Join our endodontic course for dentists. Hands-on training with online tips to enhance your skills in root canal treatments.

Enhance your skills with our comprehensive endodontic training course. Learn the latest techniques and best practices through hands-on experience and online resources.

Fluoride gets more shouting than almost anything else in dentistry. Half the internet says it's poison. The other half says skip it and you're basically asking for dentures by 40. Neither is true, and the actual story is much less dramatic than either side wants it to be. Here's what fluoride is really doing. Your enamel is mostly a mineral called hydroxyapatite. Every day, acid from the bacteria in plaque nibbles away at it — that's demineralisation. Your saliva pushes minerals back in — that's remineralisation. It's a tug of war that happens constantly, whether you notice it or not. Fluoride doesn't stop the acid attacks. It changes what gets rebuilt. Enamel that remineralises with fluoride present forms fluorapatite instead of plain hydroxyapatite, and fluorapatite is genuinely more acid-resistant. Same tooth, tougher finish. That's it. That's the mechanism. No mystery, no conspiracy. Where the argument comes from Most of the fear traces back to two things: dosage confusion and old research on very high-fluoride water areas, mostly abroad, with levels nowhere near what's in UK water or toothpaste. At the concentrations actually used here — around 1,450 ppm in adult toothpaste — the evidence for benefit is strong and the evidence for harm just isn't there. The one real, well-documented risk is fluorosis, and that's a cosmetic issue in developing teeth from swallowing too much toothpaste as a young child, not a systemic health risk. It's also entirely avoidable. What I actually tell patients Adults: pea-sized amount, 1,450 ppm, twice a day, don't rinse afterwards. Rinsing washes away the whole point of putting it there. Children under 3: smear, not a pea. Supervise brushing so they're not swallowing it. Children 3–6: pea-sized, supervised, same rule about not rinsing. If your water supply is already fluoridated, you don't need extra fluoride supplements or fluoride mouthwash on top — more isn't better here, it just raises fluorosis risk in kids for no added benefit. And the fluoride-free crowd? Some of you will still choose fluoride-free toothpaste, for your own reasons, and that's your call to make. If you do, the trade-off is real: you're relying entirely on brushing mechanics and diet to protect your enamel, with none of the chemical backup. Hydroxyapatite toothpastes are a legitimate alternative with their own evidence base, not snake oil — but for most people, most of the time, standard fluoride toothpaste at the right concentration, used correctly, is still the simplest way to keep your teeth ahead in that daily tug of war. Just bloody brush. Fluoride just makes the brushing count for more. Related reading: Sugar: It's Not the Amount. It's the Frequency. | Why Your Gums Bleed When You Brush. And What It Actually Means.

Internal resorption is the diagnosis that punishes complacency. You're looking at a symptomless tooth, maybe a slightly odd radiolucency on a routine bitewing, and the temptation is to file it under "watch and review." That's exactly how it gets missed until the crown's gone translucent-pink and you're explaining to the patient why their tooth is suddenly a different colour. What's actually happening Internal resorption starts inside the pulp chamber or canal, not on the root surface. Chronic pulpal inflammation — usually from trauma, a deep restoration, or a low-grade pulpitis that never fully declared itself — activates clastic cells inside the canal wall. They eat away dentine from the inside out, and if the process breaks through to the periodontal ligament before you catch it, you've lost the tooth's structural integrity from a direction you can't easily reach or predict. Why it's easy to miss The tooth is often asymptomatic for a long time. There's frequently a history of trauma years earlier that the patient has forgotten to mention because they don't connect it to a tooth that currently feels fine. And on a single periapical, internal resorption can look deceptively like external resorption or even a normal canal outline, depending on the angle. The tell on the radiograph This is the bit worth drilling into your own habits: take a second periapical at a different horizontal angle before you commit to a diagnosis. Internal resorption stays centred on the canal and appears to travel with the root outline as you shift the angle, because it's genuinely inside it. External resorption, by contrast, appears to shift position relative to the canal as the angle changes, because it's sitting on the surface, off-axis. That parallax difference is the single most reliable chairside distinguishing feature, and it costs you one extra film. CBCT earns its place here more than almost anywhere else in endo. If you've got any doubt after two angled periapicals, or if the lesion looks large enough that perforation is a real possibility, get a small-volume CBCT before you commit to a treatment plan. It tells you whether the lesion is contained within the canal wall or has already perforated — which changes everything about prognosis and whether root canal treatment alone will resolve it. Treatment reality If it's caught early and hasn't perforated, conventional RCT with warm vertical obturation to fully obturate the irregular internal defect gives a genuinely good prognosis — the resorptive process stops once the pulp is removed and the space is sealed. If it's perforated, you're into MTA or bioceramic repair territory, sometimes combined with surgical access depending on the perforation site, and the prognosis drops accordingly. This is the point where "have a low threshold to refer" isn't a throwaway line — a perforated internal resorption managed well early is a saveable tooth; managed late, it often isn't. The practical takeaway Any symptomless pink-tinged crown, any radiolucency that doesn't quite make sense on a single film, any tooth with an old trauma history you'd otherwise dismiss — take the second angled periapical before you write it off. It's the cheapest diagnostic step in dentistry and it's the one that catches this before the patient notices their tooth changing colour in the mirror. Related reading: Save or Extract? How We Make the Decision. | Consent and Documentation for Complex Endo Cases.

By Dr John Barclay | GDC No. 210844 | DRJB Smile Clinic, Ruabon, North Wales Non-surgical root canal retreatment resolves the majority of failed endodontic cases. But there is a subset of cases where it either cannot be attempted, has already been attempted and failed, or is unlikely to succeed — and where the choice becomes apical surgery or extraction. Understanding which cases fall into this category, and what apical surgery actually involves, is worth knowing before you refer. When Non-Surgical Retreatment Is Not the Answer There are specific clinical situations where attempting non-surgical retreatment is contraindicated or has a very poor prognosis: Post-retained teeth where removal of the post carries an unacceptable risk of root fracture. Where the post cannot be safely removed, the canal beneath it cannot be reinstrumented. Surgery is the only option that preserves the tooth. Previously retreated teeth where the canal system has been modified to the point that further non-surgical instrumentation cannot address the source of failure. A tooth that has had two non-surgical treatments, with persistent periapical pathology and no identifiable cause accessible from the coronal approach, is a surgical case. Cases where the source of failure is definitively at the apex and cannot be addressed coronally — an apical delta that hasn't been adequately debrided, a persistent biofilm on the external root surface, a foreign body beyond the apex. Cases where canal anatomy makes non-surgical retreatment technically impossible — severely calcified canals in a previously treated tooth where the canal cannot be negotiated from above. What Apical Surgery Involves Apical surgery — apicoectomy with retrograde root filling — involves a surgical approach to the apex of the root via the alveolar bone, rather than from the crown of the tooth. Under local anaesthetic, a flap is raised to expose the bone overlying the root apex. A window is cut in the bone to access the apex. The apical few millimetres of the root — including any infected tissue, apical delta, or persistent biofilm — are resected. A cavity is prepared in the resected root face using ultrasonic tips, and sealed with a biocompatible retrograde filling material, typically MTA or Biodentine. The flap is repositioned and sutured. The patient goes home the same day. The procedure sounds more dramatic than it typically is in experienced hands. Most patients report that it was more comfortable than they expected and that the post-operative course was manageable with standard analgesia. Prognosis Apical surgery has a good evidence base when cases are selected appropriately. Success rates of 85 to 95 percent are reported in prospective studies using modern techniques — microsurgery with ultrasonic retrograde preparation and MTA retrofill — compared to significantly lower rates with older techniques. The prognostic factors that matter most: the size of the periapical lesion, the adequacy of the coronal restoration, the presence or absence of periodontal disease on the tooth, and whether the tooth is restorable. A large lesion does not preclude success — large periapical lesions resolve well post-surgery when the root-end seal is adequate. The cases with the worst prognosis are those with concurrent periodontal disease extending to the apex, vertical root fractures, or teeth with insufficient tooth structure for restoration. These cases need to be identified before surgery, not discovered during it. CBCT Before Surgery Cone beam CT is not optional for surgical cases. A three-dimensional view of the apex, the lesion, and the adjacent anatomy — the sinus, the inferior dental canal, adjacent root apices — is essential for safe and effective surgical planning. A periapical that shows a periapical lesion is not sufficient pre-surgical information. CBCT shows the buccal bone thickness, the three-dimensional extent of the lesion, and whether the root apex is anatomically accessible. It changes the surgical plan in a meaningful proportion of cases. What to Tell Patients Patients referred for apical surgery are usually surprised that it's offered. They often assume that a failed root canal means extraction. A clear explanation — that surgery provides a direct approach to the source of infection that non-surgical treatment cannot reach — helps frame it correctly. Realistic expectations: some swelling and bruising for several days post-operatively, mild to moderate discomfort managed with ibuprofen and paracetamol, a follow-up appointment, and a healing period of several months before radiographic resolution is visible. It is not an immediately dramatic resolution — the bony lesion heals gradually. When to Refer Refer when non-surgical retreatment has failed or is not technically feasible. Refer before extraction is presented as the only option. And refer with CBCT where possible — it makes the surgical consultation significantly more productive. 📞 01978 823490 📧 infodesk@drjbsmileclinic.co.uk References & Further Reading 1. Torabinejad M et al. Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review. Journal of Endodontics, 2009. → Comparative outcome data for non-surgical retreatment vs apical surgery; supports case selection framework. 2. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. Journal of Endodontics, 2006. → Comprehensive overview of microsurgical technique, including ultrasonic retrograde preparation and MTA retrofill. 3. Patel S et al. European Society of Endodontology position statement: use of cone beam computed tomography in endodontics. International Endodontic Journal, 2019. → Supports CBCT as mandatory for surgical case planning. 4. Song M et al. Prognostic factors for clinical outcomes in endodontic microsurgery. Journal of Endodontics, 2011. → Evidence base for the prognostic factors discussed in this post. 5. European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report. International Endodontic Journal, 2006 (updated 2019). → Defines the standards against which apical surgery indications and outcomes should be benchmarked. Related Reading Retreatment vs Re-root Canal: How I Decide Cases I Take On That Others Don't. Save or Extract? How We Make the Decision. Microscope-Assisted Root Canals: What It Actually Changes Clinically. Endodontic Training Courses with Dr John Barclay

Welcome to the Comprehensive Endodontic Course for Dental Practitioners offered by Dentalchemy! This course is designed for newly qualified dentists and new associates who are looking to enhance their skills in endodontics. With a focus on hands-on training and up-to-date theory, this course will provide you with the knowledge and expertise needed to excel in this specialized field. Throughout three learning units, you will delve into the essential concepts and techniques of endodontics, covering topics such as pulp biology, diagnosis, treatment planning, and advanced root canal procedures. By the end of this course, you will have the confidence and proficiency to handle a wide range of endodontic cases effectively and efficiently, setting you apart as a skilled practitioner in the field. Join us on this educational journey and take your endodontic skills to the next level!