Standing up for teeth
Endodontists - and the teeth they fight to preserve - face challenges from implants. The economy isn’t helping things either.
Editor’s Note: The better you understand your customer, the better prepared you are to serve him or her. Throughout the remainder of 2009, First Impressions will look at the challenges and opportunities facing various specialties today. First up? Endodontics.
To call a molar or incisor a "victim of our disposable society" might seem a bit far-fetched. Yet each full-page newspaper ad and TV spot broadcasting the ease and merits of implants is one more blow to the tooth. And, by extension, that’s one strike against those who are committed to preserving it - your endodontist customers.
Indeed, the rising popularity of implants, as well as competition from general dentists and the poor economy in general, are three challenges facing endodontists today, according to those with whom First Impressions spoke. The fourth would be the shortage of endodontists who are committed to teaching students how to perform the craft.
Endodontists rescue dying teeth, that is, teeth whose pulp has been injured. Their procedure of choice is the root canal, and their tools tend to be burs, files and irrigants. They may also use technology such as operating microscopes, electronic apex locators, ultrasonics and digital imaging, to perform their services.
As of 2005, there were more than 4,500 endodontists in the United States, according to the American Dental Association. But it is a small specialty. Endodontists comprised only 1.7 percent of the dental 2005 graduating class. That’s about 36 people. To become an endodontist, the person must complete a minimum of two additional years of advanced specialty education in diagnosis and root canal treatment, according to the American Association of Endodontists.
Misconceptions
Although competition from implants is definitely an issue for endodontists, it really shouldn’t be, says Louis Rossman, DMD, president of the American Association of Endodontists, and a practicing endodontist in Philadelphia. "There shouldn’t be a conflict. It should be clear when the natural tooth should be saved." Though endodontists know this, the general public may not. Indeed, they may be harboring several misconceptions.
First, people are afraid that root canals hurt, despite the fact that they’re virtually painless. Second, they think implants are easier than root canals. Again, that’s not the case. Implants require extraction of the tooth followed by multiple surgeries to insert a metal post in the jaw and affix a crown to the post. The procedure spans three or more visits over a period of months. Root canals, on the other hand, can usually be completed in one visit.
Third, dental patients may believe that implants yield better long-term results than root canals. Again, that’s not necessarily the case. A recent study published in the November 2008 issue of the Journal of Endodontics showed that root canals require less follow-up treatment and generally last a lifetime, whereas implants have more postoperative complications and higher long-term failure rates.
The challenge for endodontists is to dispel these misconceptions among the public, says Rossman. Their message must be clear: Implants have their place, but patients with injured teeth should consider root canals first.
Challenge from general dentistry
Approximately 22 million endodontic procedures - 15 million of them root canals - are performed annually in the United States, according to the American Dental Association 2006 Survey of Dental Services Rendered. That would be a lot of root canals for 4,500 professionals
to perform. In fact, just 25 percent of root canals are performed by endodontists. Close to 70 percent are performed by general dentists, and the rest by other dental specialists, according to the ADA. And therein lies another challenge facing endodontists.
Although these specialists focus on the root canal and generally achieve positive results, general practitioners - particularly in a sluggish economy - may be tempted to perform more of these procedures than they otherwise would, says Rossman. "But many procedures can be complex and should be referred out [to an endodontist]," he says. "Dentists need to consider the best interests of their patients when deciding on performing the procedure."
"GPs are keeping as much business as possible," adds Deidre Leibrandt, associate brand manager, DENTSPLY Maillefer North America, Tulsa, Okla. "In the past, they would refer even the easy cases. But now, they aren’t referring the ones they’re able to do themselves."
The sluggish economy is affecting endodontists in other ways too. First, people are cutting back on visits to their dentist, and that in turn leads to even fewer referrals to endodontists, says Rossman. Second, even those patients who know they need a root canal may delay it as long as possible. Naturally, those who are in pain will incur the cost no matter what. But the majority of patients in need of root canals aren’t in pain; their injury may have been detected on the radiograph. Lacking insurance or even lacking a job, they may delay the procedure as long as possible.
Time to hit the road
Given these circumstances, the No. 1 priority for today’s endodontists should be reaching out to general dentists and dental students, says Rossman. "The general dentist has to be made aware that they can’t do everything, and that endodontists are part of the dental team. And the predoctoral student has to be taught the value of specialists." They also must be taught that root canals can function for decades, if not the lifetime of the patient.
Leibrandt agrees. "Endodontists need to build a strong referral network now." GPs remain a tremendous source of referrals, and those relationships must be cultivated. Doing so will pay off not only in today’s tough economic climate, but even more so, in tomorrow’s more prosperous one, she says. [FI]
Sidebar:
Seven steps of the root canal
- Diagnosis. The dentist uses several methods to determine the exact tooth causing the problem, including X-rays, percussion testing and/or thermal testing (with ice or heated objects).
- Access. Entry to the pulpal chamber is made through the crown of the tooth using a series of burs.
- Extirpation, or removal of pulp tissue, is accomplished using a variety of files or barbed broaches.
- Debridement. The canal is cleaned and shaped with a variety of instruments and irrigants, and the apex (or bottom) of the canal identified.
- Drying. The canal is dried using a series of paper points.
- Obturation. The canal is filled primarily with gutta-percha, an inert and biocompatible natural material, to avoid bacterial growth.
- Restoration of the tooth back to its original form.
Source: "Seven Steps of Endo," DENTSPLY Maillefer, http://www.maillefer.com/html/7_steps.html.
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