Education versus Marketing in Endodontics

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Education versus Marketing in Endodontics

Postby BarryMusikant on Sat Jul 11, 2015 12:25 pm

Given the large number of endodontic systems that are available for  instrumentation and obturation, I am interested in the impact of both education and marketing on the decisions dentists make in what systems they are going to use. Endodontic education gives us information based on the accurate description of pulpal morphology, the various types of disease that can affect pulpal tissue, the impact of instrumentation and obturation systems that have been employed to remove this tissue and seal the canal environment off from the rest of the body. In light of the research that documents the strengths and weaknesses of the techniques used to instrument and obturate canals, reappraisal of presently used techniques as well as an open mind for newer and potentially safer and more effective procedures should be an active part of the educational process. Marketing may use components of education. However, the goal is not to inform, but to sell. With sales the goal, negative aspects of any given system will be underplayed or ignored altogether. The challenge for the dentist and the student is to know if we are being primarily marketed to or being educated.

The challenge of differentiating between the two is compounded when marketing is done under the auspices of traditional education institutions: namely, dental schools. By definition what we learn in school is defined as an education, one we pay dearly for. Furthermore, components of endodontic education, such as histology and pathology do not lead to the purchase of products eliminating marketing as a factor in these aspects of the educational process. Where education leads to the purchase of product, the educational process is the single most critical factor in what the student/dentist will decide to buy and where education morphs into marketing. Examples of marketing include the exclusivity of a school teaching one system, a focus on a particular brand to a student body that does not know a variety of alternatives exist with specific steps taken to minimize that knowledge. Exclusivity is further maintained by a selection of research studies that reinforce what is being taught. For example, many schools teach greater tapered rotary NiTi instrumentation whether employed in a continuous or interrupted fashion, but don’t discuss the data that documents the production of dentinal defects and the weakening of the roots induced by the use of these systems. As educators, the positive and negative impact of systems on the tooth structure would be part of the discussion. As marketers, however, the educational process is compromised with an emphasis on the positive for the purpose of directing the future dentists to make the “correct” purchase.

A proper education calls for an increased understanding of the compatibility between attaining the stated goals of maximum cleansing, followed by as thorough a seal as possible with the least loss of tooth structure and the least damaging impact on the remaining tooth structure. Education should not have the emphasis on the system used, but on the impact of a system on the teeth being treated. It should be an understanding of the impact of the systems on the integrity of the remaining tooth structure that determines what are the safest and most effective systems.

From my perspective, a glaring departure from making the tooth the center of attention is the documented incidences of instrument breakage when using greater tapered rotary systems. Instrument separation has led to techniques that require the excess removal of tooth structure that weakens the root. Education should direct us to systems that are not prone to separation and do not require removing extra tooth structure as a safety measure for the instruments. Marketing, on the other hand, incorporates these steps as part of a “disciplined” approach accepting the loss of tooth structure as a necessary part of the technique. In short, critical review is not brought up when the thrust of the response to the problem is adaptation to the instruments’ weaknesses rather than developing systems that are safer for the tooth.

Once marketing takes hold to emphasize the modifications in techniques that must be incorporated to reduce the incidence of separation, the dentist has been convinced to use systems that he/she knows are vulnerable to breakage and will follow a protocol that is safest for the instrument with considerations for the tooth of secondary importance. We don’t think of it this way, but that is the end result. As a result of this “educational conditioning”, the dentist learns that greater tapered rotary systems are most safely used when they stay centered imparting their conical shape to the canals. The shortcoming of this approach is that most canals are not conical. Rather they often have an oval isthmus-like configuration with a thin mesio-distal width and broad buccal and lingual extensions. Not only are the dentists using greater tapered shaping that takes too much tooth structure away in the mesio-distal plane, but they are reluctant to use these instruments vigorously in the wider bucco-lingual plane. Research has shown that the lack of bucco-lingual cleansing is compounded by the impaction of debris laterally into the isthmuses of highly oval canals when greater tapered rotary instruments are used.

The inability to cleanse in the bucco-lingual plane is an obvious disadvantage. Education brings this limitation clearly into vision. Marketing ignores the bucco-lingual plane emphasizing the conical shaping done in the mesio-distal plane disregarding the micro-cracks and weaker roots that result from greater tapered preparations. What is emphasized without scientific support is the superiority of conical shaping in the mesio-distal plane, a marketed look without evidence to support it.

Another aspect of marketing are claims that are wholly made up, but defy common sense, something that should be encouraged in education, but eradicated where the schools must market what they teach. Let’s consider irrigation. We already know that greater tapered shaping superimposes conical shaping while impacting debris into the buccal and lingual isthmuses of highly oval canals. Where the space created in the roots is close to the exact dimensions of the instrument being employed, little room is left for irrigants. We know irrigation digests tissue chemically that has not been mechanically removed. For this to happen we need an effective volume, something that is not possible during the instrument procedure when using instruments that create a duplicate of their own shape. On the other hand, 02 tapered relieved reamers confined to a 30-45º arc of motion are virtually invulnerable to breakage, can be used vigorously against the buccal and lingual extensions resulting in a space that is broad bucco-lingually and quite thin mesio-distally resulting in the preservation of tooth structure in the mesio-distal plane and the removal of more tissue in the bucco-lingual plane. However, once an instrument has the ability to create a space greater than itself, it works more and more in an environment flooded with irrigants. This advantage is further enhanced when the shaping instrument is in the 30-45º reciprocating handpiece oscillating at 3000-4000 cycles per minute activating the irrigants for greater effectiveness.

The use of 30-45º reciprocation oscillating at 3000-4000 cycles per minute does not represent the approach that the major manufacturers market. As a result, despite the fact that it solves most of the problems associated with greater tapered rotary instrumentation, it is not marketed as a solution. Rather 30-45º reciprocation is ignored by the major manufacturers and their spokesmen because it will lead to diminished sales. This would not be possible without the cooperation of the universities. That is, however, a subject for another discussion, but does touch on the impact of corporate money on our educational processes, most obvious where the end of the “educational” process ends in the purchase of tools and equipment.

Regards, Barry
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