Tuesday, May 12, 2009

Strengthening the future of endodontics

In the May 2009 issue of the Journal of Endodontics (JOE) two very important topics have been addressed that are shedding light on what the future of endodontists may look like.
One of the articles is : Update on Imbalanced Distribution of Endodontists: 1995-2006, by H. Barry Waldman and George A. Bruder.
The other, is the letter from AAE president Dr. Louis Rossman addressing the issue of ”Super generalist”.
Before I get into the importance of these two articles, let me point out some very important facts that have changed the economics of dentistry in the USA.
A) In the past 40 years the caries rate has dramatically gone down which has resulted in less number of patients requiring dental treatment due to less number of carious teeth.
B) At the same time, more dentists are practicing longer and opting for delayed retirement.

C) Today’s ratio of dentists to population is 58 per 100,000 which is very high compared to golden age of dentistry in 1960-70s, when this ratio was 49 per 100,000.

D) Today there is an oversupply of dentists in the USA. The areas where there is a shortage, namely the rural areas and the inner-cities, have been chronically underserved, and less than 5 % of graduating dental students have shown an interest practicing in these areas, over the years.( Refer to many articles published in the Journal of Dental Education). [Unfortunately ADA has not taken a strong leadership position on this issue, and I do not see any foreseeable action on their part regarding the oversupply of dentists in the USA. The article “Future of Dentistry” published in the JADA Vol.133,Sep 2002 , 1226-1235, calls this oversupply problem, “maldistribution of dentists.” The problem here is that no entity can make these dentist move from supersaturated metro areas to rural and inner-city area where there is a shortage thus oversupply of dentist in USA will not go away for years to come. ]

E) The student loan debt for an average graduating dental student has tripled in the past 15 years, to $ 180,000. ( 2006 statistics)

F) Dental insurance companies are taking advantage of these oversupply trends, by reducing reimbursement rates per procedure, further eroding the profits for dentists.

G) Three new dental schools have opened in the past 3 years, one in California, and two in Arizona, adding to the number of dentist coming into the marketplace.

As a result of the above, there has been a significant and growing economic pressure on the general dentistry market over the past 20 years causing erosion of profits and decrease in “busyness”, which will continue for years to come.

Which brings me back to the two articles in May 2009 issue of JOE.
Based on the above facts, it is obvious why we are seeing more and more “Super generalists”. The general dentists are under pressure to keep whatever comes in, in-house, and are tempted to do procedures they are not well trained for, to make money and pay their office overhead, student loans and make some profit.

That is why we are seeing an explosion of “retreat-odontics” by endodontists, re-treatment of failed implants by periodontists, re-dos of botched full mouth reconstruction by prosthodontist and more lawsuits and state dental board actions, all emanating from the “hungry general dentist syndrome.”
With all this happening on the general dentistry side, it is obvious that all specialists, including endodontists are negatively impacted. Less referrals are made to us, and when the referral is made, it is a retreatment of a case that is already problematic, or maybe beyond help, requiring extraction.
(This explains why some endodontists are getting into implant therapy.)

The other article by Waldman and Bruder, highlights the problem that we endodontists need to address or face financial and clinical extinction in the next 10 years.
A 48.5% increase in the number of endodontist in the USA from 1995-2006 is recipe for disaster, considering the facts discussed above, along with the emerging “super-generalist” phenomenon.

In my opinion these should be some of the steps, we as endodontists must take to correct this emerging threat:

1) Reduce the number of endodontic residency positions immediately.
( This step was taken by the dermatology residency programs in early 1990s. As a result of that bold move more than a decade ago, today dermatologists are prospering and there is no oversupply of them nationwide.) Some chairpersons can do this now without any pressure from dental school deans or administration, and they need to act now.
The others who are under pressure not to do this, can raise the money that the dental school will lose from reducing the number of residents, from their past endodontic alumni.
2) Accept residents with a minimum of 5 years general dentistry practice experience after graduation from dental school. (Today’s cases referred to an endodontist, are very complex and require a good knowledge of endo, perio and restorative treatment.)

3) Make teaching at a dental school for 12 days a year (which could be once a month per year, or 12 days in a row or any other combination of days, as long as it is 12 days a year) a mandatory requirement for Diplomate status re-certification. This will address the endodontist shortage in the faculty at dental schools and increase exposure of the undergraduate students to endodontists. Endodontics should not be taught by general dentists to undergrad students.

4) Get involved in teaching the general dentists, by discussing cases they should, and cases they should not do.

Action is needed and is needed urgently. Otherwise one day we will look back and will be forced to admit that “We have met the enemy and he is us.”

I welcome your comments,
Robert Salehrabi, DDS


IP said...

Excellent article. Endo is in the same boat as perio in this case and we're both just a few decades behind prosth in regards to GP's referal patterns.

The vast majority of dentists (in contrast to the medical community) are general dentists and so the ADA will never come out with a strong statement regarding treatments to be performed by the dentist or via referal. It's left to the specialists to educate, who by doing so can come across as simply protecting our turf. And I understand the GP perspective too, having practiced as one before specializing.

I wish that both the ADA and residency programs had the willingness to make the tough decisions.

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Jon said...

I enjoy reading up on these types of issues (I'm a dental student). I know there are lots of issues right now relating to the security of dentistry including mid-level providers. I'd be interested to find out what type of organizations exist or what type of plans are in motion to address the underserved and rural populations. Seems to me that as these areas continue to be "neglected", the government will step in and the dental profession will loose the autonomy that has existed for so long.

As a small side note, I believe there have only been 2 new dental schools in the past three years (Midwestern U in AZ and Western U in CA). I am pretty sure A.T. Still will be graduating their third class this summer meaning they matriculated their inaugural class approx 7 years ago. Interesting how the figues I've heard state that every 3 dentist retiring, 2 are graduating from school. I guess the real issue is that those 2 dentists graduating are opening up practices in the same neighborhood.

Anonymous said...

Your blog entry just made me (a patient) feel a lot less guilty about second-guessing my General Dentist's assurance that he could do a root canal. For some reason, I just didn't feel enough confidence in his expertise.

Considering it's my mouth, I decided to ask around and came to realization that I'm better off getting the procedure from an Endo. I have my first consult tomorrow.

I know there is no "guarantee" with any procedure, but I feel better taking my issue to someone who performs them on a "routine" basis.

Thanks again.

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Anonymous said...

Well said. As a general dentist I do feel pressure to do everything that I can. Dental school tuition is rising and GP's aren't retiring. They can't. It's all supply and demand. I would love to do crown and bridge everyday. Ain't gonna happen. Therefore I have to find something else to do or make what my hygienist makes.

Anonymous said...

Well said. As a general dentist I do feel pressure to do everything that I can. Dental school tuition is rising and GP's aren't retiring. They can't. It's all supply and demand. I would love to do crown and bridge everyday. Ain't gonna happen. Therefore I have to find something else to do or make what my hygienist makes.

Thornhill Dentist said...

Very well thought-out article. I am a general dentist and I do try to expand the services that I offer to keep competitive. But I do know my limitations and when to refer. There are many general dentists out there that unfortunately do not know their limitations and get into trouble.

Anonymous said...

In the early part of the 20th century, there was a medical specialy for the treatment of tuberculosis. TB became a none issue, so did the specialty. These specialists began doing other things.

Periodontists, also went throught that route. Less busy doing open flap cleanings. They stoped complaining and began placing implants.

A friend of mine, an endodontist, always wanted to be on a stage to teach GP`s to do mechanized endo. Now he is teaching more often than ever, because he has less endo cases, and wants to recrute as many retreatmetns as possible.

So. please stop complaining. You applauded those endo showmen at your aae, you fantasized to be an aae endo-showman. Well, you did not need to be an oral surgeon or rocket scientist to figure out that one day: GPs PLUS NiTi PLUS Endo-Showmen equals what you are experiencing right know.

Signed. OMS replacing teeth with bad endos, with implants.

Thank you endo-showmen

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