L E A D I N G T H E W O R L D T O O P T I M A L O R A L H E A LT H

White Paper on Endodontic Care

Ove A. Peters and Gerhard K. Seeberger

www.fdiworlddental.org
Table of contents
Executive summary 1

Section 1 Definitions, Scope and Relevance of Endodontics and Endodontic Health 2

What is endodontics? 2
Aetiology and disease: why do we perform endodontic treatment? 2
Importance of end Endodontic treatment and prevention of disease/trauma odontic
health for general health and epidemiology 3
Endodontic treatment and prevention of disease/trauma 4

Section 2 The Challenges of Endodontics and Maintaining Health 8

What are the overarching outcomes of endodontic care? 8
What are the specific challenges to achieving and maintaining optimal endodontic outcomes?
9

Section 3 Improving Endodontic Care and Outcomes 12

Potential solutions for achieving and maintaining optimal endodontic outcomes 12
Call to action 14

Acknowledgements 15

References 16

The White Paper on Endodontic Care was made possible through an unrestricted educational grant from:
Executive summary
This white paper summarizes the main issues Section 2 addresses the current challenges faced
currently affecting the provision of endodontic care. in providing endodontic care and maintaining
It provides a reference and tool for dentists, national health. Most quality criteria and treatment outcome
dental associations and other oral health actors, measures have historically focused on technical
outlining what endodontics is, why it is important goals and clinical symptoms after treatment. The
and what can be done to improve endodontic development of more patient-centred outcomes,
outcomes and health. such as those focused on teeth retention, quality of
life, and overall health, can ensure that endodontic
The first section outlines the scope of endodontics, care addresses and is measured against a broader
describing the aetiology of endodontic conditions spectrum of health outcomes as valued by the
and how changes to the pulp and periapical tissue patient (Section 2.1). Beyond measurement, a
determine current endodontic diagnoses (Sections range of contextual challenges exist to achieving
1.1 and 1.2). It then discusses why endodontic and maintaining these outcomes. They include
conditions are important and addresses the challenges related to health systems, regulation of
prevalence and burden of endodontic disease. oral health care, dental education, the availability of
Untreated endodontic conditions can have a resources, and patient perceptions of endodontic
significant impact on quality of life, particularly procedures (Section 2.3).
through craniofacial pain, the inability to chew,
and disturbed sleep. The potential connections The third section of this white paper builds on
between endodontic disease and overall health, the challenges identified and discusses ways
and their implications for the importance of in which they could be tackled to improve
endodontic care, are also considered (Section 1.3). and maintain endodontic health. While the
Section 1 concludes with an overview of endodontic appropriate strategies to work towards this goal
prevention and treatment. The measures that can vary considerably according to national context,
be taken inside and outside the dental practice to some general principles and possible solutions
prevent pulpal and periapical disease are discussed, are discussed (Section 3.1). The paper concludes
followed by a summary of endodontic procedures with a call to action, inciting stakeholders to work
to treat disease when it manifests, including their towards the accessibility and provision of optimal
indications and objectives. While this summary endodontic care and improved endodontic health
describes the scope of endodontic treatment worldwide (Section 3.2).
from regenerative and reparative procedures to
surgical endodontics, the standard of endodontic
care varies worldwide according to a variety of
contextual factors, as discussed at the end of this
section (Section 1.4).

White Paper on Endodontic Care www.fdiworlddental.org 1

Section 1 Definitions, Scope and Relevance of
Endodontics and Endodontic Health

1.1 What is endodontics? 1.2 Aetiology and disease: why do

According to the glossary of the American
we perform endodontic treatment
Association of Endodontists1, endodontic therapy
The first line of defence in endodontic therapy
relates to “the aetiology, diagnosis, prevention and
is prevention of dental decay. This recognizes
treatment of diseases and injuries of the pulp and
that dental caries and its associated microbiota,
associated periradicular conditions”. According
if not removed before pulpal disease becomes
to Ørstavik and Pitt Ford2, the biological aim of
irreversible3,9, lead to changes in pulpal
endodontic therapy is to “either prevent or cure
microcirculation. Consequently, the process may
apical periodontitis”. The most frequent cause of
become unstoppable, as the local absence of
pulpal and periapical disease is deep dental decay
blood supply allows further and deeper entry of
(caries)3; however, dento-alveolar trauma and
pathogens into the root canal system. Predominantly
certain periodontal conditions and their respective
gram (-) flora and their cell wall components,
sequelae may also lead to endodontic disease.
e.g. lipopolysaccharides or LPS, then drive periapical
The scope of endodontic treatment includes
bone resorption, and apical periodontitis is
regenerative procedures and dental traumatology
ultimately established2,10. This process may occur
to prevent microbial entry and subsequent host
with or without clinical symptoms, both at the
defence effects. Importantly, it is vital pulp therapy,
pulpal and the periapical disease stage, due to the
an occasionally overlooked area of endodontic
on-going, but variable, level of interplay between
treatment, that is likely to address patient needs on
irritants and host defence10.
a global scale. This should include screening for
pulpal status as a routine diagnostic step.
Dental trauma may, in the case of deep crown
fractures, give oral microorganisms direct access
Endodontic societies and textbooks suggest certain
to the pulp space. In case of luxation-type injuries,
quality criteria and competencies4,5. Historically,
the blood supply is compromised or lost at the level
these criteria have focused on technical goals, such
of entry into the pulp and, subsequently, the dental
as the appropriate working lengths, effectiveness
pulp becomes necrotic. When secondarily infected,
of irrigation, and root canal filling quality; in most
this avascular pulp space is also associated with
cases, these criteria apply to a best-case scenario
apical periodontitis.
where both patients and providers have access to
unlimited resources. In contrast, basic root canal
Pulpal changes are often detected indirectly via
treatment (BRT) has been described as effective and
patients’ responses to thermal or electric stimuli,
comparable to standard endodontic treatment6,7.
while changes in periapical bone are visible only in
radiographs. The diagnostic efficacy of conventional
Primary clinical goals of eliminating pain and
pulp testing is about 80% or higher11; however, the
infection notwithstanding, the long-term goal of
inability to detect asymptomatic cases of pulpal
endodontic treatment is the preservation of a natural
disease and the lack of correlation between
dentition, including oral function and oral health.
disease severity and test outcomes are significant
Consequently, endodontic health may be defined
shortcomings of current pulp tests.
as the absence of any clinical and sub-clinical
symptoms, while retaining all dental functions
Periapical changes may be detected via pain on
required for oral health8.
percussion or palpation, while changes in bone

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mineralization are historically visualized in periapical It is important to note that these current diagnostic
radiographs. More recently, cone beam tomography terms, while of superior utility in the current dental
has been introduced into endodontic practice in practice model, focus primarily on local conditions
some countries12. While this technology can detect and do not include any oral health terminology. In
three-dimensional bone content, and therefore is this regard, current concepts address a patient’s
more accurate in showing apical changes, it does condition along the triad of disease, illness and
not determine the degree of inflammation and sickness15 and should in the future address potential
infection and requires sequential imaging to assess and actual connections between endodontic
healing trends. conditions and oral and overall health16,17. They also
have other shortcomings, such as lacking a clear
Through determining pulpal and periapical definition of what biologically separates reversible
conditions, typical endodontic diagnoses are from irreversible pulpitis.
developed in the clinical setting. The current and
widely-adopted terminology was established at
the AAE Consensus Conference in 200913,14 and 1.3 Importance of endodontic
is used unaltered today1. As indicated in Table 1,
an endodontic diagnosis in the current system is
health for general health
a dual diagnosis, with a description of pulpal and and epidemiology
apical conditions, respectively. Treatment modalities
have been developed to address acute and chronic About 4 billion people were, in 2013, reportedly
disease conditions. afflicted with oral diseases, with untreated caries
accounting for 35% of the cases and more than
TABLE 1 Current diagnostic terms describing 65% of the individuals18. The high prevalence and
pulpal and periapical diseases the recurrent nature of dental caries, as well as
periodontal disease, result in direct annual costs of
Sinus US$102 billion in the United States alone19 and an
Diagnosis Sensitivity Pain Radiolucency
tract estimated US$300 billion worldwide20. Moreover,
there is growing inequality in oral health between
Healthy pulp yes no no no
and within countries21-23.
Reversible
yes yes/no no no
pulpitis Pulpal disease is frequent, with estimates of the
Irreversible
proportion of people affected ranging from 16.4%24
yes yes/no no no to more than 30%25; however, irreversible pulpitis
pulpitis
may not be painful, and therefore undetected,
Condensing
yes no radiopacity no in up to 40% of cases26. For people who receive
osteitis
regular dental care, emergency visits for endodontic
Necrosis no no no no treatment appear to be relatively low, with an
incidence of 5–14%27. On the other hand, the overall
Symptomatic
apical no yes yes/no no burden of often asymptomatic apical periodontitis is
periodontitis believed to affect 40–50% of individuals, increasing
with age and the number of root canal-treated
Asymptomatic
apical no no yes no
teeth28. As dental caries is highly prevalent in
periodontitis developing countries with access to sugary food, the
estimated need for dental treatment of pulpal pain is
Acute apical
no yes yes/no no also high and often results in extractions. No current
abscess
figures are available regarding worldwide needs for
Chronic apical
no no yes yes/no
endodontic treatment due to trauma, but it has been
abscess estimated to affect up to 1 billion people29.
Adapted from 'Arens DE, Gluskin AH, Peters CI, Peters OA. Practical lessons in
endodontic treatment. Chicago: Quintessence Publishing; 2009.'

White Paper on Endodontic Care www.fdiworlddental.org 3

The impact of unmet endodontic treatment needs that diseases of the pulp and periapical tissues are
on Quality of Life (QoL) is obvious and substantial, occurring in a larger context – within the human
specifically when QoL is impacted by craniofacial body. On this matter, there are known systemic
pain and the inability to sleep. Liu and colleagues30 diseases and conditions, such as diabetes or
estimate that patients requiring more extensive systemic immunosuppression, that harm endodontic
endodontic care are more likely to have poorer outcomes and can result in specific endodontic
oral health-related QoL, with endodontic treatment entities, such as acute abscesses, that reduce
leading to improved QoL30,31. In those studies, overall health.
QoL is measured by versions of the Oral Health
Impact Profile (OHIP), which assesses self-reported
dysfunction, discomfort, and disability. 1.4 Endodontic treatment and
Endodontic disease is distinctly different from
prevention of disease/trauma
“focal infection”32,33. The focal infection theory
Prevention of pulpal and periapical disease
held that bacteria concealed in portions of a
addresses their most common causes, which are
treated root canal system could somehow escape
dental caries and trauma. Primary and secondary
and lodge in distal organs, causing, for example,
prevention of dental caries are required to stop
arthritis and diseases of the kidney, heart, nervous,
progression to the pulp and onset of pulpal disease.
gastrointestinal, endocrine and other organ systems.
Population-level approaches, such as community
It was believed, but never proven, that the extraction
water fluoridation and sugar-reduction policies, as
of root canal-treated teeth would heal systemic
well as individual-level interventions in the clinic,
diseases. The focal infection theory, as the basis for
are needed to advance primary dental caries
wholesale tooth extraction, was widely discredited
prevention38,39. Clinical measures include nutrition
in the 1950s with the advent of controlled laboratory
and hydration counselling, oral hygiene education,
and clinical studies in endodontology. Moreover, it
and professionally applied gels, varnishes and
became clear that the removal of teeth or tonsils,
sealants. Even when dental caries manifests in a
which were also suggested as a potential source of
patient, secondary prevention measures can arrest
harmful bacteria, did not eliminate diseases that had
and regress the process, preventing its progression
been thought to be caused by focal infection.
to the pulp and the need for endodontic treatment.
Many of the strategies for primary prevention
On the other hand, possible connections between
are applicable to secondary prevention if dental
oral disease and overall health have been
caries is diagnosed early and lesion activity is
increasingly studied in the last two decades.
adequately assessed3,40.
In periodontics, there have been reports of
associations between active periodontal
Improving the safety of the environment is the most
inflammation and significant health problems,
important aspect of oral trauma prevention. Policies
such as cardiovascular disease. Recent studies
to improve road safety, reduce violence in the
have shown the relationship between tooth loss,
home and school, and increase the use of adequate
the associated lacking masticatory function, and
helmets, facemasks and mouth guards in certain
the development of different types of cancer and
sports are good examples of ways in which oral
mental disease34-37. Conversely, research shows
trauma can be prevented39.
that chewing may help improve cognitive function
and be beneficial to Parkinson’s disease patients37.
1.4.1 Scope of treatment: Regenerative/reparative
It must be mentioned that association and a cause-
procedures
and-effect relationship are systematically different,
and the latter has not yet been demonstrated.
Vital pulp therapy offers significant benefits if
Nevertheless, it has been suggested, similar to
microorganisms’ access to the pulp is limited in
the term “periodontal medicine”, to establish
amount, virulence, and time41. Conversely, when the
“endodontic medicine”, accounting for the fact

4 www.fdiworlddental.org White Paper on Endodontic Care

pulp is necrotic, regenerative procedures may be avenues of endodontic treatment aimed to retain or
selected to treat periapical disease and manage repair a functional pulp.
root growth. The following table illustrates principal

TABLE 2 Retention or repair of a functional pulp

Pulp capping Pulpotomy apexogenesis Guided pulpal repair

Indications Deep carious lesions near viable Coronal pulp sections are Immature teeth with necrotic
pulp (indirect pulp capping) irreversibly inflamed or infected, pulps in which additional growth
or pulp exposure through and preservation of pulp vitality in root wall thickness and length
non-infected dentine (direct is desired is desired
pulp capping)

Objective Protect vital pulp from additional As a definitive procedure, maintain Promote healing of apical
injury and allow healing and repair the vitality of the radicular periodontitis and retain a
pulp when the coronal pulp is functional dentition, ideally restore
exposed or diseased, or alleviate structure, including dentin and
symptoms of pulpal disease as an root wall, as well as cells of the
interim procedure pulp-dentin complex

Main procedure Removal of caries from the Surgical removal of the coronal Canal debridement and
tooth and treatment of the pulp and capping of the radicular disinfection, eliciting of apical
remaining dentine or application pulp at the appropriate level bleeding with ingress of stem
of biocompatible material on the cells and mediators as well as
exposed pulp formation of scaffold to promote
continued hard tissue formation in
the canal space

1.4.2 Scope of treatment: Non-surgical root therapy is required to retain the affected tooth. The
canal treatment extent of the therapy is dependent on the level of
progression and vitality of the pulp. The table below
If dental caries progresses to affect the pulp beyond illustrates the principal treatment spectrum in root
the point of possible repair, non-surgical endodontic canal treatment.

TABLE 3 Removal of diseased pulp

Apexification Root canal treatment Root canal retreatment

Indications Teeth with immature root Irreversible pulpitis or necrotic Continued periradicular disease
development and a necrotic pulp, pulp, cracked or fractured teeth or symptoms due to failure of a
in which an apical hard tissue with significant pulpal involvement, previous root canal treatment
barrier is desired or as elective treatment

Objective Management of cases with Eliminate pulpal and periradicular Eliminate pulpal and periradicular
wide root canals and immature disease, and promote healing of disease, and promote healing of
apical foramina that require root the periradicular tissue the periradicular tissue
canal treatment

Main procedure Canal debridement and long- Mechanical debridement of the Removal of existing canal filling
term disinfection with medication, canal system, followed by shaping, material, complete mechanical
allowing for hard tissue deposition irrigation, and filling debridement of the canal system,
or placement of apical plug with followed by shaping, irrigation,
biocompatible material and filling

White Paper on Endodontic Care www.fdiworlddental.org 5

1.4.3 Scope of treatment: Surgical endodontics further damage. Dental trauma often requires
endodontic treatment to resolve or prevent pulpal or
Some presentations of pulpal and periapical disease periapical disease. The treatment given will depend
cannot be treated using non-surgical interventions on the type of injury. The following table illustrates
and require surgery to alleviate pathosis and prevent examples of surgical endodontic treatment.

TABLE 4 Endodontic surgery and treatment of the traumatized dentition

Incision and Apical surgery Resective therapy Treatment of

drainage/ traumatized teeth
trephination

Indications Accumulation of fluid in Periradicular disease Periradicular disease or Traumatic events, such
soft or hard tissues that that cannot be root defects that cannot as crown/root fractures,
cannot be accessed addressed through be treated with root luxations and avulsions
through the root canal root canal therapy or canal therapy or apical and alveolar fractures
endodontic retreatment, surgery, periodontal
or overextension of a defects, or crown and
root filling vertical root fractures

Objective Reduce fluctuant Treat pathosis in Alleviate periradicular Successfully reposition

swelling of soft tissue, the radicular pulp disease or canal and/ a tooth that has been
promote repair of and periradicular or coronal defects; displaced from its socket,
affected tissue, and tissue and prevent alleviate signs and achieving re-attachment
prevent damage to teeth further progression symptoms of crown and/ of periodontal ligament
and other structures or root fracture fibres to retain
function; promote
root development in
immature teeth

Main procedure Opening of the soft or Removal of diseased Surgical removal of one Pulpal management,
hard tissue to remove periapical tissue, or more roots, or one or repositioning and
accumulated fluid, using resection and retrograde more roots and a portion splinting as appropriate;
a drain if necessary filling of root sections of the crown, of a multi- use of conditioning
that cannot be treated rooted tooth media and medications
through root canal and to include follow-up
therapy, or intentional
replantation of teeth
that cannot be treated
with conventional
endodontic surgery

1.4.4 Potential contraindications for 1.4.5 Standard of treatment: a response to global

endodontic treatment quality needs

Lack of patient compliance, insufficient periodontal The standard of endodontic treatment depends
support, impossibility of a functional long-term on a multitude of criteria, such as being sensitive
restoration, and a severely compromised patient to the operator, the patient, technique, technology,
medical history are potential contraindications for and the working environment. Endodontic societies
endodontic treatment. However, the large majority and health ministries of different countries have
of the national or regional guidelines do not contain drawn-up treatment guidelines, many of them being
any restrictions for endodontic therapy5,42. Prosthetic technique- and technology-oriented and sometimes
or implant/prosthetic rehabilitation options exist for not revised in a timely manner. The treatment
“hopeless teeth” but the utility of that approach has benefits of the latest technology and techniques,
also been questioned43,44. which often require high investment costs and

6 www.fdiworlddental.org White Paper on Endodontic Care

are found in high-end practice settings, may not better compensated, but less effective, procedures
be essential when considering the outcomes of also goes against the standard of professional
basic root canal treatment (BRT), a technique ethics45. The only essential standard criteria to be
based on simple instrumentation, tactile working applied worldwide should be the best achievable
length determination, and the independence of quality of care and the guarantee of patient
an electrical power supply, which can be easily safety46. The keys to ensuring these minimum
performed in the most remote settings. standards are adequate undergraduate education
and lifelong learning. Any definition of treatment
As discussed below, fee-for-service schemes are not standards should go hand in hand with a standard
a reliable way of remunerating the treatment options of prevention47.
with the best outcomes for patient health. Favouring

White Paper on Endodontic Care www.fdiworlddental.org 7

Section 2 The Challenges of Endodontics and
Maintaining Health
of significant exacerbations over the long term is
2.1 What are the overarching comparatively low, being around 5%58.
outcomes of endodontic care?
When root canal treatment is followed by
In early disease stages, the main treatment goal appropriate restorative treatment, long-term teeth
is to retain a vital and functional pulp. This can retention rates of 80–90% after 10 or more years of
be achieved with high likelihood, depending on function have been reported for root canal-treated
diagnosis and operative strategies48-50. teeth59-62. However, it is important to consider that
vital teeth have a better long-term retention rate
As discussed before, root canal therapy has been than root canal-treated ones59, suggesting the
defined as treating or preventing apical periodontitis. potential for vital pulp therapy to enhance overall
Consequently, outcomes of root canal treatments endodontic outcomes9.
have historically been described primarily in relation
to apical conditions (as judged from radiographs) On the other hand, apical periodontitis remains a
and clinical symptoms after treatment. Using this prevalent health issue63, with the current definition
paradigm and criteria of varying stringency, the of endodontic medicine considering potential effects
prognosis of root canal treatment was found to vary of systemic diseases on the outcome of root canal
greatly among all included studies in a systematic treatment16. However, much is still to be learned
review by Friedman, with 46–91% of cases healed51. about the relationship between persistent apical
inflammation and overall health52.
More recently, the variable “retention” has gained
attention in relation to root canal treatment. Indeed, While there is no evidence that persistent apical
Kvist52 has argued that the need to save teeth is periodontitis directly causes, for example, coronary
a significant challenge going forward due to an heart disease, it may be argued that a strategy
increase in populations being affected by dental preventing microorganisms from establishing
caries. The variable “retention” is an example of themselves deep in the root canal system would
patient-centred outcomes53-55 that are now being be advantageous64. This approach would call for
used to describe the efficacy of endodontic therapy. a renewed focus on pulpal diagnosis and early
intervention to retain pulp vitality48.
In essence, endodontic therapy, when seen from a
patient’s perspective, has the following goals: Patient-centred outcomes, most notably
i. to cure or prevent pain, measurements of oral health8 and related quality
ii. to retain the function of the affected tooth over of life, are served by the endodontic treatment
the long-term, and spectrum, from vital pulp therapy to apical surgery.
iii. to prevent negative consequences to
overall health. Endodontic therapy that is driven by patient-centred
outcomes focuses on the absence of symptoms,
Root canal treatment is often initiated when dental retained oral function, and limited impact on overall
caries has led to pulpal disease and pain56, and the health. This kind of endodontic therapy is an
treatment is typically very effective in eliminating example of a multifaceted approach to oral health.
pain in a short timeframe57. Moreover, the likelihood

8 www.fdiworlddental.org White Paper on Endodontic Care

2.2 What are the specific a challenge. The reasons for political neglect are
complex but well-recognized challenges include
challenges to achieving a failure to coordinate multisectoral action to
and maintaining optimal implement population-level prevention approaches,
disconnect between oral health and general
endodontic outcomes? health, including in the measurement of the oral
disease burden, and a lack of political leadership
Despite the global importance of endodontic
and civil society activism39,65,66. In addition, neglect
health, there are many barriers to achieving and
of oral health within health systems and public
maintaining optimal endodontic outcomes. These
health strategies is typically coupled with low
barriers exist at multiple levels, ranging from national
financing, resulting in inadequate reimbursement
policy to the dental practice, and concern diverse
and remuneration of endodontic procedures as
sectors, including health system organization and
discussed below.
financing, dental education, and the dental industry.
Challenges vary considerably by country, and
2.2.2 Reimbursement and remuneration
potential strategies and solutions for addressing
them, as discussed below, must be appropriate
In many countries, particularly in low-resource
within the national context. National dental
settings, the dental procedures covered by health
associations (NDAs), governments, and other actors
authorities or insurers are limited, resulting in
have independence and primacy in determining the
foregone treatment and inequitable access67,68.
strategies and policies to pursue improved care and
Evidence from several high-income countries
oral health in their countries.
similarly suggests that out-of-pocket payments
and public health insurance programmes with
To identify and better understand the challenges
restricted eligibility and limited benefit packages
related to achieving optimal endodontic care,
act as barriers to dental treatment, particularly
FDI conducted a survey and Political, Economic,
for low-income populations69-73. Of the NDAs who
Social, Technological, Environmental and Legal
responded to the FDI survey, nearly half reported
(PESTEL) survey exercise among its member NDAs
lack of reimbursement of endodontic procedures as
and national endodontic societies. The exercise is
a challenge to providing optimal endodontic care.
used to identify the major challenges and potential
In many instances, endodontic treatment is subject
solutions to a given problem across several domains
to partial or no reimbursement and is available only
and rank their relative importance. In total, 63 NDAs
to those who have access to insurance or who can
and endodontic societies completed the exercise
afford out-of-pocket payments. Depending on the
from all five FDI regions. The sub-sections below
system, financial aid for endodontic treatment may
outline the major challenges identified through the
only be available for very low-income groups or
exercise and in the published literature.
children. Several countries, including both high-
and low-income countries, reported that patients
2.2.1 Political commitment and
opt to have teeth extracted rather than undergo
financing challenges
endodontic treatment due to high costs.
A lack of political commitment to oral health and
Surveys of dentists in several countries have also
an absence of policies to strengthen oral disease
revealed insufficient remuneration to be a commonly
prevention and care provision can act as barriers
cited reason for non-compliance with endodontic
to optimal endodontic care. While the importance
treatment standards74-76. Dentists may opt to extract
of oral health on the political agenda varied among
teeth rather than perform endodontic restoration if
the countries responding to the NDA survey,
remuneration for endodontic treatment is perceived
many indicated that the lack of national oral
to be too low40,77. Root canal treatments by National
health policies, or low importance being placed
Health Service dentists in the UK fell by over 45%,
on oral health in national health policies, presents
with extractions increasing in parallel, following

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remuneration changes in 200678,79. Remuneration They should also address the increasing demand for
systems also have implications for the prevention of care, varying levels of access to care, and existing
pulpal disease, with only a few systems adequately self-care skills18,85,86.
incentivizing preventive practice40. Twenty percent
of NDAs in the FDI survey reported that low 2.2.4 Availability of materials and technology
remuneration levels, particularly in view of the time
taken to complete endodontic procedures, were a In some countries, dental equipment may be
barrier to optimal care. unavailable or unmaintained due to a lack of means,
technical expertise, or infrastructure6,87. A lack of
2.2.3 Challenges related to the patient and society adequate training in using new technologies and a
lack of decision-making power by dentists regarding
Patient perceptions of endodontic treatment can the technologies and materials purchased in some
result in avoidance of treatment and difficulties health systems can also act as barriers75,88. One-
in carrying out procedures. Fear of visiting the third of the NDAs reported availability of equipment
dentist may cause patients to delay dental visits as a challenge in the FDI survey. Several countries
until their problems are severe80,81. Several in Africa, Asia, and Latin America reported low
studies have suggested that root canal treatment availability of endodontic equipment in their dental
provokes particularly strong dental anxiety due practices, particularly in rural areas. The cost of
to the expectation of pain during and after the equipment, such as surgical microscopes, was also
procedure82-84. Over 20% of NDAs identified cited by several countries, regardless of income
negative patient perceptions, especially related level, as a challenge to providing optimal care in
to the perceived complexity and painfulness of all clinics.
endodontic procedures, as an important problem.
2.2.5 Dental education and
Patient awareness and knowledge of oral health and endodontic specialization
endodontics were also frequently cited by surveyed
NDAs as barriers to optimal care. Over 40% of The quality of undergraduate education, including
NDAs reported that some patients in their country the time dedicated to endodontics, teaching and
forego endodontic treatment because they do not assessment methods, and availability of staff with
consider oral health or the preservation of their specialization or a specific interest in endodontics,
natural dentition to be important health concerns. varies across countries and regions and has a clear
Similarly, NDAs reported a lack of patient awareness impact on the subsequent quality of care provided
about the goals and outcomes of endodontic by graduates87,89-92. The evolution of undergraduate
procedures; in certain countries, patients believed curricula also means that dentists who graduated
extractions and implants to be the only solutions for years ago may be less likely to adhere to current
painful teeth. standards of care77,93,94. Access to continuing
education, including time to pursue courses and
Low-income countries frequently cited patient the availability of courses with high-quality content
awareness and knowledge as a factor in the and methods, is important for dentists to maintain
extraction of treatable teeth, and many countries up-to-date knowledge of endodontic procedures
also cited differences between wealthy and poor, or and technologies88,95,96. Similarly, undergraduate
urban and rural, populations in this respect. and continuing education for preventive practice
is still lacking in many areas, with curricula focused
As with all areas of dentistry, demographic and on restorative dentistry40. In the FDI survey, limited
societal change present further challenges procedures being taught at the undergraduate level
to providing endodontic care. An increase in and limited to no availability of specialist courses
population ageing worldwide requires new models were identified as challenges by many NDAs in
of oral care, which should focus on the physical low- and middle-income countries. In high-income
needs of the elderly as well as their personal values. countries, the most commonly cited challenge

10 www.fdiworlddental.org White Paper on Endodontic Care

was the lack of availability of suitable patients for that allow malpractice litigation against dentists,
students to treat. such as the US system, may encourage referral of
more complex cases to specialists. On the other
A lack of access to appropriate dental care in some hand, systems that prioritize open investigation of
health systems or geographic areas can result in malpractice claims over financial compensation
lower- quality care. General dentists may treat cases may promote learning from errors and continued
beyond their competency if no specialist is available improvement of care standards73,101,102. The FDI
for referral, or long waiting times for specialist care survey revealed diverse systems for monitoring
can result in increased extraction as tooth condition adherence to standards of treatment and dealing
deteriorates73,97-99. In some low-income countries, with malpractice claims, including integration into
poor access to any kind of dental care, which is law, regulation by dental associations or other
often limited and clustered in urban areas, seriously non-governmental bodies, and non-existence of
compromises endodontic health100. formal regulations or malpractice procedures. Some
countries reported that malpractice procedures
2.2.6 Regulation and legal challenges might encourage referral, but this was not
widespread. Insurance to protect practitioners from
The regulation of endodontic care and malpractice the cost of malpractice payments is also common in
systems vary significantly across countries. Systems several countries.

White Paper on Endodontic Care www.fdiworlddental.org 11

Section 3 Improving Endodontic Care
and Outcomes
and epidemiological changes. The availability
3.1 Potential solutions for of qualified practitioners could be improved by
achieving and maintaining optimal emphasizing less learning-intensive, i.e. less
complicated, procedures, such as some forms of
endodontic outcomes vital pulp therapy.
From a biomedical and population health
ƒƒ New ways of collaborating within the dental
perspective, a focus on prevention, in this case
team and new types of oral health professionals
prevention of pulpal disease and prevention of
may offer solutions to inadequate access to care.
bacterial presence deep in the root canal system,
For example, the UK Department of Health’s
has been suggested as a strategy103-105. Vital pulp
Dentists with Special Interest programme
therapy is currently discouraged, as explored
allowed general dentists to gain additional
throughout this paper; however, changes to health
skills in specific areas without undertaking a
systems and education can address this.
full specialization, including the provision of
more complicated endodontic procedures in
3.1.1 Health Care Systems and Financing
the primary care setting. Dentists aware of, or
involved in, the programme expressed positive
ƒƒ Ideally, health care financing should strive to
opinions of its ability to improve patient care109-
provide universal oral health care coverage, 111
. Similar programmes exist that reallocate
including endodontic care, to the population
tasks within the dental team or empower non-
concerned. Different models of universal
dentist oral health professionals to provide
coverage exist, including systems based on
preventive care22,40,112. Some believe that fewer,
taxation or multiple third-party payers. The
not more, specialists would be better able
important commonalities are financial risk
to provide health services to the population,
protection and the provision of quality essential
especially if case managers were to have an
services106. Systems offering universal coverage
expanded role22.
also require adequate funding to ensure they
can respond to the care needs of the population,
3.1.2 Clinical Practice of Endodontics
fairly reimburse dentists for quality treatment,
and allow patients to access treatment in a
ƒƒ Vital pulp therapy in its various forms41 is
timely manner107,108. Moreover, fee-for-service
expected to become an attractive alternative to
models may wrongly incentivize clinicians to
root canal treatment, even in cases diagnosed
select treatments that are pricier but not more
with what is now called “irreversible” pulpitis.
effective, for example root canal treatment over
The long-term cumulative success rate of
pulpotomy for adolescents.
vital pulp therapy in treating such cases is
compellingly good48, in particular in younger
ƒƒ Health system planning should consider the
patient groups49. Without a doubt, improvement
availability of practitioners who are able to carry
in vital pulp therapy outcomes will be driven
out endodontic treatment. Population needs
by further development of diagnostic and
vary between countries, but planners should
clinical technology50.
consider evidence regarding patient access
to appropriate practitioners, the availability of
ƒƒ Basic root canal treatment (BRT) uses tactile
specialist care for referral from general dentists
working length determination to allow root canal
when required, and anticipated demographic

12 www.fdiworlddental.org White Paper on Endodontic Care

 treatment to be undertaken in the absence of ƒƒ Efforts to improve access to continuing
x-ray equipment or electric power supply. The education by reducing time pressures on
technique has shown promising results for dentists and making courses more affordable
incisors and premolars in a real-world setting, may also be important to ensure that dentists
and therefore offers a viable alternative to stay up to date with procedural developments
extraction in under-resourced settings where and new technologies114.
traditional root canal treatment is not possible6,113.
3.1.4 Adapting Endodontic Care Outcomes
ƒƒ Certain specialist-level treatment, such as
microscopic apical surgery, tomography derived ƒƒ The adoption of patient-centred outcomes in
3D treatment planning, and dentoalveolar treatment guidelines and reimbursement models
surgery should be accessible if the case can help ensure that endodontic care responds
requires it. adequately to patient needs and contributes
more fully and sustainably to patient health.
3.1.3 Dental Education Patient-centred outcomes can also play an
important role in guiding the development of
ƒƒ Dental education needs to provide adequate new treatment and diagnostic procedures and
training in endodontic procedures for both technologies. As described earlier in this white
general dentists and endodontic specialists. In paper, patient-centred endodontic treatment
undergraduate dental curricula, this includes implicates prevention and early intervention to
an appropriate number of hours dedicated to improve tooth retention and reduce symptoms.
endodontics, effective training methods, and It should also consider potential connections
access to specialist endodontists or educators between endodontic and systemic health.
with a special interest in endodontics.
ƒƒ FDI is currently working to develop an oral health
ƒƒ Hands-on training and mock-clinical settings measurement tool, providing a standard set of
have been effective in improving procedure measures that incorporates patient perspectives
quality and in adopting new technologies at both into the assessment of oral health outcomes8.
the undergraduate and continuing education This set can be adapted and used by a variety
level91,95. Together with revised curricula, of stakeholders, including health care authorities
improved funding and job flexibility to increase and payers, to better integrate patient-centred
the number of clinically-focused endodontic outcomes into endodontic care models.
educators in universities may also help improve
the capabilities of newly qualified dentists89,90,92. 3.1.5 Treatment Standards and Competencies

ƒƒ With regards to prevention in the dental practice, ƒƒ Guidelines on endodontic treatment procedures
a shift in dental curricula is required to promote and care are important resources for formal
preventive dentistry over restorative dentistry40. education and for ongoing guidance for
This should cover primary prevention, such as practicing dentists. A number of national and
the provision of, or referral to, tobacco cessation international endodontic associations publish
services, nutrition counselling, reduction of guidelines, which describe treatment standards
alcohol intake, promotion of fluoride products, and provide general dentists with guidance for
and application of dental sealants86. As stated case difficulty assessment and referral4,5,42.
before, the very same approach may be
extended to endodontic therapy, where retaining ƒƒ Several tools for case difficulty assessment
a vital pulp for as long as feasible appears to and referral decision-making exist to assist the
offer benefits to the patient. general practitioner; these need to address the
full spectrum of endodontic therapy. Methods

White Paper on Endodontic Care www.fdiworlddental.org 13

 to facilitate implementation in the dental clinic, profession, should constantly evaluate fee-for-
including a short screening questionnaire to service systems to incentivize treatments that
assess the need for further evaluation, and are most likely to improve population health. This
integration into a mobile app, have been applied is closely linked with outcome assessment and
to such tools115,116. This would allow practitioners educational conditions.
to treat cases that are more realistically within
their ability, reducing obstacles to providing In endodontics, prioritizing periapical health as the
adequate care75. outcome does not appear to address the needs
of an ageing population for functional long-term
ƒƒ Accordingly, a chairside guide published as an teeth retention. Researchers and professional
accompaniment to this white paper will provide bodies should adapt outcome assessment
general dentists with guidance on providing models that consider patient-centred variables
endodontic care, including the implementation of and oral health outcome measures for use in
relevant solutions as identified in this paper. endodontics and push for their adoption in care
and preventive measures. This includes a focus on
3.1.6 Awareness Raising and Advocacy vital pulp therapy. Such models could then be tied
to remuneration and would likely result in a more
ƒƒ Communications to dispel myths related to diverse treatment spectrum to routinely include
endodontic treatment are needed. It is a myth various regenerative procedures.
among patients that endodontic treatment is a
painful and complicated procedure; it is a myth Education of dental specialists comes with a
among dentists that patient acceptance is, or significant cost and limits access to care. Health
should be, a barrier to rubber dam use. Public authorities and educators should prioritize care
awareness campaigns are specifically needed in models with a focus on preventing pulpal disease
the era of widely accessible and unmoderated - this may include dental auxiliaries to manage
information on digital media. patients. Conversely, wider access to education
is needed to improve the quality of endodontic
ƒƒ NDAs and other non-governmental organizations care delivery.
(NGOs), including FDI, have an important role
to play in advocating for the changes proposed Finally, political neglect of oral health and failures
in this paper and obtaining more attention and to adequately implement population-level health
funding for policies to improve oral health. promotion measures, including age-adapted patient/
Better evidence of the oral disease burden public literacy campaigns and awareness-raising for
and of programmes and policies that improve oral and general health, impact endodontic health
oral disease prevention, quality care, and oral and broader oral health. Governments should
health promotion can help reinforce these accord adequate attention and funding to oral
advocacy messages. health, including the coordination of multisectoral,
population-level approaches to prevent dental
caries and other oral diseases.
3.2 Call to Action
Ongoing advocacy by NDAs and other relevant
Key issues identified in endodontic care should be organizations is required to increase the attention
addressed on multiple levels, such as remuneration and funding given to oral health; advocacy efforts
systems, outcome assessment, and educational can be supported by research emphasizing the
strategy. First, health authorities and third-party oral disease burden and effective interventions to
payers, in strong and constant collaboration improve oral health.
with the representatives of the oral health

14 www.fdiworlddental.org White Paper on Endodontic Care

Acknowledgements
FDI would like to thank Professor Paul Dummer and Dr Unni Kunjukrishna Pillai for their valuable
contributions to this white paper. FDI would also like to recognize the following NDAs, endodontics societies,
and other organizations for their participation in the survey, which informed part of this work:

ƒƒ Academia Brasileira de Odontologia ƒƒ Guam Dental Society

ƒƒ Academy of Dentistry International ƒƒ Hong Kong Dental Association
ƒƒ Albanian Dental Association ƒƒ Hungarian Dental Association/Hungarian
ƒƒ American Dental Association Association of Endodontists
ƒƒ Asociación Dental Mexicana Federación ƒƒ Indonesian Dental Association/Indonesian
Nacional de Colegios de Cirujanos Endodontic Society
Dentistas, A.C. ƒƒ Iran-German Implant Association
ƒƒ Asociación Mexicana de Endodoncia, Colegio de ƒƒ Irish Dental Association
Especialistas en Endodoncia, A.C. ƒƒ Israel Dental Association/Israeli
ƒƒ Asociación Nicaragüense de Endodoncia Endodontic Society
ƒƒ Association Dentaire Française ƒƒ Lebanese Dental Association
ƒƒ Association Marocaine de Prévention ƒƒ Macau Dental Association
Bucco-Dentaire ƒƒ Malaysian Dental Association
ƒƒ Association Rwandaise des Chirurgiens- ƒƒ Mauritius Dental Association
Dentistes et Stomatologues ƒƒ Myanmar Dental Association
ƒƒ Associazione Italiana Odontoiatri ƒƒ Nepal Dental Association
ƒƒ Bahamas Dental Association ƒƒ New Zealand Dental Association
ƒƒ Bangladesh Dental Society ƒƒ Ordre Nationale des Chirurgiens-Dentistes de la
ƒƒ Botswana Dental Association République Démocratique du Congo
ƒƒ British Endodontic Society ƒƒ Pakistan Dental Association/Aga Khan University
ƒƒ Cambodian Dental Association ƒƒ Polskie Towarzystwo Stomatologiczne
ƒƒ Circulo de Odontologos del Paraguay/Sociedad ƒƒ The Royal Dutch Dental Association
Paraguaya de Endodoncia ƒƒ Singapore Dental Association
ƒƒ Colegio de Cirujanos Dentistas de Costa Rica ƒƒ Slovenian Dental Association
ƒƒ Colegio de Cirujanos Dentistas de Honduras ƒƒ Sociedade Portuguesa de Estomatologia e
ƒƒ Colegio Estomatológico de Guatemala Medicina Dentária
ƒƒ Consejo General de Dentistas de España ƒƒ Société de Médecine Dentaire (Belgium)
ƒƒ Cyprus Dental Association ƒƒ Sri Lanka Dental Association
ƒƒ Czech Dental Chamber ƒƒ Stomatological (Dental) Association of the
ƒƒ Dental Association of Bosnia & Herzegovina Kyrgyz Republic
ƒƒ Dental Association of Malta ƒƒ Swedish Dental Association
ƒƒ Dental Association of Seychelles ƒƒ Swiss Dental Association SSO
ƒƒ Dental Section of the Hungarian ƒƒ Syndicat Tunisien des Médecins Dentistes de
Medical Chamber Libre Pratique
ƒƒ Egyptian Dental Association ƒƒ Tanzania Dental Association
ƒƒ Egyptian Dental Syndicate ƒƒ The Dental Association of Thailand
ƒƒ Federación Odontologica Colombiana ƒƒ The South African Dental Association
ƒƒ Finnish Dental Association ƒƒ Vanuatu Dental Association
ƒƒ Ghana Dental Association

White Paper on Endodontic Care www.fdiworlddental.org 15

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