good and bad of perio and endo in terms of job outlook, earning potential, etc...

[fakebun]

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hi all
i've been practicing for 2 years and right now and I'm torn between perio and endo. I was wondering if you guys could offer some insights to the good and bad of those two specialties. Not looking to have you guys make a decision for me but just want to be informed.

Also what is the best way to obtain LORs now that I've been working for 2 years? Shadow three different nearby endo/perio?

 

[321931]

Endo all the way in my opinion.

 

[FutureDent020]

hi all
i've been practicing for 2 years and right now and I'm torn between perio and endo. I was wondering if you guys could offer some insights to the good and bad of those two specialties. Not looking to have you guys make a decision for me but just want to be informed.

Also what is the best way to obtain LORs now that I've been working for 2 years? Shadow three different nearby endo/perio?

You have been practicing for 2 years and I assume have already seen a lot of the pros and cons of each. Why don’t you go ahead and write out your list and we can expound on it or help clarify. The best thing you can do is fully understand why YOU want one specialty over the other. Perio and Endo are incredibly different disciplines.

And yea, LOR’s are tougher to obtain if you are just in private. Any type of mentor in the specialty is good. Otherwise, yea, shadow your referring specialists and go from there.

 

[fakebun]

I've always enjoyed extractions and implant placement and I thought about taking courses are extracting simple partial bony impacted 3rds. I had a traveling perio coming into the corporate office i was at once a month and him telling me perio isn't all about crown lengthening and gum surgeries but also includes IV sedation, 3rd molar ext, implant placement, sinus lift I thought that's what I want to do.

But nowadays newer grads are all doing implant placements and that pretty much leaves gum surgeries and 3rds exts but why would a GP refer to perio for 3rds instead of OS? That really only leaves gum surgeries on the table...or so I think..

I've always had fascinations with endo and I can appreciate a beautifully done RCT and I like the idea of traveling endo, low OH, and potentially fewer staff to manage. However, the cases i'll be getting will probably be extremely difficult that it takes so long to make the procedure unprofitable.

I've thought about staying as a GP but one thing i hate the most is to unreasonable patients and patients with unrealistic expectation. As one posters in another old thread put it i'm probably just at the stage of "dental puberty".

all in all i worry about specialties because almost every GP has the specialist they refer to already and unless that specialist really F-ed it up I dont know how to break into existing referral networks of all providers near me. The only thing I can see is working for corporate at a paycut but be well-fed since they don't allow GPs to do specialty work. This is all my own personal perception and please correct them as you see fit

 

[FutureDent020]

You nailed the main cons with perio. Market/ procedure saturation. OS, general, and prosth really competing for a lot of the same procedures. I don’t have too much insight into perio otherwise. It still has a place and they are great at what they do, but it would just make me a little more nervous.

Breaking into a referral network is always a challenge. But dentists are always looking for quicker ways to get patients seen. As long as you hustle, network and do good work, the referrals will come. Just make sure you set up somewhere where the specialty is needed. Or you can join an existing group as an associate to start out. I’ve been talking to dentists about where I should go after residency and they will just say “go here, there is like a month long wait for an Endo appointment.” Obviously it’s not that simple, but you get my point.

 

[fakebun]

I hope with the training of 2 year endo residency what is considered hard cases will be only medium cases...

I have never thought about residency so my GPA tanked a bit near the end of school and I was never that good at small talk so some faculty I think will remember me but not to the point where I can ask for a good LOR...should I still reach out?

 

[charlestweed]

Endo is much harder to get into than perio. People who apply for endo tend to have better stats (higher class rank, research, GPR/work experience etc) than people who apply for perio. I know a couple of people who couldn't get into endo and had to settle for perio.

Your success as a specialist (endo or perio) depends on how well you communicate with the refering GPs, the insurance plans your office accepts, your office hours etc. Some GPs, who hate how the RPDs fit and believe in implants, will refer a lot of implant cases to you. Some GPs, who believe in perio surgeries to give the teeth with bone loss the 2nd chance, will refer patients to you. Some GPs don't believe in perio will not refer to you. It's important to meet as many GPs as possible. If you hate going around meeting the GPs, then I don't think you should specialize. If you don't like begging, you can work for the corp or GP offices that hire in-house perio and endo. Since each office only saves for you a few cases in a month, you have to travel to work multiple offices in order to have busy work schedule.

 

[321931]

Endo is much harder to get into than perio. People who apply for endo tend to have better stats (higher class rank, research, GPR/work experience etc) than people who apply for perio. I know a couple of people who couldn't get into endo and had to settle for perio.

Your success as a specialist (endo or perio) depends on how well you communicate with the refering GPs, the insurance plans your office accepts, your office hours etc. Some GPs, who hate how the RPDs fit and believe in implants, will refer a lot of implant cases to you. Some GPs, who believe in perio surgeries to give the teeth with bone loss the 2nd chance, will refer patients to you. Some GPs don't believe in perio will not refer to you. It's important to meet as many GPs as possible. If you hate going around meeting the GPs, then I don't think you should specialize. If you don't like begging, you can work for the corp or GP offices that hire in-house perio and endo. Since each office only save you a few cases in a month, you have to travel to work multiple offices in order to have busy work schedule.

Ironically the pretty endodontist down the street is booooooooked out hell, while the old grumpy endo is pretty open in his schedule. I actually go with the person closest to the office- makes it most convenient for patients.

 

[charlestweed]

I've thought about staying as a GP but one thing i hate the most is to unreasonable patients and patients with unrealistic expectation. As one posters in another old thread put it i'm probably just at the stage of "dental puberty".

Specialists (endos and perios) have to deal with a lot of unreasonable patients as well. You do not only have please the patients, you also have to please the referring GPs as well. The referring GPs constantly check your work. The GPs often dump the "unreasonable" patients to you to avoid the headaches. Perio patients, who have severe bone loss due to years of dental neglect, get mad when you recommend multiple extractions and implants and $10-20K price tag. They get mad when they see roots are exposed and their teeth have sensitity after the perio surgery. Endo patients get mad because your office is not opened on Saturday and they are in pain.

 

[charlestweed]

Ironically the pretty endodontist down the street is booooooooked out hell, while the old grumpy endo is pretty open in his schedule. I actually go with the person closest to the office- makes it most convenient for patients.

As you are getting older, you tend to care less about the your practice because you no longer have any debt. You get tired of going door to door to beg the GPs. I am 47 and I am happy with what I make. I no longer go door to door to meet the referring GPs like what I used to do 8-9 years ago. My production has dropped but my net earning is still higher than in the past because I no longer have to use what I make to pay back the debts. There are some of the referring GPs that I never even met. They refer to me because my patients also go to see them for general dental care...and my patients told these GPs that my fees are reasonable.

 

[fakebun]

Thank you for the good points. Just curious how did you "meet" GPs for potential referrals? Also, if you take insurances aren't your fees be determined by the insurance? or are you just talking about the FFS part?

 

[mmc12]

I've thought about staying as a GP but one thing i hate the most is to unreasonable patients and patients with unrealistic expectation. As one posters in another old thread put it i'm probably just at the stage of "dental puberty".

GPs often refer pain in the butt or extremely nervous patients that require RCT to the endodontist. So don't think that you will get away from unreasonable patients once you specialize...

 

[fakebun]

true. didn't think about that part.
I take it as endo you pretty much have to treat all cases? does any endo say they can't do it (whether canal is too calcified or limited opening) and punt the pt back to GP?

 

[321931]

true. didn't think about that part.
I take it as endo you pretty much have to treat all cases? does any endo say they can't do it (whether canal is too calcified or limited opening) and punt the pt back to GP?

After doing endo day in and day out....it will be like sleeping. There isn't much that phases my endodontist. All of them become easy after a while. He might run into a hard one every once in a while, but in those cases, he does the best he can and follows up within a year and tells the patient. Being a specialist has it's merits because you are the "specialist" and you are the expert opinion in a sense.

 

[charlestweed]

Thank you for the good points. Just curious how did you "meet" GPs for potential referrals? Also, if you take insurances aren't your fees be determined by the insurance? or are you just talking about the FFS part?

I am neither a perio nor an endo. I am an orthodontist.

I was clueless when I first started. When I came in to meet this one GP and gave her a stack of my business cards, she corrected me and told me that I should give her the referral slips, not business cards. She was kind enough to give me 2-3 different referral slips from other ortho offices for me to use as referrence. She asked me about my fee and if I accepted medicaid. I told her my fee, my weekend office hours and that I accepted everything including medicaid. She was very please and started referring patients to me. About 6 months later, she came to my office and asked me to put braces on her.

I instructed my receptionist to call the GP office to ask them if I could buy lunch for the office. When the GP said yes, I ordered pizza. And while they ate, I came in to meet the GP and his/her staff.

And for some GP offices, I just walked straight to their offices. If the GP was in the middle of the procedure, I just sat there and waited. And after the GP was done, he/she usually came out to meet me....and we talked for about 5-10 minutes.

I accepted a wide variety of insurance plans including HMO and medicaid because I was desperate. As a new office owner, I wanted as many patients to accept the treatments as possible. At the beginning, my schedules were empty and I'd rather work than sitting around doing nothing. Getting paid something is better having zero patient and getting paid nothing. The more patients I treat, the more people (patients and their GPs), who will hear about me. Reputation doesn't happen overnight. Another reason I wanted to treat a lot of patients (even though their insurances didn't pay much) was I wanted to teach myself as much as possible. 2-year ortho residency only taught me the basic stuff.

For perio, you can come to the GP offices to teach them how to restore implants....and help them with the implant tx planning. Once the GPs are more confident with restoring the implants, they'll refer more patients to you. To make the GP's and patient's lives easier, you can help the GP to deliver the stayplate or denture (and reline it if necessary) at your office right after you extract a tooth and place the implant.

 

[fakebun]

my apologies. But ya the thought of hard cases being thrown to me is daunting, but hopefully 2 years of residency train me enough that those 'hard' cases are just medium cases for me. Whereas those really hard cases....does an endo ever tell pt that the canal is too calcified to do anything and return back to GP?

 

[BocasDelToro]

my apologies. But ya the thought of hard cases being thrown to me is daunting, but hopefully 2 years of residency train me enough that those 'hard' cases are just medium cases for me. Whereas those really hard cases....does an endo ever tell pt that the canal is too calcified to do anything and return back to GP?

Yes, there are some cases, albeit rare, that are too calcified for even the endodontist to achieve a good result without decimating the tooth. The endodontist will inform the patient and RD as such. Again, this is not the norm though. Endos can usually get an impressive result with even the most calcified of canals. It's all about informed consent and realizing that yes even though he or she is a specialist, we're all human. Some things just can't be done.

 

[TanMan]

I've always enjoyed extractions and implant placement and I thought about taking courses are extracting simple partial bony impacted 3rds. I had a traveling perio coming into the corporate office i was at once a month and him telling me perio isn't all about crown lengthening and gum surgeries but also includes IV sedation, 3rd molar ext, implant placement, sinus lift I thought that's what I want to do.

But nowadays newer grads are all doing implant placements and that pretty much leaves gum surgeries and 3rds exts but why would a GP refer to perio for 3rds instead of OS? That really only leaves gum surgeries on the table...or so I think..

I've always had fascinations with endo and I can appreciate a beautifully done RCT and I like the idea of traveling endo, low OH, and potentially fewer staff to manage. However, the cases i'll be getting will probably be extremely difficult that it takes so long to make the procedure unprofitable.

I've thought about staying as a GP but one thing i hate the most is to unreasonable patients and patients with unrealistic expectation. As one posters in another old thread put it i'm probably just at the stage of "dental puberty".

all in all i worry about specialties because almost every GP has the specialist they refer to already and unless that specialist really F-ed it up I dont know how to break into existing referral networks of all providers near me. The only thing I can see is working for corporate at a paycut but be well-fed since they don't allow GPs to do specialty work. This is all my own personal perception and please correct them as you see fit

Specialists aren't miracle workers either. NSRCT is definitely the main tool, but not the only tool. If you were thinking of doing endo, look into a program that emphasizes surgical endo. If you can't approach the tooth non-surgically, go the surgical route. Most GP's won't do apicos or intentional replantation.

 

[charlestweed]

If the tooth is too difficult to treat endodontically and the chance of success is questionable or low, the patient should be informed of the alternative more predictable option: extraction, implant, and crown. An implant is, of course, not as good as the natural tooth's root but implants have been proven to have very high success rate. You should informe the patients the pros and cons and the overall cost for each option. And let them decide.

 

[fakebun]

sorry. didn't mean to disappear. Right now I'm afraid that I'll be getting cases that are broken files, retreat, bailing GPs out, and etc. Would it hurt my practice (if i do become an endo) if a tooth's restorability is questionable and return the pt back to GP because I "didn't help" the GP by doing the RCT. Also, is it at all possible to become a GP again after you specialized or you're pretty much doomed if you choose to go GP again.

 

[FutureDent020]

Yea you’re going to get the tough root canals. That’s part of the gig. They may not feel as tough to you though. And you should have good communication with the referring GP. A lot of times they’ll do the restorability eval. If they deem it restorable, then it’s just your job to do the RCT. If you really think it’s non restorable even after they say it is, just communicate with the GP. But I would be hesitant to tell the patient conflicting info without discussing it with the GP. If you cause them to lose a pt they will not be happy.

 

[FutureDent020]

If you have these concerns, I would really continue to do more Endo and shadow before you consider committing.

 

[fakebun]

yes I believe the GP should do the restorability testing but does endodontist do their own evaluation as to whether the endo will be successful? Yes I plan on shadowing a whole lot before committing since i'm too late for this application cycle anyway. Gives me a good year to decide.

 

[charlestweed]

sorry. didn't mean to disappear. Right now I'm afraid that I'll be getting cases that are broken files, retreat, bailing GPs out, and etc. Would it hurt my practice (if i do become an endo) if a tooth's restorability is questionable and return the pt back to GP because I "didn't help" the GP by doing the RCT. Also, is it at all possible to become a GP again after you specialized or you're pretty much doomed if you choose to go GP again.

If you are not willing to help bailing the referring GPs out, they will choose another endo in the area who is willing to help. Your job as a specialist is to help make the GPs' lives easier. It should be an honor that a GP chooses you over another endo guy down the street. If you are a new unknown endo guy in town, this should be a good chance for you to prove to the GPs how good you are. You will become their hero when you help them correct their clinical mistakes. That’s how you earn their trust. That's how you build your reputation.

If you think the tooth’s prognosis is questionable, you need to inform both the patient and the referring GP. Both the patient and GP understand that you are the expert in this field because you have extra years of training. And they usually go with what you recommended. The patient would be more upset if you did the RCT and the tooth fails within a couple of months. So you actually help both the patient and the referring GP by them by telling them your honest professional opinion. My wife is a perio and she has seen a lot of cases that were misdiagnosed by the referring GPs. She often had to change the GP’s original tx plans. The GPs don’t mind the changes. The reason they refer patients to her is to seek better tx options from her.

 

[fakebun]

thank you for the reply. I'd be happy if a GP is choosing me as their referring endo and I wasn't implying that I don't want to help the GP out. I guess I'm just very worried about not knowing how to treat super difficult cases that are referred to me and thereby killing the confidence of any GP in me. But then again I worry too much about stuff that I shouldn't be worrying right now since I didn't get in yet 😀

 

[Cold Front]

Endo is much harder to get into than perio.

I would say Endo is hard to get in directly from pre-doc and as a new grad than working for few years and applying to Endo.

Most people don’t realize that Endo programs first and foremost are looking for applicants who have real world experience, who will be less needy in the clinic, and will see more cases and produce more for the clinic. That’s it! A former associate of mine just recently applied with 5 years experience to just 1 Endo program and he got in. He was not in the top half of his class, but he met the “criteria” most Endo programs look for; experience, less needy compared to new grads, can and will see more patients (aka more $$$). The downside to Endo program these days are; 1) potential income loss as a general dentist for 2 years (probably $350-400k) plus $200-300k in additional student loans and interest in Endo residency. Economically speaking, the opportunity cost to specialize in Endo is $550-700k before compounding interest, but realistically closer to $800-900k. My 2 cents.

 

[321931]

I would say Endo is hard to get in directly from pre-doc and as a new grad than working for few years and applying to Endo.

Most people don’t realize that Endo programs first and foremost are looking for applicants who have real world experience, who will be less needy in the clinic, and will see more cases and produce more for the clinic. That’s it! A former associate of mine just recently applied with 5 years experience to just 1 Endo program and he got in. He was not in the top half of his class, but he met the “criteria” most Endo programs look for; experience, less needy compared to new grads, can and will see more patients (aka more $$$). The downside to Endo program these days are; 1) potential income loss as a general dentist for 2 years (probably $350-400k) plus $200-300k in additional student loans and interest in Endo residency. Economically speaking, the opportunity cost to specialize in Endo is $550-700k before compounding interest, but realistically closer to $800-900k. My 2 cents.

I thought endo gets paid a stipend? Is the only dental residency that gets paid a stipend....omfs? It's crazy how we have to pay to go to residency. Other medical specialties get paid- and don't have to pay.

 

[Huskk]

I thought endo gets paid a stipend? Is the only dental residency that gets paid a stipend....omfs? It's crazy how we have to pay to go to residency. Other medical specialties get paid- and don't have to pay.

Generally it's the hospital-based programs that receive stipends/have no tuition. The big ones are OMFS, Peds, and Anesthesiology. Only a fraction of the other specialties are hospital-based or receive a stipend.

 

[FutureDent020]

Yea, Albert Einstein and the NY VA programs are the only paid residencies. Some state funded programs don’t have tuition, but do have equipment fees ~ $8K-$15K a year

 

[P7898]

Anyone want to shed some light on perio in this discussion for student interest?

 

[Cold Front]

I thought endo gets paid a stipend? Is the only dental residency that gets paid a stipend....omfs? It's crazy how we have to pay to go to residency. Other medical specialties get paid- and don't have to pay.

No. Almost all Endo programs don’t have stipends. You pay them $100’s of thousands and produce $1M+ worth of Endo procedures. You pay programs to make money for the programs. Best business model.