Endo by a General Dentist

[saydental]

How often does a general dentist opt to do posterior root canals or just RCT on teeth with more than one canal?

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[PerioDont]

depends on each person's skill level and desire to do RCT. Some gps like @******* have done thousands of endo cases and would be just fine doing the vast majority of posterior RCTs. Some do absolutely none at all.

That is the beauty of being a GP, you can choose which cases you want and which to refer. You often may even refer 'easy' cases if the pt is a pain to deal with as well.

 

[Jshilkof]

How often does a general dentist opt to do posterior root canals or just RCT on teeth with more than one canal?

I’m not quite sure that the number of canals or anterior vs posterior is an adequate assessment of difficulty. I think any endodontist would agree that sometimes single rooted teeth can prove most difficult. As others said... that’s the beauty of being a gp. You can cherry pick the cases in which to refer. I believe that it takes a certain level of experience to adequately assess each case in order to practice within ones ability’s.

 

[Molar Whisperer]

I'm very fortunate to have 23 yrs of observations on other dentists in PP and corp. More often than not, the high producing PP owners do a lot of posterior/multi-rooted RCTs. I had the once in a lifetime opportunity to do full time RCTs for my first DMO from 2003 - 2012. Technology now is so efficient such as the reciprocating Wave One system. When I first started out, I was doing 2 - 90 min appts for molars. Now is easy slo-mo 35 min!

DS teaches very frustrating ways to do RCTs. IMO, the endodontist instructors want to protect their specialty by scaring the Dental Students to refer endo to them. I had to relearn cold lateral obturation in the USAF during the late 1990s because my school's technique was crap. Even the instructors' chart notes on their own endo procedures were nothing like they taught us (one instructor used Thermafil metal carrier obturation). I'm not sure if there are any free sponsored workshops by the big endo supply companies like Dentsply Sirona. One can have a rep come in for lunch and learn. I understand workshops now are very expensive. Cliff Ruddle and John West YouTube videos can be very helpful.

 

[Mauricio45]

I do many molar endos as a GP. Great production once you get the hang of it. I didn't do any molar endos when I was in school because they would always shuttle them off to grad endo. I luckily work in one private office where the owner doesn't do any endos; thus, allowing me to hone and practice my skills in molar endos. I use Edge Endo X7 with single cone BC sealer. Never really got into WaveOne Gold. Pricey and aggressive in coronal half for molars IMO.

I try to get most done in 1 appt (usually 1.5 to 2 hours). Sometimes temporize with formocrescol pellet (yes, formocrescol) and finish endo 2nd visit if pus drainage or difficult canals.

IMO, the hardest cases are splitted premolars with 3 or more canals. I refer those out.

 

[TanMan]

How often does a general dentist opt to do posterior root canals or just RCT on teeth with more than one canal?

GP's are on a spectrum when they perform RCTs. Some refuse to do any endo (even anteriors), and some will do any and every tooth. New technology has made endodontics a lot more predictable. With WaveOne Gold and the lightwalker laser, I can push 30mL+ of naocl/edta/chx without extruding in a few minutes, cleaning the system in 3 dimensions (especially if you use hot and high naocl concentrations (6-12%)). If you're looking for an average, a lot of GP's stick to premolars or anteriors. I find that that hardest endo are maxillary laterals with large periapical lesions. They tend not to resolve with NSRCT. Usually needs NSRCT + Apico/retrofill + Graft. Thankfully, anterior apicos are easy, but you have to be mindful of flap design to prevent recession and scarring, especially if they have a high smile line. Submarginal and semilunar flaps tend to scar more in my experience. Molars are easier for me than anteriors. Much easier to extrude hypochlorite on the anterior, esthetics can sometimes be compromised if the tooth looks darker after endo (and I prefer not to do a full coverage on anteriors unless there's a significant loss of tooth structure), and variations tend to be harder to navigate through. 2 rooted lower anteriors tend to be annoying too, since they usually have two portals of exit and compensation is less than a molar rct.

Practice your molar endos. They are the true bread and butter of general dentistry. Molar RCTBUCrn in 30 mins of doctor time @ 2500 results in a 5k/hour production. It may not be as good as 10 minutes of doctor time for a Crown @ 1k+(6k+/hour), but you often won't find enough crowns in a day to stuff the schedule with 48 crowns (assume 8 hour working day, 6 crowns an hour). RCTs are a nice gap filler, BUT I'm finding out that in an extremely busy schedule, they can disrupt your workflow sometimes (15 mins can be a long time if you have 9 patients in queue).

WaveOne Gold is expensive, but it's probably the best system out there. However, WaveOne gold isn't too expensive, if you buy in bulk (200-250 packs at least at a time). That should be enough for at least 300 molar endos, since you have to use more than one file in heavily calcified systems... but that's the beauty is that it won't let you separate the file and if you can't get through with a handfile, you can get through with the WO gold. That might not be much for an endodontist, but it's a fair amount for GPs. Price can drop by at least 33% depending on the timing of the order.

Good luck, whatever stage you're in and you want to be a GP, I hope you enjoy RCTs and do plenty of them for fun and profit.

 

[saydental]

The instructors are very specific about what they want and it seemed meticulous which I'm sure root canals are. I want to learn how to do great root canals but it seems like I'm just trying to get done before the end of lab rather than practice and learn before doing them on actual patients. Doing them in less than an hour seems impossible right now but maybe without the check offs it can be possible. Since it takes me so long to do just one canal, I was thinking it would be so much harder and time consuming to finding some of the canals on a molar and obturating. Also, I feel like there is alot of risk involved with perforating, sealer going past the apex, NaOCl damaging tissue, not reaching working length, cleaning out canal properly, etc.

 

[schmoob]

The instructors are very specific about what they want and it seemed meticulous which I'm sure root canals are. I want to learn how to do great root canals but it seems like I'm just trying to get done before the end of lab rather than practice and learn before doing them on actual patients. Doing them in less than an hour seems impossible right now but maybe without the check offs it can be possible. Since it takes me so long to do just one canal, I was thinking it would be so much harder and time consuming to finding some of the canals on a molar and obturating. Also, I feel like there is alot of risk involved with perforating, sealer going past the apex, NaOCl damaging tissue, not reaching working length, cleaning out canal properly, etc.

It takes practice and repetition. Good access and visibility is key. Trust your apex locator. Don’t force the irrigant. When you finally obturate, use the tapered cone that matches your rotary file. Not too much sealant, place your cone in SLOWLY to avoid hydraulic trapping and so it can flow into accessory canals.
In private practice you can buy different supplies that you like and makes you more efficient. Don’t stress it.

 

[Molar Whisperer]

I use Edge Endo X7 with single cone BC sealer. Never really got into WaveOne Gold. Pricey and aggressive in coronal half for molars IMO.

I try to get most done in 1 appt (usually 1.5 to 2 hours). Sometimes temporize with formocrescol pellet (yes, formocrescol) and finish endo 2nd visit if pus drainage or difficult canals.

IMO, the hardest cases are splitted premolars with 3 or more canals. I refer those out.

Edge Endo is a capable, less expensive competitor to WaveOne Gold. Since I work at a predominant Medicaid DMO, I don't have as many choices. I wanted to try Edge but never materialized. I never have any problems with aggressive instruments because I exert very light, passive pressure. I appreciate the reciprocating action which makes light, passive instrumentation very efficient. I watched on YouTube how endodontists negotiate very challenging canals. They have a lot of toys I won't be able to obtain so more power to them.

The instructors are very specific about what they want and it seemed meticulous which I'm sure root canals are. I want to learn how to do great root canals but it seems like I'm just trying to get done before the end of lab rather than practice and learn before doing them on actual patients. Doing them in less than an hour seems impossible right now but maybe without the check offs it can be possible. Since it takes me so long to do just one canal, I was thinking it would be so much harder and time consuming to finding some of the canals on a molar and obturating. Also, I feel like there is alot of risk involved with perforating, sealer going past the apex, NaOCl damaging tissue, not reaching working length, cleaning out canal properly, etc.

When I was in the USAF, my day was ruined every time I see any endo cases on my schedule. I asked an endodontist how she accesses the molars and she uses the Brasseler Endo Z pulp shaping bur. That bur revolutionized my RCT procedures. Imagine smoothing the canals so the instruments slide in instead of impeding on ledges. Endo is ACCESS, ACCESS, ACCESS, It will reduce iatrogenic events like perforation, ledging, and instr separation. Many molar accesses done by GPs are deficient. The accesses I see are too wide (very ledged) and orifices are not fully opened. If you can achieve proper molar access which IMO is one that your DA can stick paper points down all 4 or 5 canals, you can complete it in very short time.

 

[Molar Whisperer]

Trust your apex locator.

True that.

 

[schmoob]

Edge Endo is a capable, less expensive competitor to WaveOne Gold. Since I work at a predominant Medicaid DMO, I don't have as many choices. I wanted to try Edge but never materialized. I never have any problems with aggressive instruments because I exert very light, passive pressure. I appreciate the reciprocating action which makes light, passive instrumentation very efficient. I watched on YouTube how endodontists negotiate very challenging canals. They have a lot of toys I won't be able to obtain so more power to them.



When I was in the USAF, my day was ruined every time I see any endo cases on my schedule. I asked an endodontist how she accesses the molars and she uses the Brasseler Endo Z pulp shaping bur. That bur revolutionized my RCT procedures. Imagine smoothing the canals so the instruments slide in instead of impeding on ledges. Endo is ACCESS, ACCESS, ACCESS, It will reduce iatrogenic events like perforation, ledging, and instr separation. Many molar accesses done by GPs are deficient. The accesses I see are too wide (very ledged) and orifices are not fully opened. If you can achieve proper molar access which IMO is one that your DA can stick paper points down all 4 or 5 canals, you can complete it in very short time.

I like Edge Endo as well, but I use their Glidepath files. I get WL with a #10 K-file and I switch to glidepath rotary and get it to a size 35 in one pass. I use protaper rotary so I just switch out to the included orifice opener followed by cleaning and shaping and single cone obturation.

 

[allDAT]

It depends on your skill level/comfort with the procedure AND your patient demographics.

I love endo, but it’s not something I get to do every day. Not even close.

I’ve always kept this in mind though: The most successful general dentists I’ve met with (and these guys are absolutely killing it, and their level of dentistry is what I aspire to do), have always had 1 thing in common - every single one of them refers 100% of endo to an Endodontist - even anterior teeth. They didn’t even have files in their practices.

 

[Molar Whisperer]

It depends on your skill level/comfort with the procedure AND your patient demographics.

I love endo, but it’s not something I get to do every day. Not even close.

I’ve always kept this in mind though: The most successful general dentists I’ve met with (and these guys are absolutely killing it, and their level of dentistry is what I aspire to do), have always had 1 thing in common - every single one of them refers 100% of endo to an Endodontist - even anterior teeth. They didn’t even have files in their practices.

I know some busy dentists that don't do any endo. Many of them make up for it by placing and restoring implants. At my oversaturated metro location, many dentists aren't busy and they will lose production by not doing any. When I was briefly in a PP setting, the most patients I see in a day was only 3 or 4 and many of them were redos of my predecessor's work. When a dentist can become busy is when I see referring all endo as viable.

 

[Molar Whisperer]

Last week I referred #14 with PARL on MB root to an endodontist. He couldn't find the MB2 canal. He has the usual endo toys of ultrasonic, operating microscope, CBCT and various other instruments for that purpose. He didn't use the CBCT but had to schedule a 2nd visit which I believe he will use it. The pt is in her mid 30's with no crown on #14 so the x-ray looked doable (the older the pt, the smaller and more calcified the canals are). Fortunately I punted that case. According to an endodontist on Youtube, he could only locate and instr about 80% of MB2s.

 

[FutureDent020]

Last week I referred #14 with PARL on MB root to an endodontist. He couldn't find the MB2 canal. He has the usual endo toys of ultrasonic, operating microscope, CBCT and various other instruments for that purpose. He didn't use the CBCT but had to schedule a 2nd visit which I believe he will use it. The pt is in her mid 30's with no crown on #14 so the x-ray looked doable (the older the pt, the smaller and more calcified the canals are). Fortunately I punted that case. According to an endodontist on Youtube, he could only locate and instr about 80% of MB2s.

He should have used the scan before treating it. Why on earth would you spend 100K on a machine and not use it for a maxillary molar with a lesion on the MB root? ALARA (2015) is dated and has no scientific backing. I have no problem with 2 visit treatment if it’s indicated. But if you have a CBCT, didn’t take an image, now have to bring the patient back to take an image and look for MB2, that just seems like poor decision making.

 

[Molar Whisperer]

He should have used the scan before treating it. Why on earth would you spend 100K on a machine and not use it for a maxillary molar with a lesion on the MB root? ALARA (2015) is dated and has no scientific backing. I have no problem with 2 visit treatment if it’s indicated. But if you have a CBCT, didn’t take an image, now have to bring the patient back to take an image and look for MB2, that just seems like poor decision making.

I'm thinking he thought he could breeze through it because the x-ray looked straight forward. By the time he encountered difficulties, his next pt is coming in. I was watching RealWorld Endo on Youtube and the guy could only get 80% MB2s. I got spooked because in the past I must have been doing them wrong. The only upper molars I will be doing will be no PARL (could still have apical lesions that haven't penetrated cortical bone) on young pts with large canals.

 

[allDAT]

I'm thinking he thought he could breeze through it because the x-ray looked straight forward. By the time he encountered difficulties, his next pt is coming in. I was watching RealWorld Endo on Youtube and the guy could only get 80% MB2s. I got spooked because in the past I must have been doing them wrong. The only upper molars I will be doing will be no PARL (could still have apical lesions that haven't penetrated cortical bone) on young pts with large canals.

I'd agree. It was probably a time-management issue and he or she just ran out of time. If the plan was to 2 step from the get-go, the 2nd visit didn't change the plan or the amount of time the case will take.

 

[TanMan]

Just because you can see an MB2 on a CT, doesn't always mean you can access it. All endodontists in my area seem to give the green light for restore, even if they don't instrument MB2... and when it fails, they have traveling perio to ext and place an implant if they get sent back.

 

[Molar Whisperer]

I think endodontists can get away with not instrumenting MB2s, MB3s, etc. We GPs can not. If we couldn't locate and instr them, then it is our fault for not referring them.

 

[145bluz]

I've been in GP practice 34 years...I haven't done endo for 20 plus years. From a practice management standpoint I always felt it was disruptive to my schedule. I have planned emergency time in my day but I want it to be predictable. I don't want 50 minutes of emergency time in the schedule because some days we may not have any emergency calls. Also, I found endo patients called over the weekend more than other procedures. I am a good source of referrals so the endodontists will see my patients the same day-which I insist on. This is what has worked for me.

 

[2TH MVR]

I've been in GP practice 34 years...I haven't done endo for 20 plus years. From a practice management standpoint I always felt it was disruptive to my schedule. I have planned emergency time in my day but I want it to be predictable. I don't want 50 minutes of emergency time in the schedule because some days we may not have any emergency calls. Also, I found endo patients called over the weekend more than other procedures. I am a good source of referrals so the endodontists will see my patients the same day-which I insist on. This is what has worked for me.

This makes sense. A seasoned veteran dentist who knows what works best for his office. I would also add that this dentist is most likely financially comfortable and is in a position to pick and choose what procedures work best for him/her.

Now enter the cash strapped, debt laden new dentist. Are they economically forced to perform difficult molar RCTs, implants, ortho aligners, difficult extractions, etc. etc.? Not wanting that potential production to be referred down the street?

Or are they doing these difficult procedures because they like them?

 

[biochem5]

This makes sense. A seasoned veteran dentist who knows what works best for his office. I would also add that this dentist is most likely financially comfortable and is in a position to pick and choose what procedures work best for him/her.

Now enter the cash strapped, debt laden new dentist. Are they economically forced to perform difficult molar RCTs, implants, ortho aligners, difficult extractions, etc. etc.? Not wanting that potential production to be referred down the street?

Or are they doing these difficult procedures because they like them?

Can’t really get an associateship now a days without doing at least molar endo, all surgical extractions if not implant placement as well. It’s getting ridiculous, it wasn’t like this even 3-4 years when I graduated and was interviewing for associateships.

I feel like every time I become good at a “speciality” skill there’s always another one I don’t have. I am very good at extractions and I have been doing more endos. But because I don’t place implants I can’t get a job now!? Pre-pandemic back in Jan feb when I was looking for an associateship and now as well. Some offices want implant placement but don’t provide a CBCT for it, makes no sense.

 

[yappy]

Can’t really get an associateship now a days without doing at least molar endo, all surgical extractions if not implant placement as well. It’s getting ridiculous, it wasn’t like this even 3-4 years when I graduated and was interviewing for associateships.

I feel like every time I become good at a “speciality” skill there’s always another one I don’t have. I am very good at extractions and I have been doing more endos. But because I don’t place implants I can’t get a job now!? Pre-pandemic back in Jan feb when I was looking for an associateship and now as well. Some offices want implant placement but don’t provide a CBCT for it, makes no sense.

wow, just wow. How can someone do all these things well as a gp. Let alone be efficient at all them? I would much rather plug away doing 90 min cad cam crown appointments, staggering them by a half hr, than try to do all these specialty procedures like implants and molar rtc that carry a lot more risk and inhibit you from leaving the room. It doesn’t make business sense to me unless you’re hard up for patients and have to accept anything. Even doing quads of restorative treatment can be better for us gps than dabbling in all the specialties. Especially considering the high cost of the equipment

 

[TanMan]

Can’t really get an associateship now a days without doing at least molar endo, all surgical extractions if not implant placement as well. It’s getting ridiculous, it wasn’t like this even 3-4 years when I graduated and was interviewing for associateships.

I feel like every time I become good at a “speciality” skill there’s always another one I don’t have. I am very good at extractions and I have been doing more endos. But because I don’t place implants I can’t get a job now!? Pre-pandemic back in Jan feb when I was looking for an associateship and now as well. Some offices want implant placement but don’t provide a CBCT for it, makes no sense.

I think this is put into place to separate the go-getters v. the ones that require formal training to perform a procedure. Anyone can say they can place an implant or do a molar rct, and I think that people looking for these associates are ones that want someone who will do any procedure regardless of the quality/generated liability just to increase production and billable procedures.

 

[LaughingGas]

Can’t really get an associateship now a days without doing at least molar endo, all surgical extractions if not implant placement as well. It’s getting ridiculous, it wasn’t like this even 3-4 years when I graduated and was interviewing for associateships.

I feel like every time I become good at a “speciality” skill there’s always another one I don’t have. I am very good at extractions and I have been doing more endos. But because I don’t place implants I can’t get a job now!? Pre-pandemic back in Jan feb when I was looking for an associateship and now as well. Some offices want implant placement but don’t provide a CBCT for it, makes no sense.

Yes. Ridiculous requirements.

I think this is put into place to separate the go-getters v. the ones that require formal training to perform a procedure. Anyone can say they can place an implant or do a molar rct, and I think that people looking for these associates are ones that want someone who will do any procedure regardless of the quality/generated liability just to increase production and billable procedures.

My previous owner was like that. He could do "all procedures", but personally, it was pretty ****ty quality. Crown prep in 10 minutes for all teeth, feather edge all = no apparent margin or found few J shape ones, molar endo without rubberdam or missing MB2s. Those RCT fail in a year or two and he would extract and do implant + bone graft. Not checking KT around implant and those would fail eventually. Then would do "gingivectomy" when patient gets peri-implantitis, list goes on.
Having seen that, I don't think I can be a "go-getter". I understand practice makes perfect but as new grads, I believe one should take enough CEs and personally, this way of practice is not ethical.

 

[TanMan]

Yes. Ridiculous requirements.


My previous owner was like that. He could do "all procedures", but personally, it was pretty ****ty quality. Crown prep in 10 minutes for all teeth, feather edge all = no apparent margin or found few J shape ones, molar endo without rubberdam or missing MB2s. Those RCT fail in a year or two and he would extract and do implant + bone graft. Not checking KT around implant and those would fail eventually. Then would do "gingivectomy" when patient gets peri-implantitis, list goes on.
Having seen that, I don't think I can be a "go-getter". I understand practice makes perfect but as new grads, I believe one should take enough CEs and personally, this way of practice is not ethical.

It's an unfortunate state of affairs, but as the dental market tightens, profitability will take even more precedence in practice rather than quality patient care.