Seeking validation

The need for validation is a complex interplay of social, psychological, and emotional factors. Validation serves as a mirror reflecting our worth and competence, helping to build self-esteem and confidence by affirming that we are valued and respected. This is especially relevant to endodontists who often seek validation for our treatment philosophies, technology, and protocols.

Negotiating complex root canal anatomy and achieving high levels of disinfection are among the most challenging aspects of performing endodontics. To address these challenges, we have incorporated various technologies designed to activate chemical solutions. These technologies include sonic, ultrasonic, multisonic, and laser activation using different wavelengths and protocols.

Validation of these technologies and protocols is often empirical, relying primarily on research conducted with extracted teeth featuring artificially created biofilm, which lack complications associated with treating patients. Caution must be exercised when applying this data to patient scenarios. Moreover, many endodontists frequently modify or adjust manufacturers’ protocols, rendering the original data less valid.

We no longer perform bacterial testing to validate protocols. The culturing technique is no longer performed due to its arduous nature and the time-consuming process involved in identifying microorganisms. DNA-based identification methods such as polymerase chain reaction (PCR) are expensive and prone to high false-positive readings due to the detection of DNA from dead bacterial cells. However, there is much interest and excitement surrounding the recently introduced rapid, inexpensive, chairside adenosine triphosphate (ATP) assay test (Endocator™) for identifying viable bacteria in the root canal.

ATP, the primary energy source for cellular functions, serves as an indicator of metabolic activity in viable cells and degrades rapidly; thus, any detectable ATP indicates recent viability. The test is highly sensitive and capable of detecting small variations in root canal contamination, identifying bacterial levels below 10 culturable bacteria. Additionally, ATP high/low findings correlate with culture positive/negative results. The Endocator™ reader measures bioluminescence emitted when ATP is reduced to AMP in the presence of oxygen and the enzyme luciferase. The device converts the detected light intensity into a score ranging from 0 to 100.

In essence, the test scores can validate (or invalidate) the endodontic protocol used. Elevated scores can be mitigated by modifying or reapplying the activation protocol and chemical irrigant used. Using the Endocator™ to assess the laser-assisted Radial Apical Cleansing protocol (Biolase and EdgePro®) showed its high effectiveness in root canal disinfection, with scores usually between 0-5. Higher scores were often lowered by repeating the disinfection phase. After testing over 200 cases in patients, it was determined that NaOCl concentration, laser energy per pulse, laser tip diameter, and duration of activation are important factors in achieving low ATP scores, indicating high levels of disinfection.

The addition of this highly sensitive ATP assay test will play a pivotal role validating endodontic protocols, providing accurate data on their efficacy as well as readiness of canal systems for obturation.