tooth? 

Actually, no. I can see this crack here. At this stage, is it, oh, this tooth is not saveable, or do we need to do our due diligence and explore into the pulp chamber and confirm there as well? 

[Omar]
That’s a really great question. So I’ve got a couple of really useful comments on that. If we’ve decided to go ahead with saving the tooth and you’ve had this conversation with the patient about age and what we want to do, we are saving the tooth because we want the tooth to last well into their 60’s or whatever the reason is, we’ve got the patient on board and I think this is been a really important thing with me. 

And the way I communicate with patients in the last few years is that the patient is on board to save this tooth. Firstly, as an endodontist, they’re in my chair so they wanted to save the tooth, if they didn’t want to, they maybe went for the implant straight away or the extraction or whatever with the general dentist or come to the surgery, didn’t go for the consult.

But when you start exploring that crack, there’s a couple of things. First of all, CBCT will show you that if there’s any periodontal defects, if the periodontal defects deeper than inter proximity and you can’t probe it, very easy. If it’s deeper than five millimeters, it’s pretty much game over because they’re going to have a periodontal disease there even when you do the root canal treatment because that’s essentially impossible to clean region and all that stuff. But if there’s no defect deeper than five millimeters- 

[Jaz]
This is a clinical measurement or a CBCT measurement. What you’re saying here? 

[Omar]
I measure on the CBCT because often you can’t probe between the two. Yeah. So assume that if it’s three or four millimeters, let’s say, but you can’t probe it because interproximal.

[Jaz]
And just again, just so for clarity for the younger audience, are you measuring from the CJ to the bone crest? Where is this measurement being taken from? 

[Omar]
Yeah. CEJ. 

[Jaz]
CEJ to the bone level.

[Omar]
The depth of the pocket. Yeah, you measure on the CBCT because a lot of the times you cannot get the probe into proximal and probe it and measure it. And sometimes even with those 4, 3, 4, it seems like less it’s not that deep. I mean, obviously you’ve got the deep pocket all the way to the apex, then it’s gone. 

It’s obvious, but what I’m saying here is you see these defects and you go, there’s gonna be a crack involving the bone. Next question is, how deep is it? If it’s five millimeters or more, then they’re not going to be able to clean that. And they’re going to do the best endo in the world, and this is going to be gone because of periodontal abscesses and they’re still going to get pain. They’re going to get that swelling of the ginger and all that stuff. They can’t get their toothbrush out and clean down that defect.

The next thing you go is on vitality. If the pulps vital, that’s a good thing because vitality is actually something that means that the crack is not causing necrosis. So if the crack is not deep enough to cause necrosis, then the pulp will have warned the patient of pain and the crack is early. 

The pulps, like an early warning signal. If we have that intact, we have an early crack. If we don’t, then the crack could be anywhere and it could be like a hay line down past the route. And even though there’s no pocketing now, there might be in three or four months time and maybe it’s not worth it. So vitality is the big one for me. 

[Jaz]
Vitality is good. It makes sense there because if it’s necrosed, it’s too far down. But what about that middle ground of irreversible pulpitis? Something that I understand that as GDPs, we might see more than new endodontists. We see the irreversible pulpitis come in at that stage and we can see that it’s clearly a crack. That was the etiology behind this. At that stage, are we in a crossroads or is that again, we’re putting that in we’re still probably Okay. because it’s still technically vitality. 

[Omar]
Okay. This is a really interesting one because if you get to that sort of stage and you’re looking at irreversible pulpitis, well firstly irreversible pulpitis is actually vitality as well, so that’s good. But like that’s a positive. But the other thing is that don’t forget that you need to then start looking at the patient’s occlusion and why they have a crack as well. So you start bringing that. 

But sometimes I’m seeing patients I’m, look, you don’t have any molars on your left side. The right hand lower right first molar is cracked now because you don’t have any lower left molars and we need to hold onto this tooth.

We need to hold onto the lower right first molar because you want to maintain it because you’ve cracked it and you’ll crack other teeth. If I recommend extraction, I mean there is a limit, as I said, with periodontal pocketing and necrosis and things like that will sway me to extraction. But generally you are trying to now justify why you are keeping the tooth if there’s a crack. 

You’re basically justifying the exploration, I would say is the best way because sometimes you don’t need to explore much more than that and go look, it’s just not going to be worth it. I mean, if it’s necrotic and there’s a crack there, I’m starting to look at, having said that, I often clean out the root canals, obviously, to get rid of the infection and then seal it up and say, look, sometimes with those necrotic cases, maybe just keep managing it. 

It’s not worth finishing, but maybe just keep monitoring it and then when it starts to bother, you have the tooth out. But plan to get the opinion now and then again, see if you want to do it soon, or whether you want to do it later or it fits in with your job. But I’ve got into, into a stable state where the tooth is now cleaned out and sealed. The crack will obviously open up at some point, but it might take a few weeks or months. Then you have a bit more time 

[Jaz]
In this scenario, to what extent of your endodontic protocol are you carrying out for disinfection? Obviously you’re not obturating with GP, you are just hyper chloride, are you doing any shaping and any long-term predicament?

[Omar]
Yep. I’m shaping with rotary or reciprocating files I like for shaping something smallish but not too small. I like 20/06, 20/07 as I suppose 20/07 wave, one gold sizes. Something that’s quickly gonna get down there but produces shape that you can kind of clean out. You don’t want to go for like a small file that’s kind of like, then you have to use another file when you’re going to tell the patient that tooth’s not going to be completed. 

You want to quickly clean it out to a certain size. Like, as I said, 2007 wave one gold is kind of something that resonates with me. Clean it up, fill it up with calcium hydroxide, seal it with IRM. That’s my favorite seal because of the antibacterial activity and it’s got that sealing effect.

IRM is a wonderful material, I think in Australasia it’s not as popular as it is in say the Uk. And since I’ve trained in New Zealand and in England, I have both sides of the coin. And I have to say IRM was loved over in the Uk. It’s such a good material. It is used for apical surgery. It was in the past before we had MTA. 

So that’s how good it seals. It can be used as a retrograde filling and it works. And so basically seal it up with IRM and then put a little GIC on the top or something that’s gonna last a bit longer. And then say the patient, look, I’ve stabilized it for your trip or whatever. And then you’ll lean to have the tooth out because it’s cracked really badly. 

And often I show them pictures and that’s quite handy. Just go look how badly tooth. because the patient will often go away and go, but it doesn’t hurt anymore. And there must be no problem. It’s like, no there is a problem because structurally this tooth isn’t good. 

[Jaz]
In Singapore, Omar, I came across this term from an endodontist and I loved it because essentially what you’ve described, and I say this to my patients now, is Palliative Endodontics. This is a palliative, patients get it. In that very niche scenario, I appreciate it’s a very niche scenario, and I’m sorry if I distracted from the lovely point we were exploring about that scenario with the crack duty. 

You mentioned the CBCT, you mentioned a great guideline about looking at the CBCT. Now, one thing worth mentioning is even with the best resolution CBCTs we still can’t see the cracks, right? They’re still not good enough to see the cracks. Am I right in saying that right? 

[Omar]
That’s pretty much correct. The problem is, a lot of the time what we’re dealing with is we’re dealing with a lot of scatter and we’re dealing with a lot of beam hardening and everything looks like a crack. And then you can sort of mistake the real crack for the actual beam hardening or the scatter. There’s a lot of that going on. So reading CBCTs is actually quite a skill, but what we are looking for is the bone defect. We’re looking for that little, I call it a Pacman bite or a little bite out of the bone in one area.

If you’ve got Periodontal disease, the area’s broad. If you’ve got a wisdom tooth that was removed, say it’s a distal of a lower seven, it’s broad that somebody’s taken the bone away. The pericarditis has caused a periodontal defect. Essentially, it’s broad. If you’ve got one little tiny bite out of the bone in one area, and you can see that on the axial. 

So the axial scroll down, it’s like a little dark area, just goes down the route, but it’s like a semicircle. Then you are pretty sure, and often I will correlate that with the GDPs pictures they’ve sent me. So the nice referrers that I have here, send me a picture and go, this is where the crack was. Check it and then you go, well, that correlates with the crack that they’re showing in their picture when they open the tooth up with the CBCT and this will be gone.

Having said that, as I mentioned. If it’s a lower seven or something, there’s no tooth behind. There’s no food trapping. If the patient’s quite elderly, do you want to joggle the tooth along for a few more years? If it’s not that five millimeter defect, I’m often saying it’s up to you. You can try and save the tooth, it won’t last forever. Again, what I was about to say before I got onto this subject is that second molars are such a big talking point as far as retaining versus extraction. So this is where we’re going with this scenario. 

They’re also the most cracked teeth around, so you’re often saying to the patient, look, again, if you’re a third of an 80-year-old patient or whatever, maybe take the tooth out, it’s cracked. You could function with the first molar, there’s no problem. Or sometimes just saying, look, you are under 60. The tooth in front, which is first molar, it’s going to get a lot of wear and tear. If you take the seven out, if they take the second molar tooth out, it’s going to be solely the, it’s going to be the terminal tooth in your arch for the next 30 years or so.

That will mean that you lose that tooth before it should be lost if you have this tooth out. The other thing I’m commonly saying to patients now is, if you think about a first molar that’s heavily restored, because it’s been there since the patient was six years old, maybe it’s had a crown, maybe it’s had a endo. 

Ask the patient, even though you’re looking at the second molar, ask the patient how long they’ve had that six or the first molar root filled for, they’ll say 15 to 20 years. And you go look, that life expectancy for the tooth is coming up and you need a bridge option. Sometimes if they’re an older patient, you may need a bridge option when you’re older, you may go for an implant, but you may need a bridge leader. 

So you have to preserve the second molar tooth because the bridge option won’t be an option if it’s not there because you took it out on the whim. If you took the second molar out one day, because you were feeling it was painful and you weren’t sleeping and you just felt angry, you will lose the option of a bridge later in life.

Even if it’s like when you’re 75 or 80, you won’t even have it there. So I’m talking a lot about this with patients like, you know, look at the first molar, see what the restorative plan is into their life, and then work from there. The second molar is a good one because often second molars can’t be replaced with an implant or dentists don’t want to replace that tooth with an implant because they don’t see value. Obviously oral hygiene’s difficult in that region. All those things bone- 

[Jaz]
Higher forces.

[Omar]
High forces maxillary sinus close to ID nerve. If you’re talking about people with high ID nerves and things like that, there are problems. So I often say to patients, there won’t be many dentists who will placed an implant in this position. If you have it out, then that’s the end of that tooth forever in that position. I’m not saying it’s necessarily the main tooth because that’s your first molar and that’s what you really need, but you’ll lose that option of a bridge forever when that’s gone. That’s, that’s really important. 

[Jaz]
I like this idea of looking at the adjacent teeth and trying to talk sense and this logic that we’re talking about them, they can really apply it to themselves much better personalized care. And that’s at the crux of it. So can we just do a little quick summary of the red flags where you put your hand up and say, you know what, Palliative Endo is technically always an option in a way. Right? 

As long as you can get some sort of seal. So putting palliative endocyte in that we can actually deem this endo palliative because we can’t get you a reasonable result because, okay, well lack of two structure is one, but that doesn’t mean you can’t do palliative. You can still clear out the infection and put some sort of material there. And there’s benefit in preserving the periodontal ligament for even for the future implant. Right. 

So tell us about that retained roots actually maintain, because that was one of the questions I sent you in advance. What do you feel about retaining roots that are root filled so that in the future it’s more a timely to have a procedure or an implant in the future? 

[Omar]
Yeah, that’s a really good thing to do. I mean, if you can maintain alveolar bone, that’s going to be a good thing. It maintains the width and the height that’s important to mention is that with implants you need width. You don’t want a knife edge ridge to put an implant into. It’s just not going to happen without bone grafting. And bone grafting is another procedure, as I say to many of the patients. They know sinus lift is another procedure, bone graft, these are all procedures they’re going to make the implant more costly.

And I think most people who place implants want to place implants in the bone of the patient, not grafted bone. It’s much better, it’s better to place it in the patient’s bone. So I think retaining roots is definitely a good way to go. If you can, root burial is what some people do for those pediatric patients where it’s like you’ve got an unrestorable central, it’s been smashed by an accident or trauma or even resorption cases where you’re like, oh well it’s so resorbed, it’s not gonna be able to be restored. Then maybe root burial is something that you can do with endo or without the endo means sometimes if it’s vital you can just bury the root. 

[Jaz]
And when you’re doing that, is that something that you’ve done much of either in your training or than if it’s commonly done in private practice? One of those things, isn’t it?

[Omar]
I have done it for patients who are on bisphosphonates and not in the sense that they’re going to get an implant, but that they’re going to retain the tooth and not require an extraction. And what was really interesting about those cases was that these patients actually end up with you risk assess the patient before you recommend for extraction.

And so when I was working at the dental hospital, many patients were coming in and they’d been, previously, they had bisphosphonates, they had previous episodes of BRONJ, or Osteonecrosis. MRONJ, and the other thing is spontaneous episodes of osteonecrosis. So they might hit their lingular of the mandible with a toothbrush or even the alveolar ridge at behind the tooth retromolar region, and then all of a sudden come to you and say, I’ve got this spine of ulcer that isn’t healing. 

And you look at it and go, that’s not just an ulcer, that’s spontaneous osteonecrosis due to bisphosphonates. Those patients you need to prioritize keeping root stumps and things like that because they’re high risk of getting a osteonecrosis from removal of the tooth and complications, I would say. But if they’re taking lower level bisphosphonates, taking them for less time, haven’t had all these things, then you can sort of risk assess and say, look, if they follow the various protocols that we have for extraction, you’ll probably be okay.

So I always risk assess the patients like that when I’m talking to them. So maintaining the root stump sometimes is necessary. The other ones that come up with obviously previous radiation therapy patients, where I remember there was a patient from overseas who came and my oral surgery said, this woman needs her teeth retained. She’s got literal radiation burns from the radiation treatment that they’ve done for her. 

Head and neck will be very susceptible to damage you’re going to have to do it. So I ended up retaining those roots, it’s very hard. You end up clamping the gingiva with the rubber dam. Then you end up getting some coronal seal, which you hope is another of the seal because we all know that’s so important. But yeah, they go from there. I used to do that more, I’d say in in hospital dentistry. 

[Jaz]
That’s what I would’ve thought. Now I’ve got a similar scenario, lovely gentleman who been seeing for five years now. When I first met him, you know, he did have a oral cancer in the past. He had a radiotherapy on the side of his face and we decided together with an endodontist that, okay, it’s really important we avoid the extraction.

And so essentially he did a palliative endodontic. Okay. He managed to disinfect and a couple of canals. He managed to put some GP and the other one he put some calcium hydroxide. And what we’ve done over time, I believe he just either put some IRM or GIC. And so now it’s like a retained route with like a millimeter or two of restorative material as the seal. Now I’m just thinking about this scenario again. 

Would it be better in that stage just actually drill that coronal tooth structure until, let’s say the bone level or maybe even deeper than the bone level? Because I’ve never done a root burial myself, so I don’t know what the guidelines are to allow the blood clot and then the gingiva and everything to remodel over it. Is that how it works? Would that actually be better than actually leaving a restorative material out exposed? 

[Omar]
Well in theory it would be better to bury the root because of course if you have restorative material, then it’s very difficult to keep that clean. It’s like food impaction. We all know those cases where you’ve got root caries and things like that. And often these patients, they do have root caries. That’s why you’re doing the palliative endodonic. I mean, if it’s restorable, it’s not palliative. So what happens is you end up doing a root burial. It makes sense because by doing a root burial, then they don’t have to worry about keeping it the dentine.

[Jaz]
And so what are the guidelines? How much do you remove the tooth structure when you’re doing a root burial? Like are you going like sub crestal? I’ve never done it before, sir. 

[Omar]
You just need to go at the elbow crest and you need to be able to stretch over the gingiva, over the root fragment. I mean, this isn’t something I do, obviously being an endo, but it’s a max facts kind of oral surgery. They incised the periosteum because the periosteum keeps the gingiva stiff can’t drag it over. People who do this are very skillful at their incising, the periosteum and it’s a bit like an oral antral fistula repair kind of scenario. The same kind of idea. The gingiva comes all stretchy if you inci the periosteum.

[Jaz]
That’s what I thought, but I’m just glad you’ve done that and it’s important we mentioned that as an option for very niche patients that we can’t cover all the scenarios, but in some patients like that patient I described who’s had the history of radiotherapy, that makes a lot of sense. 

[Omar]
Here’s another one root amputation. Don’t forget about that as an option. Some patients with resorption on the mesial root of a lower six. If they need to keep that tooth for a few more years, let’s do the root canal treatment on the distal root and get the root amputated on the mesial. Like as long as it’s not if you’ve got that crack going into the distal root, then you probably it’s game over.

But what I’m saying here is, again, you have to justify the need to retain the tooth. If the patient’s that age, you don’t want them to have an implant failure, you want to juggle the tooth along. So I am recommending root amputation in a few cases, again, niche patients. 

[Jaz]
I do about one a year of root amputation. It’s very satisfying and totally has a place, and going in line with everything we’ve said quite often it’s a, yeah, a molar or even a second molar is the most recent one I did. Access can be tricky, but it’s very rewarding to do that kind of a longevity based treatment. Right. 

We were just summarizing the different causes of concern whereby you think, okay, we definitely need to go down have that consultation with the implant let’s plan that. What are the things that would make it a palliative endo rather than, okay, let’s give this a really good shot. 

[Omar]
Okay. So the obvious one is the root fracture of the split tooth, where you can basically not, you can’t restore it, the structure’s gone. The other one is I look at pericervical dentine. So pericervical dentine is what determines longevity. Again, that’s a call for the prognosis of the patient. Like if they needed to for two years, maybe that’s enough. If they need it for 25 years, then probably it’s more of a problem. 

So pericervical dentine I always encourage all dentists that I’m teaching to write a note in their radiographic report about the pericervical dentine state, as in like tooth looks, restorable, pericervical dentin is adequate, or tooth looks very heavily accessed or heavily treated. Pericervical dentine is inadequate for longevity.

Sometimes you’re saying that to patients. So percervical, dentine to me, plays a role in whether I, again, it depends on the patient’s prognosis and how long they need, but quite a lot of the time I’m going, look, it’s not really worth it because it’s so hacked up and treated previously that we’d better get on with something else. 

Again, an opinion to look at something else, but if you really want to save that tooth, I know that it’s not got a good longevity. But if you come and that gives them the opportunity from dental legal perspective, they haven’t signed up on the day they’ve gone, got your quote, got the ideas, you’ve given them an exit strategy to go on and get the implant or the replacement.

They’ve gone and done that and gone. That’s not what, not for me. I want to go back and get this tooth saved. Even though he said the longevity was not as good and dento-legally you have that in your notes it’s the consult. They went away, they got another opinion and came back and then you are all good to go, even if it’s only a short term option.

And it’s important to explain that’s why I love consults now for every patient, I rarely start treatment on the day because basically it just gives them that calling off period of going, look, I don’t want to do it, I do wanted to do it. If they’re in there on the day that the tendency is just to get there, sign up on, get going because they took the day off work, or they, you know, rearrange all their meetings or whatever they’re doing and then they go, I should have done something else.

So it gives them that cool off period just to think about it so that’s the one. So Pericervical, dentine and basically longevity and things like that? Yes. There’s not actually that many cases where I straight up recommend extraction. 

[Jaz]
The nasty crack and the lack of tooth structure is pretty much summarizes the worst from even in the resorption. It’s a lack of tooth structure problem. And we have a crack problem where you have, it looks like you have ample tooth structure, but the crack is so nasty that you know that the prognosis is not gonna be so good. And I think some of the main questions I get is, oh, can we do more podcasts about cracks and stuff? 

So can you give us some guidelines? Okay. What kind of cracks? What visual features or tactile features? You mentioned a imaging feature, which is fantastic about seeing that Pacman bite. I love that. Any other features of cracks that you can describe either clinically tactile or imaging that point towards a poor prognosis?

[Omar]
We talked about depth of the crack on the CBCT. The other one I look for is the occlusion of the patient. So they’re totally biting on this tooth all the time. The chances are this tooth is very cracked. Things like that, their habits. Because even if the tooth is cracked but not severely now if they crack it in four months, that’s not ideal because you’re looking at the occlusion history of cracks, previous restorations and what they look like. So are the composites all smashed up and ditched? And also, which teeth? 

So a great example of this, I had this really lovely youngish, she must have been like 30, maybe 32, 33 lawyer in the chair. And I looked at her teeth and they were all cracked. And I just said, you’re a stressed out lawyer lady, aren’t you? I mean, it’s just so sad. You’re young and your teeth are all cracked. Like I was treating all her cracked teeth, but she had premolars that were cracked restorations that were absolutely smashed up. And she wasn’t an old patient. So you have to look at the previous restorations whether they’re cast and they’re really smashed up. 

Because that’s a really bad sign, whether they’re direct restorations and the age of those restorations. So how long ago did you get the restoration done? Oh, like five years ago. It looks terrible. It’s like they are smashing their teeth. So again, if you are looking at cracked teeth history and prognosis, you want to consider their history of their general dental condition. 

[Jaz]
On the dental condition. Tell me if you agree or disagree with me here. When I look around, we do a scan, we get an, an image of the patient, like an overview, right? And if I see that this patient may be older in their 60s and they’ve got like lots of MOD amalgams, which like with mostly like stained cracks, which look to be in enamel, that is a better scenario than the patient who’s got tiny restorations or unrestored and got virgin cracks that for me is the more dangerous patient than the one that’s got heavily restored but smaller cracks. 

[Omar]
Correct. Yeah, that’s it. Because the restoration, I know it sounds a bit strange, but it acts like a little stress breaker in the sense that you might get a mesial or distal cracked, but you may not get an MOT crack. It’s kind of like the crack has to actually go through the entire restoration and the rest of the teeth, whereas if you have those cracks in virgin teeth, it tends to make you think the patient’s really clenching. 

You’ve cracked a virgin tooth, that’s actually quite bad. Also, the fissure pattern of the say the second molar is a problem. It’s a W shape, the cracked as fast, right through the whole tooth, and it’s closer to the TMJ. So you basically end up with that loading of the joint. But again, you look at the patient’s wear and tear on the teeth and say, look, I really think you’re smashing your teeth up. You really need to do it have a splint.

And sometimes I’m even offering them, stress therapy, like, go and read a self-help book and that person at work is annoying you and making you do this, don’t let them annoy you. Honestly, I actually talk to them about stress and say, look, I know you’re caring for someone who’s sick sometimes, and that’s going to be really hard. 

But don’t let that affect your own teeth. It’s already hard enough what you are doing to look after this ill person. But that’s not gonna help. If you have damaged your tooth and you can’t help them because you are a dentist or something like that, it’s not going to help them if you are in pain from toothache, you won’t be able to care for that person.

So really just separate the two things and work on that stress as well, because there’s always a reason why patients have pathological wear on their teeth. It’s essentially pathological wear from mental health issues to clenching, to grinding, to stress and all of those kind of things. So really, that’s a really important point, but trying to manage that stress because people say, oh, get Botox, it’s like, yeah, but that’s just putting a bandaid over the thing. 

The actual problem is the stress that from whatever the stress is try to manage that. I mean, you can’t eliminate it sometimes, but manage that stress as much as you can. And also maybe do the splint or the Botox or whatever you want to do, but like you can do something. Your health is within your own control also. It might be only 50%, 25%, but some of it’s within your own control. 

[Jaz]
Omar I’ve just popped up a nice image of a crack for us. So I’m gonna describe it for those Spotify listeners who removed the amalgam and it was like MODish, lovely, nasty stained cracks. So again, stained means bacteria is able to get inside. There’s worse a prognosis, but in terms of like there are cracks that are a bit more delicate in terms of appearance and then those that are nasty. This is very much in my books, a nasty one. Would you agree with that? 

[Omar]
Yes, I totally agree. Probably necrotic as well, isn’t it? 

[Jaz]
Yes. And so is this one, without even accessing the pulp chamber, are you thinking, okay, this is the either palliative or have that consultation and plan for implant future or you know, are you surprised sometimes by accessing into the pulp chamber and seeing actually it comes to not necessarily a halt, but it becomes not stained anymore, for example, or it kind of stops a few millimeters? Subgingival, what are you thinking there? 

[Omar]
I would say, actually in my experience, generally the crack ends up a bit worse than I was hoping. And with these kind of cases, even if it’s necrotic and it’s stained like that, if you see a crack and it’s kind of going down the route and you cannot see the absolute end of it, it’s going to be way worse than what you thought. Now that’s the problem again, you would take a CBCT and go, look, there isn’t a defect right now, or there is a defect if there is, obviously probably taking the tooth out or recommend an opinion. But if the tooth doesn’t have a defect in the bone, then you might consider something. Because I guess the best way of visualizing a crack really is use of CBCT in the bone defect. Because you can’t see beyond the orifices. You’re not going to drill all the way down that route to find out where the crack finishes. 

And if you do, it’s just removing structure, which we all know is so important for survival. So this is where CBCT is absolutely important because you know you’ve got your clinical, it goes into the pulp. Yes, I can see the crack, but does it go into the pulp and then kind of stop? Or does it just go down all the route? I tend to find that in these cases exactly like the one you’re showing. I would be hoping for it to save it and I would be, my heart would start sinking away and I’d be like, this is going to be gone.

[Jaz]
I know I’m putting you on the spot here, but as a percentage, what percentage do you think that look like? This obviously ignoring the patient inclusion roaring patient age, just appearance of the stained crack going mesial to distal. Would you say that actually we end up doing the root canal and it’s a job well done versus I go in and I’m bringing the patient back up and saying, look, I’ve addressed it, but you’re gonna have to have it.

[Omar]
I would say it probably getting towards the 20% range, not many. And again, you have had that discussion. We’ve all got this in our mind of like, how badly does this patient really need to hold this tooth? And sometimes it’s like, ah, they’d do okay with an implant. Oh, they wouldn’t do then you start going, well, I really need to hold onto this tooth. And it provided all the other red flags on with the periodontal defect and stuff. 

You would try and save that tooth and you’d justify it in your notes and say, look, the patient is not going to be a good candidate for implants or maybe has had implants that have failed it’s another one. It’s a first molar, we really need to hold that tooth that’s so important for this person and they’ve had implant failure, so I’m going for it. 

You can do that, you can say like, that’s the reason why I’m gonna totally go and do this. And, and as long as they’re on board with that, I can’t see anything wrong with trying to do that, as I said. But you do have to have the not split down the middle and the periodontal defect there because then it’s going to work against you. 

[Jaz]
I picked a nasty one for you, so those who are listening maybe want to catch the visuals on the app to see the image and almost talking points there. I guess, I mean, I had so many questions, but in the interest of time, I’m gonna just say, I think something that’s really important to mention here is the whole thing about success versus survival. Can you explain to dentists, remind us about success versus survival and then what is the data implants versus and onto treatments when we look at those characteristics of success and survival? 

[Omar]
Well, it’s an interesting point and my colleague that I work with in Crows Nest now, she’s done a few talks and I liked her talk, so she went through it with me and she brought up some interesting points that I didn’t bring up before. So success and survival. So successes very much endodonic healing of the apical lesion. But it has been in the research modified with a whole lot of few ways. Like some people even don’t quite classify them the same way. So some of those people call retaining the tooth success, but that’s not success. Success in how I understand it and Endodonic is essentially healing of the apical disease radiographically or on a CBCT imaging success. 

And that’s the traditional way of looking at it. Survival is just the tooth is there, and so the implants are assessed on survival generally, there is a success criteria with implants, but it’s quite loose compared to the success of root canal treatments. Because root canal treatment success is actually pretty reasonably hard to get. I mean, especially if you use CBCT, first of all, we need a patient who’s gonna heal. Second of all, we obviously need to do the endo really well. And third of all, we need the time to elapse for the patient to heal, whatever that time is.

Many studies say within five years, but there is research showing that it takes 20 years for the root canal lesion or the endodonic lesion to heal Molven’s study. So there are those cases, and so what I’m trying to say here really is that success and endo can be often difficult to achieve. So as I’ve got more experience as a clinician, I’ve more got away from worrying about the little dark area, although I’m trying to heal that. It’s one of those things I want to do both, of course, I want to do both. I want the patient to have the tooth that’s their benchmark of success, it’s survival in my book. 

But I also want the lesion to heal because we wanna show pretty cases in their lectures now. We want to just make sure that the patient’s happy and everything’s going planned. It’s beautiful and that makes us feel good for the day. Because at the end of the day, it’s all about patients feeling good and ourselves as well. But like basically aiming for success as the first point is often a difficult one to satisfy because of the time it takes to heal or the difficulties of the treatment.

So then I default back to like survival. A lot of the times say, look, all the criteria that came up a number of years ago was called asymptomatic and functional. And I liked that kind of terminology because it gives us a nice way to segue and we’re keeping the tooth there. Because of this, we need to keep the tooth there. It doesn’t matter if the lesion takes 3-4 years to heal. It’s going to heal it might heal. 

It might take a long time to heal we know that from research, but what I’m trying to say here really is that it’s really important to start with the focus of keeping the tooth. And if the patient’s not in pain and you’ve kept the tooth, then that is a good, you’ve accomplished something quite good for the patient.

Asymptomatic and functional, I like that because if you talk about survival, you’re saying, well they could have a draining sinus tract surviving. It’s like, yeah, it sort of isn’t what we’re going for here. Or they could be every now and again, I have to take antibiotics because it swells up that’s survival but that’s not what we’re looking for. Yeah. We want the patient to go on holiday and not be worried about the tooth. That’s the way I look at it. We want them to go. 

[Jaz]
That’s very real world metric. 

[Omar]
Yeah. I want the patient to go on holiday and not be sitting there worrying about whether their tooth might be bothering them and they have to go to a dentist and take antibiotics because that’s what they’re doing. If they’re having to–

[Jaz]
Always on holiday Omar, always on holiday. 

[Omar]
If they’re having to do something in their life to keep themselves out of pain or stop the swelling, or that’s not asymptomatic and functional. because survival criteria would say asymptomatic and functional says the tooth is still there and the tooth is not bothering them at all, so I like that criteria. 

[Jaz]
I love that as well. I love, I’m going to write that down. Asymptomatic and functional, I think is a really real world way of looking at it. 

[Omar]
Yeah. Yeah. I like that. And so implants, again, when I was just talking to you about implant implants, a lot of the research is done on survival of implants. And the problem with that is, first of all, implants are placed often by experts in the field. Whereas endodonic often done by dental students, dentists anyone who’s in the study. Then the other thing is, implants just aren’t placed in people who are gonna be high risk for losing the implant. If you’ve had five implant failures, they’re not going to use you in a study for the sixth implant.

Whereas root canal treatment is a go-to whenever there’s a problem. I mean, like in institute split, all those things we talked about. So you’re going to get a bias towards implants looking better. Because first of all, the criteria of survival is basically the only criteria. I mean, there’s a successful criteria, but it changes. With endo, it is harder to get, say, success than asymptomatic and functional. 

And then survival again with endo is easier because it could be a sinus tract and all that stuff. So basically if you look at them head to head, they have a very similar survival rate. I think the last time I looked at this was quite a while ago, and it was a King’s college study, Shannon Patel, he was doing single visit endo with a one year follow up. 

I believe there’s been more research on that paper. And he was showing that his success rates for root canal treatment on an incisor teeth was high, like in the sort of a hundred percent sort of level. But as you got towards the back of the mouth, it was dropping to around 75%. And then implants, if you look at them, they’re the same. We were looking at obviously success of Endo and a CBCT one year later. A small sample size, it’s is practice cases for a year. And then if you look at survival of implants, that’s in the sort of similar kind of level. 

[Jaz]
They’re both similar, then it just makes sense that it goes back to the very first point you made, right? If endo is on the table, it’s feasible because it’s got enough tooth structure and the crack is not so nasty. And even if it’s looking a bit dubious, then there is still so much to be gained by getting some survival and allowing the patient to have an implant later on in life. 

Then first up, and one thing that we actually didn’t elaborate on, but the whole thing about using retained roots and doing endos on them to keep them in the mouth, we sometimes forget because what we think is, oh, let’s take out this retained root, then do a socket graft, but actually just work with that retained root ’cause.
If they’re basically going to walk around with nothing there anyway, then you might as well do a retained root and then keep that PDL, keep everything, keep the bone preserved there rather than putting artificial bone or whatever for the future. But again, I’m the implant dentist, i’m not the person for that. But Omar, thanks for the brilliant overview today. We covered a lot of ground, a lot of different topics, from root burial to successful versus survival to different characteristics, red flags. Is there anything else that you would like to leave us with before I ask how we can follow you? How we can learn more from. 

[Omar]
So I’ve got Instagram and Facebook @specialistendo on Instagram and Facebook’s Specialist Endo Crows Nest clinical hacks. I’ve been doing this teaching online for, wow, it’s been over like 12, 13 years now and it’s been so fun. We are running courses in Sydney this year. I’ve got one in Melbourne. I’m hoping to come to the UK soon and at what some point, and we are looking at doing a bit of lecturing maybe in Taiwan later in the year. So that’s going to be super exciting. 

So we’ve got lots of things planned for this year. The other thing is just new breaking news for me, is that I’m now opening my own educational based dental practice with the kind of concept of creating a facility where specialists work there like me and my colleagues, and we provide opportunities for people to come and observe cases. With a set up with screens. And also there’s a facility for educational courses within that same practice. So that’s something really exciting that I’ve just come up with in the last amazing few months.

And like the idea is to create like a dental hub where people come learn and even if you’ve had a bad day at work. Come in and talk to me about your bad day at work and we’ll have a coffee and discuss why it was a bad day and ’cause that’s what I would’ve wanted when I graduated. I would’ve wanted someone that would, would take me aside and go, look, it gets better. 

And all those discussions that you can have with your younger dentists or even older dentists who are having a bad day, it doesn’t matter. So basically, that’s the exciting news for me. And so thanks so much for having me. It’s been really great to talk to you again. Our previous discussion about, I believe it was files and all those interesting things– 

[Jaz]
Being more efficient in Endo. Thank you so much for your time Omar, I’m honestly an absolute superstar in everything you do, and you’re a Mr. Motivator man. You literally are a Mr. Motivator. I think, I love talking to people like you who, we talk about the clinical, we geek out, but you bring the world and life experience and philosophy into it, which I’m always a big fan of that. I’ll put all the links for Omar programs and his Instagram account and his Facebook page as well. 

And as soon as you have something they can give me about any UK visit or any other links I can put on. People always ask me, where’s the link for this? And I’d love to put it all in the show notes. So please do send me that, Omar. And I’d love to distribute to all the producer from us. Thank you so much for covering these varied themes. I had a lot of fun. 

[Omar]
Thanks Jaz for having me and have a good day. 

Jaz’s Outro:
Well there we have it. Guys, thanks so much for listening all the way to the end. I wonder if it means now I need to record the same episode with an implant dentist. Do you think that would be necessary? You know, I don’t know because. All the implant dentists I respect, would probably agree with 80 to 90% of what me and Omar were saying in this episode.

And to get a dentist to agree 80 to 90% with another dentist, that’s a pretty good thing right. Of course in this episode, there was some bias because it’s an endodontist we’re talking to. They live and breathe endo and saving teeth. But the message is a good one. As restorative dentists, first and foremost, we preserve vitality. And if that’s not possible, we preserve the tooth and the PDL for as long as possible. And if that’s not possible, we want good survival and success of our implants, and ultimately we want the patient to win. And that is at the crux of healthcare, my friends. 

Now, if you’re listening on Spotify, apple, etc, please do hit that subscribe button and share it to your WhatsApp group, share it to your colleagues. If you found it interesting, we’ve got hundreds of episodes in the backlog. If you’re just discovering protrusive, where the hell have you been, welcome. And of course, join the Protrusive app, www.protrusive.app. 

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Thank you to thousands of dentists who have joined us on protrusive guidance. It is so beautiful, the community you’ve created. And with that, I’m going to say goodbye. I’ll catch you same time, same place next week. Bye for now.