Endo Tribune Middle East & Africa No. 2, 2023
Small but powerful: Microrobots may enhance endodontic treatments / “Dentists therefore have a key role in connecting manufacturers with patients”
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DTMEA_No.2. Vol.13_ET.indd
PUBLISHED IN DUBAI
www.dental-tribune.me
Vol. 13, No. 2
Small but powerful: Microrobots may
enhance endodontic treatments
By Franziska Beier, Dental
Tribune International
New developments in smallscale robotics and nanotechnology
offer previously unimaginable opportunities for new diagnostic and
therapeutic approaches. In testing
the use of microrobots for endodontic applications, researchers
from the School of Dental Medicine
at the University of Pennsylvania
and its Center for Innovation and
Precision Dentistry found that the
robots were able to access difficult-to-reach root canal surfaces,
disrupt biofilm, retrieve samples for
diagnosis, and even deliver drugs.
The main cause of endodontic
treatment failure is incomplete
root canal disinfection, resulting in
endodontic infections and periodontitis. One of the reasons for
this is the complex anatomy of the
root canal system, making effective
biofilm removal difficult. Until now,
means of diagnosing and evaluating disinfection efficiency have
been limited.
The microrobotic system used
in the current study is the result of
an ongoing collaboration between
the dental school and the university's School of Engineering and Applied Science. In a previous study,
the collaboration produced a microrobotic system consisting of
nanoparticles that can not only
brush but also oss and rinse teeth
in a single step, helping to effectively eliminate biofilm from teeth.
Effective and precise guidance
of microrobots
The researchers developed and
tested two different microrobotic
platforms in their recent study. For
both, they used iron oxide nanopar-
ticles (IONPs), which share catalytic
and magnetic properties, as building blocks for the microrobots.
When asked about the biocompatibility and safety concerns for
patients, co-author Prof. Hyun Michel Koo of the Department of Orthodontics at Penn Dental Medicine replied, "IONPs are widely
used in nanomedicine due to their
minimal cytotoxicity, excellent
physicochemical properties, stability in aqueous solutions, and biocompatibility. Several IONP formulations have already been approved
by the US Food and Drug Adminis-
tration (FDA) for parenteral administration as a treatment of iron deficiency anaemia."
He added, "Our previous histopathological analysis of gingival,
mucosal, and other tissues, including major organs such as the liver
and kidney, showed no signs of
harmful effects, indicating high histocompatibility of both in-house
and FDA-approved IONP formulations."
AD
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▶ Page A2
[2] =>
DTMEA_No.2. Vol.13_ET.indd
ENDO TRIBUNE
A2
Endo Tribune Middle East & Africa Edition | 02/2023
◀ Page A1
To evaluate the effectiveness of
the endodontic microrobotic platforms, the researchers conducted
experiments using 3D-printed
tooth replicas prepared with a biofilm containing four different endodontic bacterial species.
For the first platform, using
electromagnets, the research team
concentrated the IONPs in micro-swarms and magnetically controlled them to disrupt and retrieve
the biofilm. Analysis of the collected sample found all four bacterial species. In addition, under the
microscope, all nanoparticles appeared to have been removed from
the root canal.
For the second platform, the
research team 3D-printed miniaturized helix-shaped robots and
filled them with an IONP-embedded gel. They then guided the robots within the root canal using
magnetic fields and observed that
they disrupted the biofilm chemically and mechanically with high efficiency. Especially noteworthy is
the possibility of loading the helix-shaped robots with therapeutics for targeted drug delivery at
the apical region of the root canal,
where infection is in close proximity to the surrounding tissue.
"The key limitations of current
endodontic strategies are threefold: lack of precision in targeting
biofilms infecting the apical region
and anatomical complexities of the
root canal, as well as the difficulty
of retrieving biofilm samples for diagnosis. To the best of our knowledge, there does not exist an approach capable of simultaneous
sample retrieval and antimicrobial
treatment in endodontics," commented lead author Dr. Alaa
Babeer from Penn Dental Medicine
on the relevance of the study findings for endodontic treatments.
"Our findings demonstrate the
feasibility of using the versatility of
microrobotics to access difficult-to-reach endodontic surfaces
to perform biofilm killing, removal,
and retrieval for microbial detection in real-time. Furthermore, we
demonstrate the feasibility of robot
tracking inside the canal using current clinical imaging modalities,"
he continued.
Future fields of application and
further research
The researchers envision a
broad range of applications for the
microrobots in dentistry and general medicine. According to Prof.
Koo, IONP microrobots could combine several functionalities in dentistry, including automated, handsfree brushing and flossing for effective removal of dental biofilms,
which can be helpful for people
with disabilities or lacking manual
dexterity to perform good oral hygiene.
Based on the results of the current study findings, Prof. Koo expects microrobotic platforms "to
Magnetically actuated 3D-printed robots are controlled precisely to target the apical region of the root canal uninterrupted
by the surrounding periodontium as visualised and tracked by CBCT. (Image: © University of Pennsylvania)
allow precision-guided therapies
to disrupt biofilms in difficult-to-reach spaces and promote
soft-tissue and bone regeneration." He added that microrobots
could perform delivery of drugs or
living cells in different oral and craniofacial sites, ranging from deep
periodontal pockets and the apical
region of the root canal to temporomandibular spaces to promote healing.
For biomedical applications,
Prof. Koo noted that "magnetically
controlled microrobots have shown
diverse applications, including anti-cancer therapy, targeted drug,
gene and stem cell delivery, and
minimally invasive surgery."
The study authors stated that
future research may expand the
possibilities for robotic application
even further to the detection, treatment, and removal of biofilms associated with other infectious diseases and biofouling of dental and
medical devices or implants.
Editorial note: The study titled
"Microrobotics for precision biofilm
diagnostics and treatment" was
published in the August 2022 issue
of the Journal of Dental Research.
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[3] =>
DTMEA_No.2. Vol.13_ET.indd
ENDO TRIBUNE
A3
Endo Tribune Middle East & Africa Edition | 02/2023
“Dentists therefore have a key
role in connecting manufacturers
with patients”
An interview with Prof. Gianluca Gambarini
By Dr Dobrina Mollova,
Dental Tribune MEA
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 .
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
Prof. Gianluca Gambarini (left) and Dr Dobrina Mollova of Dental Tribune Middle East & Africa spoke about the use of
artificial intelligence and other technologies in endodontics, and the dentist–manufacturer relationship.
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
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.
▶ Page A4
[4] =>
DTMEA_No.2. Vol.13_ET.indd
ENDO TRIBUNE
A4
Endo Tribune Middle East & Africa Edition | 02/2023
◀ Page A3
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.
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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 costeffectiveness. 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 (As Low As Reasonably Achievable) 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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