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Interview: “Dentists therefore have a key role in connecting manufacturers with patients”

Discover the insights about the latest trends in endodontics, the role of AI and other technologies, and the importance of dentist-manufacturer relationship.
Dr Dobrina Mollova, Dental Tribune MEA

Dr Dobrina Mollova, Dental Tribune MEA

Sun. 2 April 2023


Prof. Gianluca Gambarini is head of endodontics and restorative dentistry at the Sapienza University of Rome in Italy and director of the postgraduate master’s programme in endodontics. During the 2023 International Dental Show (IDS), which was held from 14 to 18 March, Dr Dobrina Mollova of Dental Tribune Middle East & Africa spoke with him about his reasons for attending the event, the use of artificial intelligence (AI) and other technologies in endodontics, and the dentist–manufacturer relationship.

What has brought you to the largest dental trade show in the world and this 40th edition celebrating 100 years of IDS?

Well, there are many reasons. One is professional. This is a show that many manufacturers attend to reveal their newest developments and techniques, so it’s a very important event  for improving your professional knowledge. In that way, I see this fair both from the commercial side and from the education side. Dentists can learn about and see what’s new and what they could implement in their practices, maybe not today or tomorrow but in a few weeks or months.

Apart from this, since I’m an educator and professor, I need to keep up to date. Being a researcher, I need to meet manufacturers. This is the opportune place to establish relationships between researchers and industry, which is a win–win situation, since they both benefit from one another, both overall trying  to improve the quality of treatment—endodontic treatment in my case.

What is your first impression of the show after four years?

It’s nice to see so many people, so many dentists, so many manufacturers coming to IDS after the pandemic. If we want to create a better future, we should never forget the past. I don’t know what people will think about  this pandemia  in 50 years, but at least we survived, we’re here at IDS and we’re happily talking today about dentistry and the future.

You are a consultant in the development of new technologies, surgical procedures and materials for endodontics and hold patents for the endodontic technologies you have developed. What is your relationship to Henry Schein?

We do research at university and so have a friendly relationship with many manufacturers because they trust us as a well-known research group that is very fair and precise in evaluation and innovative in developing test methodologies. Moreover, Henry Schein is the biggest group in dentistry, so I am very proud to work with the company and genuinely help develop new products because we are trying to support dentists in clinical practice to ease their work.

Endodontics is a difficult discipline, so manufacturers’ support is very meaningful for dentists, especially if we can make operative procedures more user-friendly and a little bit faster. The patient will benefit too because the dentist will be more confident and the therapy shorter and less complicated, translating to less chair time.

As a dentist, I’m curious to hear your opinion on whether scientists control manufacturers or the other way around.

Manufacturers have to listen to their customers, that is, dentists, and likewise dentists have to listen to their patients. Typically, manufacturers do not deal with patients directly. Dentists therefore have a key role in connecting manufacturers with patients and in balancing the different needs. I thus think that no one party has precedence over another, but that they all need to cooperate.

What is important about the relationship between manufacturer and dentist?

Being conservative overall, dentists aren’t typically willing to change their products or techniques, especially if they feel confident with them. The manufacturer therefore has to provide dentists a good reason to change to the product. One of the simplest reasons could be cost. Offering the same quality at a lower cost has proven to be a winning strategy. Some dentists may fear that a new product would make their work a little bit more complicated, because using it would involve changing their routine. Since they usually think that the products they are currently using work fine, they will want to know what added value the manufacturer is offering them.

I can say though, because I’m also giving hands-on practical courses, that this tends to apply to dentists who have been practising for quite a long time. Young people are more willing to try new things and to experiment. They have a different approach, living in a society that is much faster paced and rapidly changing. It’s important for manufacturers to respect both viewpoints.

Obviously, some technologies have a greater clinical impact than others. Some innovations are related to a marketing choice, since dentists may claim to be updated merely by having a very new device in their office. On the contrary, some technologies are truly improving the dentists’ work .

What is next in endodontic treatment? What is the future?

In my opinion, we should try first of all to simplify because this is the future. In the long term, maybe there will be some help from AI, mainly in diagnosis and treatment plan. In the short or medium term, we have to improve traditional instrumentation, irrigation and obturation techniques to make them simpler and more predictable.

Globally, an increasing number of people, specifically in India and China and elsewhere in Asia, will need access to endodontic therapy in future years. This overall higher cost for the global community will probably require a reduced cost for some of the operative techniques.

In Europe, for example, at least 60% of people have at least one root canal therapy, so it’s a very common treatment. If you multiply this figure for a country like India, where there are so many people, you will see that there’s a lot of room for treatments in the future. We also have to take into account the social costs of this and try not only to simplify, reduce time but also to reduce the cost.

You mean that you are dedicated to simplifying endodontic treatment, to lowering the costs and to reaching communities who have financial and other barriers to access?

Yes, because we are doctors and so our main goal is to maintain people’s health. I truly believe that saving a tooth offers a lot of advantage in terms of functionality and aesthetics, and being an endodontist, I try to save teeth. Obviously, I know that sometimes it’s easier or even better to extract a tooth for many reasons, but for the majority of cases and for reasons of global social costs, it’s way more cost-effective to save teeth.

We have to try save teeth, but we need to do so in a more predictable way. Let’s say that we have a 10% failure rate. If we have ten patients, for example, that is one failure, which doesn’t seem so bad, but translate that to 100,000 patients—that’s a huge number of failures! The greater the number of dentists performing endodontics, the greater the need for a more reliable and predictable technique in order to manage failures and improve outcomes. Luckily, in endo, the survival rate of the tooth is quite high, the outcome is quite positive and the therapy is well accepted by patients.

Yes, the need for endodontic treatment is growing in many places, but don’t the financial costs make it impossible for patients?

Since you come from Bulgaria, you know that the cost of therapy differs greatly throughout Europe, up to five- or tenfold, even though the instruments and technologies cost the same in every country more or less. If you think about the costs of other products, for example phones, televisions and cars, they are similar in all the countries, varying a little because of the VAT in some countries.

What do you think about the assertion by some that extraction followed by implant treatment should be favoured over endodontic therapy?

I think that this was more common 20 years ago; nowadays, dentists are reconsidering this and putting themselves in their patients’ shoes. The patient will prefer to retain the tooth because, while an implant will work, it’s a little bit more difficult to maintain or there may be more periodontal problems. I teach my students that usually we should treat the patient like we would if we were the patient—if you think that in your mouth you would extract the tooth, then extract, and if you think that in your mouth you would save the tooth, then try save it. Acting like this means being a very honest dentist, thinking about the health and comfort of the patient rather than money. This is what should drive your therapy and your approach to dentistry.

What benefits is technology now offering endodontics?

Let’s say that you have a 90% success rate as a dentist. A new technology that could improve this by 1%, but costs quite a lot of money would have poor cost-effectiveness. If you have a therapy that has a 50% success rate and a new technology could bring it up to 80% or 90%, you would spend the money to acquire that technology.

So it depends on the true benefit the technology provides in this specific field, such as in terms of outcome and number of treatments, because if you save time you can do more treatments. From a manufacturing point of view, producing a technology that has a lot of benefits is a winning strategy; no matter the cost, you can promote it more easily.

What do you think about AI’s current position in dentistry, and what is to come?

The use of AI will have an interesting role in dentistry. AI really gives us some standards for diagnosis and treatment in the clinic, but in life there is nothing that is always good and nothing that is always bad. AI will set a certain standard and thereby support the treatment plan. For example, an AI program will indicate the possibility of saving the respective tooth. Acting against that information will have consequences for the clinician and the patient. Some people don’t like this, because they think it will reduce the autonomy of the clinician, but I see it differently. I’m not saying that we must trust the machine totally, but that the machine should give us some guidance in our decision. The decision will still be made by the dentist and the patient together, like it is nowadays, but with more support. In endo 100 years ago, there were no radiographs to support us. Now we have the support of CBCT. While it’s a significant improvement on radiographs, it’s still a supporting technology because the CBCT doesn’t decide on or perform the treatment.

Another interesting AI application is robotic dentistry, where machines and technology perform the therapy. I don’t think that this will happen in endo in the next 15 or 20 years because endo is so complicated and so micro. It would be too complex to create an endo robotic technology. However, other disciplines in dentistry may benefit from robotics, like in medicine at the moment.

You were one of the first endodontists globally to use CBCT routinely in your practice. What about today?

I had a lot of criticism at that time of my routine use of CBCT, particularly regarding radiation exposure and the necessity of taking a CBCT scan. I really learned a lot though in that I realised that, although I already knew a lot about endodontics generally, the visualisation provided by CBCT yielded important discoveries. I’d like to explain this with an example. I teach my students that there may be three canals in one root in 2% of cases, but this general knowledge is not important at all in a specific case, which might have one, two or three canals in that root. The patient doesn’t really take any interest in how knowledgeable you are. She only wants her teeth to be treated properly so that the pain can resolve. For this, the most important thing is to locate all the canals, so it’s very beneficial to have a tool to help do this.

The risk can be kept relative following the ALARA concept. According to guidelines, we have to use a CBCT scan in complicated cases, but in endo, every case can be complicated—but you only know this afterwards. I prefer to know beforehand, since it makes my work easier and probably is better for my patient. That is why I’m strongly in favour of this technology.

To use CBCT well, you need to use it routinely, because otherwise you may not see small but important details. In the future, AI will probably be able not only to show the image, but also to at least point out the anatomical details of the root canal system from the very beginning.

What are the concerns regarding dynamic navigation systems in endodontic microsurgery?

We published the very first article on endodontic surgery with dynamic navigation. It’s a costly technology, and you have to be very careful to precisely match the files to the root canal spaces to avoid mistakes. Compare the dimensions of an implant and the dimensions of a nickel–titanium file and consider that an implant is inserted axially after preparation with large drills. For an implant, a precision of 0.02 mm is great, but in endo, it would mean a file that is incorrect by one, two or three sizes, depending on the case.

Every technology has some benefits for its field of application. We believe in this so that’s why we work on developing technologies, and we have a dynamic navigation system at the university. While I like technology, of course, I always try to be very correct in my judgement. Really everything has some benefits and some disadvantages. As a dentist, you should know the disadvantages better than the advantages because then you’ll be able to protect yourself and do things in a proper way. Sometimes dentists are too enthusiastic and only see the advantages.

Do you think that only specialists should perform endodontic treatment?

Generally, what will happen in future is that more general dentists will go to endodontics because the community will ask for more endodontic treatment. So that’s why I told you we need the technology to treat cases more easily and faster.

Obviously, the specialist will still be needed, but endodontics is unique in being the only specialty with retreatment as a subspecialty. Perhaps in endo, we are a little bit more critical and so we created retreatment as a discipline.

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