Endodontics - future of and residency programs?

[the_pulp]

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I wonder what endo will be like in 15 years?? It seems that the more composite that is done the more endo that it needed no?

I think so. Not sure though. Composites are very technique sensitive. They need to be done under rubber dam's and apparently now the new protocol is to do a 1min 2% CHX rinse before etching. how many GP's use rubber dams for composites?? less than 10%? so out of those 90% composites even if 20% lead to leakage...that is a lot of endo's

Than again, who knows. The human body (including the tooth) has an amazing capacity to fight.

 

[shibby3030]

I think so. Not sure though. Composites are very technique sensitive. They need to be done under rubber dam's and apparently now the new protocol is to do a 1min 2% CHX rinse before etching. how many GP's use rubber dams for composites?? less than 10%? so out of those 90% composites even if 20% lead to leakage...that is a lot of endo's

Than again, who knows. The human body (including the tooth) has an amazing capacity to fight.

yes, yes they do. the calcification process of the pulp is very effective.

much like the calcification of your brain, Mr pulp

in 15 yrs i hope to be pissing on your grave

 

[the_pulp]

And more and more GPs are recommending implants over retreats and apicos. This is an easy sell to patients when they are told that a successful retreat/apico is still likely to fail in 7-10 years. A successfull implant, on the other hand, will last 25+years and may very well outlast the patient.

I'm not saying that is always the best course of treatment but it is a valid alternative. And many people are leaning in that direction.

Endo will be a great specialty for years to come, but it may not be the goldmine that it has been for the last few decades. Do it if you like it.

This is nonsense.
The implants that are being placed now are not the implants that branemark placed 20 years ago (under absolutely perfect conditions).

Apico and retreat if done correctly have comparable success rate to implants.
It is well known in our school that our perio department has around a 75% success rate for implants. Try telling that to the patient that just had a 8 month bone-graft + implant surgery with all sorts of complications only to have her implant fall out now.

Implants have the advantage of having low level (level 5) literature studies. There is no implant study with 10,000+ sample size followed over 10 years. There are endodontic studies (done by insurance companies) that have followed 1 million + RCT treated (and retreated) teeth for over 8-10 yr period with a 95+% success rate. Endodontic failure does not mean the tooth is lost. Most endodontic studies list a tooth as failed if the tooth has a widened PDL. Perio and prosth love to play with these numbers and imply that these teeth have been "lost". If you wish to compare endo to implants, you need to compare endodontic SURVIVAL to implant survival. It is comparable, if not higher.

A lot of GP's will likely stop referring apico and retreats (due to the exact myth or ignorance that you are posting. I dont think endodontics is in any form of danger that the implantologist like it to be. You should pick your future specialty depending on what you like doing the most. Endo can get boring if you don't like it. Make sure you are in it for endo and not just the money.

 

[DrReo]

Have many schools added implants into their curriculum since these posts?

 

[aphistis]

This is nonsense.
The implants that are being placed now are not the implants that branemark placed 20 years ago (under absolutely perfect conditions).

Apico and retreat if done correctly have comparable success rate to implants.
It is well known in our school that our perio department has around a 75% success rate for implants. Try telling that to the patient that just had a 8 month bone-graft + implant surgery with all sorts of complications only to have her implant fall out now.

1) Your apico/retreat comment is impossible to substantiate unless you say any successful procedure is "done correctly" and any unsuccessful one is not. Such a scenario is obviously useless for comparative purposes.

2) 75% cumulative success rate is far lower than the range of numbers reported in the literature. Also, to be frank for a moment, you're comparing the best and brightest of American dental students (endo residents) to another group of dentists, many of whom have received significantly less and inferior training prior to beginning perio residency. I'm not going to spell it out, but I trust you can see where I'm going. Your argument is a straw man.

Implants have the advantage of having low level (level 5) literature studies. There is no implant study with 10,000+ sample size followed over 10 years. There are endodontic studies (done by insurance companies) that have followed 1 million + RCT treated (and retreated) teeth for over 8-10 yr period with a 95+% success rate. Endodontic failure does not mean the tooth is lost. Most endodontic studies list a tooth as failed if the tooth has a widened PDL. Perio and prosth love to play with these numbers and imply that these teeth have been “lost”. If you wish to compare endo to implants, you need to compare endodontic SURVIVAL to implant survival. It is comparable, if not higher.

No disagreements here. I'm a big fan of saving natural teeth whenever it's feasible, and implant proponents have done a masterful job of distorting the literature to their benefit.

A lot of GP's will likely stop referring apico and retreats (due to the exact myth or ignorance that you are posting. I dont think endodontics is in any form of danger that the implantologist like it to be. You should pick your future specialty depending on what you like doing the most. Endo can get boring if you don’t like it. Make sure you are in it for endo and not just the money.

Amen. I enjoy doing my own anterior and premolar endo, but molars just aren't worth the hassle right now. I'll do them if I have to, but I just don't enjoy it and would much rather refer them until I've done enough endo that they aren't such a headache. I'll always be glad to have an endodontist around.

 

[eliteOMFS]

I have to say in the SF bay area, implants are beginning to take over. Endo will still be strong, but at a high end practice implants, implants, implants.

 

[Hawk2thDoc]

I have heard for years that "once implants are less expensive..." Why would they magically become less expensive one day? I don't see the cost of placing and restoring an implant to ever be less than it is today. Oral surgeons and periodontists are not going to do them for any less than they currently charge. The only way I can see them getting cheaper is if Schein starts making implants. If you have ever used a Schein product, you will probably agree that while it may work, it is cheaply made and not worth the cost savings.

Endo residencies are for the most part only two years long. They may briefly cover implants, but not to the extent that three year perio programs and four year OMFS programs teach. A three year Endo residency might, but I haven't heard of many that have their residents placing implants.

 

[JavadiCavity]

I have heard for years that "once implants are less expensive..." Why would they magically become less expensive one day? I don't see the cost of placing and restoring an implant to ever be less than it is today. Oral surgeons and periodontists are not going to do them for any less than they currently charge. The only way I can see them getting cheaper is if Schein starts making implants. If you have ever used a Schein product, you will probably agree that while it may work, it is cheaply made and not worth the cost savings.

Endo residencies are for the most part only two years long. They may briefly cover implants, but not to the extent that three year perio programs and four year OMFS programs teach. A three year Endo residency might, but I haven't heard of many that have their residents placing implants.

You're assuming that 4-year OMFS programs have strong implant programs. At my school, the OMFS residents didn't do implants until they're fourth year. And, because of the nature of the patients seen in an OMFS residency, not many pt.'s came to the school looking for implants. These pt.'s are the poorest on the planet most of the time, and what they want is to have their tooth pulled and they could care less about filling the hole that is left. It's my opinion that the specialites are trained well enough to do proper case selection and to manage the "holy crap" problems that can arise from placing implants. Everything else comes from implant-specific training after graduation when you have a patient base that can afford the luxury of implants to replace failed teeth.

It is my practice philosophy to save every tooth with a guarded or better prognosis. Which means, most teeth are getting RCT in my office or they are going somewhere else for an EXT. Only after a tooth has completely failed do we talk about implants.

 

[Guy Smiley]

Are you not doing exts in your office? And you have to remember that just because the residents at Highland are not getting tons of implant exposure doesn't mean other programs aren't doing a significant amount. It all varies from little to zero exposure to residents who place 200+ during their residency.

 

[JavadiCavity]

Are you not doing exts in your office? And you have to remember that just because the residents at Highland are not getting tons of implant exposure doesn't mean other programs aren't doing a significant amount. It all varies from little to zero exposure to residents who place 200+ during their residency.

Yeah, we do exts 🙂. Lots of them. Mostly, on patients who are so poor that they can't afford RCT or any other alternative. Sometimes the tooth is salvageable, but most of the time I only ext a tooth when it's beyond repair.

While I agree that my point of view is limited to the highland residents, I'd be very surprised to find more than a small few of programs with a strong implant program. Implants in private practice run $4,000+ depending on the need for ancillary prosthetic procedures like bone grafting, sinus lifts, etc. At Pacific, the cheapest we would do an implant for was $2000 for the fixture and the crown. A sinus lift was another $1k, and so on. The patient demographic at Pacific, despite it being in a very wealthy area of town was very poor. Most students never placed a single unit.

How with poor demographics are any programs (unless they are even more heavily subsidized than Pacific) able to place a meaningful number of implants? A few programs in the U.S.? Sure, but not many. Not enough for me to believe that an O.S. or Periodontist would be any better than an endodontist at placing single unit implants. Just my two cents.

 

[Guy Smiley]

Yeah, we do exts 🙂. Lots of them. Mostly, on patients who are so poor that they can't afford RCT or any other alternative. Sometimes the tooth is salvageable, but most of the time I only ext a tooth when it's beyond repair.

While I agree that my point of view is limited to the highland residents, I'd be very surprised to find more than a small few of programs with a strong implant program. Implants in private practice run $4,000+ depending on the need for ancillary prosthetic procedures like bone grafting, sinus lifts, etc. At Pacific, the cheapest we would do an implant for was $2000 for the fixture and the crown. A sinus lift was another $1k, and so on. The patient demographic at Pacific, despite it being in a very wealthy area of town was very poor. Most students never placed a single unit.

How with poor demographics are any programs (unless they are even more heavily subsidized than Pacific) able to place a meaningful number of implants? A few programs in the U.S.? Sure, but not many. Not enough for me to believe that an O.S. or Periodontist would be any better than an endodontist at placing single unit implants. Just my two cents.

While I can only comment on the programs I am most familiar with, I have heard that Montefiore places many implants i.e. 100-200+. At a few of the programs I have visited, the residents actually placed implants in the private community offices of faculty. Again I don't know how much other dental schools are subsidized, but our undergrad program was more subsidized than Pacific. I believe it was almost the same to do a single unit implant and crown as a 3 unit FPD at our school - 1200-1300...the implant might have been closer to 1400-1500.

 

[ElDienteLoco]

I have heard for years that "once implants are less expensive..." Why would they magically become less expensive one day? I don't see the cost of placing and restoring an implant to ever be less than it is today. Oral surgeons and periodontists are not going to do them for any less than they currently charge. The only way I can see them getting cheaper is if Schein starts making implants. If you have ever used a Schein product, you will probably agree that while it may work, it is cheaply made and not worth the cost savings.

Endo residencies are for the most part only two years long. They may briefly cover implants, but not to the extent that three year perio programs and four year OMFS programs teach. A three year Endo residency might, but I haven't heard of many that have their residents placing implants.

We do during our 3rd year...

But, it's nothing close to a perio or OMS program.

 

[rochrome]

so you guys actually think that a practicing general dentist will recommend a $3k implant for acute apical abscess?? umm... no thats not how it works. you try to save the natural tooth first. endo is safe.

maybe the pre-dents shouldnt post on the dental forums. next you guys are gonna talk about how implants are gonna take over class 1 restorations

 

[JLum]

aaahhhhhh

loud noises!!!!

 

[aphistis]

so you guys actually think that a practicing general dentist will recommend a $3k implant for acute apical abscess?? umm... no thats not how it works. you try to save the natural tooth first. endo is safe.

maybe the pre-dents shouldnt post on the dental forums. next you guys are gonna talk about how implants are gonna take over class 1 restorations

Depends on the condition of the natural tooth. For an abscessed tooth with a good restorative prognosis, by all means do the endo...but what about a tooth with half the crown fractured off at the level of the alveolar bone, and decay in the remaining tooth structure? If that's *my* tooth, I want you to spare me the expensive, unreliable herodontics and just place the implant. You have to be careful making absolute statements like that.

 

[rochrome]

actually you have to look at the restorative AND perio prognoses, billy

and obviously i wouldnt recommend doing endo on a root tip....

i was just making a point slick

 

[aphistis]

actually you have to look at the restorative AND perio prognoses, billy

and obviously i wouldnt recommend doing endo on a root tip....

i was just making a point slick

Well, slick, I was simply being succinct. Like it or not, slick, there are times when extraction followed by implant restoration is the faster, more predictable treatment. Also, slick, if you're really trying to recite the complete list of the factors I consider when I'm treatment planning a tooth, you've still got a lot of blanks left to fill in. You read me, slick?

 

[juliawehkamp]

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EXTIRPATE OR INTEGRATE: THE ENDO/IMPLANT ALGORITHM - THE ENDODONTIST’S PERSPECTIVE

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[armorshell]

Yeah, we do exts 🙂. Lots of them. Mostly, on patients who are so poor that they can't afford RCT or any other alternative. Sometimes the tooth is salvageable, but most of the time I only ext a tooth when it's beyond repair.

While I agree that my point of view is limited to the highland residents, I'd be very surprised to find more than a small few of programs with a strong implant program. Implants in private practice run $4,000+ depending on the need for ancillary prosthetic procedures like bone grafting, sinus lifts, etc. At Pacific, the cheapest we would do an implant for was $2000 for the fixture and the crown. A sinus lift was another $1k, and so on. The patient demographic at Pacific, despite it being in a very wealthy area of town was very poor. Most students never placed a single unit.

How with poor demographics are any programs (unless they are even more heavily subsidized than Pacific) able to place a meaningful number of implants? A few programs in the U.S.? Sure, but not many. Not enough for me to believe that an O.S. or Periodontist would be any better than an endodontist at placing single unit implants. Just my two cents.

Man, I can't say how things were back when you were in school, but I currently have more implants treatment planned than operative surfaces.

 

[godbless]

1)

Also, to be frank for a moment, you're comparing the best and brightest of American dental students (endo residents) to another group of dentists, many of whom have received significantly less and inferior training prior to beginning perio residency. I'm not going to spell it out, but I trust you can see where I'm going. Your argument is a straw man.

How sad its coming from a SDN Moderator who himself is significantly less informed and is generalizing the work of "another" group of dentists

 

[soybene]

You will never be sorry that you went into endo. No matter how long it takes, or how much it costs. I was well ahead of the game within two years after residency. As far as implants, who has the least conflict of interest/bias when determining rct/implant? I recommend what I feel is best, and do it.

 

[KOM]

Man, I can't say how things were back when you were in school, but I currently have more implants treatment planned than operative surfaces.

I second that. Big bucks here...but more lawsuits? If anything, one should incorporate placing implants in their practice for denture retention...have a couple patients that say the difference is like light and day.

 

[KOM]

I've seriously been considering endo now as a specialty. Haven't had much exposure to OMFS except at the gospel mission for extraction nights, but I really do enjoy doing endo a lot (from the two actual canines I've done).

The future of endo does concern me a little and it probably shouldn't but I'm rambling when I should be studying. T minus two weeks for NBDE part 1.

 

[Guy Smiley]

I second that. Big bucks here...but more lawsuits? If anything, one should incorporate placing implants in their practice for denture retention...have a couple patients that say the difference is like light and day.

Are these the same patients who think having composite instead of amalgam is like the difference between dark and night?

 

[KOM]

Are these the same patients who think having composite instead of amalgam is like the difference between dark and night?

Maybe before they lost them...

doh, now I'm catching on...it's a wise old saying my granpappie taught me once. Don't knock it.

 

[Demeter]

Why are implants being taught in Endo residency now?
No GP is going to refer an implant case to an endodontist.

 

[cheesetoast]

I think endodontists, if trained properly would have no trouble getting referrals to place implants. We're not talking full-mouth rehab pros cases, but the referral that says "please evaluate badly broken down #19 for RCT. If prognosis is poor/hopeless, please extract and place implant."

This way, the patient doesn't have to go around the specialist carousel. Think about it (for you practicing dentists out there): hopefully you know a good endodontist who sends back beautiful RCTs, apicos, etc. If this person, who takes his craft so seriously (and is so proficient), decides to bring implants into his/her practice, don't you think they would handle this treatment with the same meticulous care and thoroughness.

Like I originally said, the endodontist needs to have a solid training background. Other than that, I see no reason why they can't tackle basic implant placement.

On a somewhat related note: how often does your oral surgeon miss MB2s when they do RCTs? One of mine (who patients had previously requested to see) missed it routinely. I don't refer out to OMS for RCT, but once in a while patients will go straight to him with a toothache (they have long-term relationships with him). I'm not saying it's harder skill-wise for a OMS to successfully complete RCT vs. an endo placing an implant; just food for thought.

 

[280040]

I don't refer out to OMS for RCT

good

 

[cheesetoast]

good

Thanks for the approval?

I wouldn't refer treatment to any specialist who wasn't trained to do so adequately in a residency (or proper post-residency education)...

...That being said, there is an increasing trend that endodontic residencies are teaching implant placement. Right now, the focus is cursory (depending on the program), but this thread is about the future of endodontic residency and the field as a whole, right?

IMO, this is a very interesting time for defining what it means to be an endodontist, moving forward. With more teeth with questionable prognoses being extracted in favor of implants (rather than having RCT), as well as the fact that more GPs are doing endo with rotary systems, the specialty may be pushed to evolve as well. Perhaps we will one day see pulpal regeneration therapy on formerly necrotic teeth.

Who knows? It's an interesting thread topic though

 

[BDS DMD]

hello everyone, i am in private practice since last yr in dc as general dentist, i am applying for endo this yr.....i havent done alot of retreats, what # do they usually look for.....

 

[Presidental]

They don't care how many rcts you've done. It's mostly a stats game. GPR helps.

 

[allover]

i look forward to the day when i understand half this jargon in here, hehe. silly question question, if GP are doing endo stuff, why would you specialize in endo?