The concept of quality is pervasive in our profession. Dentists are held to an incredibly high standard. We are constantly striving to deliver care that lasts for years in a very unforgiving environment.
I frequently explain to patients that, “I work in an area where 1 mm is a really big distance.” Patients are usually amazed when they hear that, but you and I know it’s true. Because of our exacting training and exacting skills, dentists deliver care that routinely lasts decades despite the fact the human mouth is swimming in bacteria and the structures in the oral cavity are constantly taking a beating from normal everyday function. I think one of the reasons that dentistry has such a great success rate is because we make sure every step is correct before we move on to the next one. Dentists don’t cut corners, and we take a great deal of pride in that.
As dentists we constantly check things. Seating a crown? We check fit, margins, contacts, contours, and anatomy before proceeding with cementation. Performing a direct restoration? We check for complete caries removal, matrix placement, contour, marginal finish, occlusion, and final polish. Of course we perform all of those checks because we want to ensure that our procedures are done correctly. We want the best outcomes for our patients and we don’t move on to the next step until the current one is complete and conforms to our high clinical standards.
Now let’s apply this to a new technology. Statistics from the American Association of Endodntists (AAE) tell us that about 75% of endodontic procedures are performed by general dentists.1 The AAE estimates that most general dentists perform 2 root canals every week.2 However, the success or failure of root canals is difficult to evaluate the day it is done. Approximately about 5-15% of root canals performed will require retreatment. Often when a general dentist performs a root canal, if the patient continues to have problems, the patient is referred to an endodontist. That means 5-10% of root canals are performed and potentially paid for twice. Of course, the patient is out not only the fee, but also the time it takes to have the retreatment performed.
No GP wants to do a procedure and then have to tell the patient it didn’t work and now they need to see a specialist to have the same procedure performed a second time through their new crown. That doesn’t build a trusting relationship, and it certainly isn’t good for the GP office. Often a general dentist will refund the fee for the failed procedure, but in a business sense that means a doctor spent all of that time and money to perform a root canal for free.
The one area of dentistry that we’ve been unable to effectively evaluate for success on the day it is performed is endodontic disinfection. Now I realize that you could culture the canal, but that’s a difficult and time-consuming thing to do, plus the results aren’t always conclusive. What if there was a way that you could check the disinfection of an endodontic procedure before beginning obturation? Wouldn’t it be great to know that the likelihood of post-treatment infection or clinical failure is as low as possible? Oh, and what if you could find that out in 5 seconds without changing your current endo protocol at all? Well, that technology now exists. Recently I got a chance to see a new technology from Vista Apex called the Endocator and it does exactly that.
The Endocator is an ingenious chairside device about the size of a cell phone. It sits on the doctor’s endo cart or countertop and is powered by a rechargeable battery. Rather than working as a bacterial culture device, the Endocator is a device that measures the presence of adenosine triphosphate (ATP) and other biomarkers. I’m no expert in biochemistry, but I do know that ATP is the main energy carrier in cellular respiration. It’s present in every cell and in the case of endodontics it’s an indicator of bacteria or pulpal tissue left behind after the cleansing part of the procedure.
Because it’s not a culture device, there is no waiting for bacteria to multiply. Simply put, ATP is an indicator of how much potentially pathologic material remains in a canal system. ATP can be easily measured by bioluminescence in the Endocator in seconds.
Here’s how it works. The doctor performs the endodontic cleansing part of the procedure. As we all know that process is both mechanical and chemical. The doctor uses the same instruments and irrigants as always, so your instrumentation and disinfection protocol stays the same. Once the instrumentation/irrigation steps are completed, the canals are irrigated with sterile water. This removes any floating debris or irrigants. The canals are rinsed a few times and aspirated with a 30-gauge tip (Secure-Lock™ Vista-Probe™ 1" Bendable Irrigating Tips, Vista Apex) and the canals are left flooded with water. The water is then aspirated from each canal and expressed onto a special cotton swab.
The cotton swab now soaked with ATP from the endodontic sample is then pushed to the buttom of a small test tube where it combines with enzymes that cause bioluminescence. The test tube is then agitated by shaking it by hand or tapping it on the table. The test tube with the endodontic sample is then inserted into the Endocator, which generates a 0-100 score based on the amount of ATP and other biomarkers present in the sample. A high reading means there are still high levels of cellular contamination (bacteria and/or pulp tissue) in the sample and that additional cleaning is needed to better cleanse the canal of debris. ATP testing in root canals is so sensitive that it can detect ATP even in the absence of culturable bacteria, traditionally the gold standard of endodontic disinfection.3
Completing the test takes about 1 minute. Obviously, that means that adding one minute to your endodontic procedure can make the difference between success and potential failure. Think about that for a moment. By adding approximately 1 minute to your endo appointment, you can have the confidence to know if it is advisable to obturate with a high degree of accuracy.
This means for the first time in the history of dentistry doctors can actually evaluate the cleanliness of instrumentation and irrigation systems in endodontics. In my career, I haven’t seen many technologies that can give me a numeric score that lets me gauge when it’s safe to proceed, but the Endocator does just that.
When you order the Endocator, the kit comes with everything you need to get started. The box contains the device and everything necessary to complete the test. The test swabs are packaged in a resealable foil pouch labeled “Endocator Test Swabs”. The Endocator itself sits on the endo cart or on a countertop and has a stand to keep it upright and the screen oriented so the doctor can easily see the results.
I see a lot of leading-edge ideas in my job as Technology Evangelist. A lot of those products and ideas are good ones and have a chance of changing the profession for the better. However, every once in a while, I see something that is so groundbreaking I want it right then and there. The Endocator is one of those special products. I’ll be implementing it into my endodontic protocol immediately.
References
- American Association of Endodontists. Treatment Standards. Updated 2020. Accessed April 23, 2025. https://www.aae.org/specialty/wp-content/uploads/sites/2/2018/04/TreatmentStandards_Whitepaper.pdf
- What’s the difference between a dentist and an endodontist?. American Association of Endodontists. Accessed April 23, 2025. https://www.aae.org/patients/why-see-an-endodontist/whats-difference-dentist-endodontist/
- Tan KS, Yu VS, Quah SY, Bergenholtz G. Rapid method for the detection of root canal bacteria in endodontic therapy. J Endod. 2015;41(4):447-450. doi:10.1016/j.joen.2014.11.025
