How open are your clinics right now? D3/D4

[Stanelz]

---

Members don't see this ad.

Hey upper class men, how open are your clinics right now? Apparently there are tons of schools that are still not seeing patients at all as D3's and barely seeing patients as D4's. Tuitions are still going up ha...

Here at LECOM we are at half time, as D3 i am seeing (up to) 5 patients a week and there are no restrictions on what procedures I can do. Ive been able to do hygiene, restorative, endo, and prosth. We are of course wearing tons of PPE and patients are being screened at the door before entering clinics.

How are things at your school?

 

[Roy Williams]

Seeing 1-2 patients a day almost every day. D4

 

[TheSandlapper]

.

 

[New_Vegas]

My school is pretty much back to normal. Fully booked out schedule next week. (2pts per day)

 

[AONLINE]

D4 at a school in the Midwest. Technically I can see 2 patients a day (10/week) but the number of chairs available have been cut down in half so right now I’m seeing an average of 5 patients a week, depends on the week. Last week I saw only 2 patients. The patient pool is much dryer for the D3’s, most of them only have enough patients for 2 clinic sessions a week.
Endo seems to be the only thing that our class is behind. I personally have only done one anterior RCT on a live patient, while almost of half of my classmates never completed one. The D3’s are behind on almost every requirements, understandably. I think their pt flow can only improve until after our class graduate and they inherit all of our patients.

 

[Pablo Sanchez]

D3 at a school in the Northeast. Our clinics have been open and running at full capacity since early July. We each have a chair and patient flow is high. The only difference is the covid screening questions, temperature checks, and PPE.

 

[whatisit350]

D3 here. currently have 2 clinic sessions per week, and only actually seeing 1 patient per week on average. sometimes 2, sometimes 0. A combo of Corona and D4's taking our patients/procedures, I would say are the main contributors to us seeing so few patients. Also, going to a school that has all specialties doesn't help either. For example, minus the rare exception, any molar endo will go straight to PG endo.

 

[New_Vegas]

For example, minus the rare exception, any molar endo will go straight to PG endo.

As it should, for the patient's safety. Molar endo isn't easy and there's a reason why we have specialists to do it.

 

[piratewow]

D3 in the South, all of us are required to have D3/D4 assistants so capacity is basically automatically 50% or less. D4s are getting decent, albeit slower progress, but D3s are getting much lower experience than previous years. Lots of oral exams, prophys, not much else honestly. Hopefully next semester will pick up. Basically seeing 1-2 pts a week and assisting/rotation 2-3 times a week.

 

[frozenicecreamDMD]

As it should, for the patient's safety. Molar endo isn't easy and there's a reason why we have specialists to do it.

molar endo is not easy but isn't rocket science to learn, but it requires time, patience, and skills. what do you think when patient in the real world cannot pay 1500$ for a molar rct and 1000$ for a build up and crown but a general dentist can charge 700-800$ for a molar rct and 900$ for bu/crown. their next step is to choose to extract the tooth. but this should go to the oral surgeon as well for a fully erupted tooth right. so you cannot help the patient to begin with.

While some molar rct have crazy curve, partial calcification and retreat that specialists have to do, other molar with straight canals general dentists can do. if you refuse to learn something because of patient safety, you probably can only do fillings and exams. SRP can go to hygienist/ perio. implant can go to perio, endo go to endo specialists, crowns can go to prosth.

 

[New_Vegas]

While some molar rct have crazy curve, partial calcification and retreat that specialists have to do, other molar with straight canals general dentists can do.

Yeah but do you think D3s should be doing molar endo? I don't. Dental students in general probably shouldn't be doing molar endo. It's another thing if someone does it in a GPR, or gets into it after plenty of experience in private practice.

 

[MLC45]

DS3 here- I have the opportunity to see 4 patients a week (if I can get a chair) for operative/restorative, fixed, oral exam/new patient work up and perio; 2 times a week in pedo, and 1 time a week in RPD. However, I actually see 2-3 patients a week because of lack of patients. I'm actually doing better than most of my classmates. DS3's don't do any endo because the 4th years are in desperate need for any and all that comes to the school. Currently we're running at about 45% patient load.

 

[frozenicecreamDMD]

Yeah but do you think D3s should be doing molar endo? I don't. Dental students in general probably shouldn't be doing molar endo. It's another thing if someone does it in a GPR, or gets into it after plenty of experience in private practice.

the school I went to predoc does molar endo (DS3 to be specific). DS3 also do surgical ext (lay flap, reduce bone, section teeth) and do alveoplasty. If you try hard, DS4 graduate with 20-30 molar endo completed, the hardest core DS4 can get to 50 molar RCT and up to 300 ext. this is recent 2018-2020. They did'nt get to molar endo right off the bat, they started with 3 anterior first, then couple premolars rct, then molar.

if you can't start to learn complex things in dental school how can you start to learn in private practice when the environment is more fast paced, production focused, and less tolerating of errors?

it is very hard to learn molar endo in private practice if you don't have a good foundation, hence most will choose to refer. learning how to work the handfile, feel tactile sensation, use rotary shaping, and get xray with rubber dam on, I guess only dental school can teach this, you don't have to be super good (just good enough to do the straight forward molar RCTs, which comprise like 60-70% of molar RCT).

 

[Quinque]

D3 in the South, all of us are required to have D3/D4 assistants so capacity is basically automatically 50% or less. D4s are getting decent, albeit slower progress, but D3s are getting much lower experience than previous years. Lots of oral exams, prophys, not much else honestly. Hopefully next semester will pick up. Basically seeing 1-2 pts a week and assisting/rotation 2-3 times a week.

I go to a school in Texas and this is basically my exact experience lol

edit: except the reason D3/D4 are paired to a single chair is due to our new curriculum, not because a covid safety measure or anything

 

[TXftw]

If your school refers every single molar endo to residents they’re screwing their students

 

[New_Vegas]

the school I went to predoc does molar endo (DS3 to be specific). DS3 also do surgical ext (lay flap, reduce bone, section teeth) and do alveoplasty. If you try hard, DS4 graduate with 20-30 molar endo completed, the hardest core DS4 can get to 50 molar RCT and up to 300 ext. this is recent 2018-2020. They did'nt get to molar endo right off the bat, they started with 3 anterior first, then couple premolars rct, then molar.

if you can't start to learn complex things in dental school how can you start to learn in private practice when the environment is more fast paced, production focused, and less tolerating of errors?

it is very hard to learn molar endo in private practice if you don't have a good foundation, hence most will choose to refer. learning how to work the handfile, feel tactile sensation, use rotary shaping, and get xray with rubber dam on, I guess only dental school can teach this, you don't have to be super good (just good enough to do the straight forward molar RCTs, which comprise like 60-70% of molar RCT).

I don't know, even with the very limited experience I have as a D4 in dental school, I've seen far too many botched root canals already. I've seen so many patients come in with gutta percha like 5, 6, 7, 8 mm short of the apex. Or have missed canals entirely... I've extracted many teeth because root canals have failed due to operator error, and the patient can't afford a retreat. I'm of the opinion that there are far too many dentists doing molar endo where they probably shouldn't be, and likely don't have adequate equipment or expertise that they should for those procedures (microscope, etc). Having one or two cherry picked "easy" molar endo cases in dental school with someone there to bail you out or help you find the canals probably isn't going to do much for you in the long run as far as competence goes in doing molar endo.

I really doubt there is anyone doing 50 molar endos in dental school. I also very much doubt there is anyone doing 20 molar endos in dental school. I've talked to people from schools that say they have zero root canal requirements in dental school. That's probably closer to the norm.

 

[frozenicecreamDMD]

I don't know, even with the very limited experience I have as a D4 in dental school, I've seen far too many botched root canals already. I've seen so many patients come in with gutta percha like 5, 6, 7, 8 mm short of the apex. Or have missed canals entirely... I've extracted many teeth because root canals have failed due to operator error, and the patient can't afford a retreat. I'm of the opinion that there are far too many dentists doing molar endo where they probably shouldn't be, and likely don't have adequate equipment or expertise that they should for those procedures (microscope, etc). Having one or two cherry picked "easy" molar endo cases in dental school with someone there to bail you out or help you find the canals probably isn't going to do much for you in the long run as far as competence goes in doing molar endo.

I really doubt there is anyone doing 50 molar endos in dental school. I also very much doubt there is anyone doing 20 molar endos in dental school. I've talked to people from schools that say they have zero root canal requirements in dental school. That's probably closer to the norm.

a lot of these patients, if you really ask, will confess their RCTs were done in countries outside America on tourism.

The school I went to it is normal for DS4 to have 20 molar endo exp and the top performer got up to 50 molar endo. Yes GPs dont have expertise to do molar endo that have roots with 90 degree bend or partially calcified teeth, retreat with posts in, but straight root RCT GPs can do. Loupes 4x-5x helps with molar endo. you don't need a microscope for that. before microscopes come around, endo specialists did not practice with a microscope.

to be honest with you, if you dont have a foundation to do more complex dentistry, ex: surgical ext, pulpotomy/ssc, molar endo, you will be working medicaid all day to make ends need because dentistry nowadays is not about drill and fill anymore.

 

[TanMan]

the school I went to predoc does molar endo (DS3 to be specific). DS3 also do surgical ext (lay flap, reduce bone, section teeth) and do alveoplasty. If you try hard, DS4 graduate with 20-30 molar endo completed, the hardest core DS4 can get to 50 molar RCT and up to 300 ext. this is recent 2018-2020. They did'nt get to molar endo right off the bat, they started with 3 anterior first, then couple premolars rct, then molar.

if you can't start to learn complex things in dental school how can you start to learn in private practice when the environment is more fast paced, production focused, and less tolerating of errors?

it is very hard to learn molar endo in private practice if you don't have a good foundation, hence most will choose to refer. learning how to work the handfile, feel tactile sensation, use rotary shaping, and get xray with rubber dam on, I guess only dental school can teach this, you don't have to be super good (just good enough to do the straight forward molar RCTs, which comprise like 60-70% of molar RCT).

I would have to disagree with you on the idea that only dental school can teach you certain ideas. I found that experience is the best teacher and that private practice is more tolerating of errors than dental school. This is where the unproductives sink because they cannot think on their feet as a clinician. I learned a lot of my modern endodontic techniques and molar endo in private practice and if I stuck with what I learned in dental school, I'd probably be broke.

Doing 50 molar endos in dental school is still doing it the dental school way. It just reinforces bad/unprofitable habits. If there was a school that taught you how to be productive and do sub-30 min molar endos (or 1 hour rctbucrn) and 0-5 minute surgical extractions, that's a school I'd definitely advocate attending. Otherwise, if it's just like any other bureaucratic school, I'd look into just having the highest board pass rates, lowest clinical requirements, and easiest to pass.

With technology these days, molar endo isn't as difficult as it used to be. CEREC has allowed for mass production of same day crowns on a grand scale. As clinicians and doctors of our field, we are (or should be) constantly evolving to becoming faster and better. Dental school knowledge gives us the absolute basic foundation, but we should not take the procedural aspects that we learned in dschool to heart. Otherwise, we may become unproductive and unprofitable dentists.

 

[frozenicecreamDMD]

I would have to disagree with you on the idea that only dental school can teach you certain ideas. I found that experience is the best teacher and that private practice is more tolerating of errors than dental school. This is where the unproductives sink because they cannot think on their feet as a clinician. I learned a lot of my modern endodontic techniques and molar endo in private practice and if I stuck with what I learned in dental school, I'd probably be broke.

Doing 50 molar endos in dental school is still doing it the dental school way. It just reinforces bad/unprofitable habits. If there was a school that taught you how to be productive and do sub-30 min molar endos (or 1 hour rctbucrn) and 0-5 minute surgical extractions, that's a school I'd definitely advocate attending. Otherwise, if it's just like any other bureaucratic school, I'd look into just having the highest board pass rates, lowest clinical requirements, and easiest to pass.

With technology these days, molar endo isn't as difficult as it used to be. CEREC has allowed for mass production of same day crowns on a grand scale. As clinicians and doctors of our field, we are (or should be) constantly evolving to becoming faster and better. Dental school knowledge gives us the absolute basic foundation, but we should not take the procedural aspects that we learned in dschool to heart. Otherwise, we may become unproductive and unprofitable dentists.

I agree with you. My post is about the idea that all molar RCTs should be referred out because general dentist is not equipped to do them.

I am a new grad and have heard many other new grad don't do molar RCT because they take longer, nervousness, etc. At least for me, my molar RCT is getting to 40-50min including the BU.

May be I am fortunate enough to go to a dental school where endo prof teaches the most current endo technique (waveone gold, protaper gold, etc)

 

[Cavity_Search]

D3 at UNC - clinics have been TERRIBLE. The school was completely shut down from March to August - then only D4s saw patients in August. We've been at 50% clinic capacity this whole time. Only in September D3s got to see patients, and we'd only get to see 1, maybe 2 if we're lucky, patients a week. Some weeks we got ZERO patients. They've made our D3 class assist D4s and residents for probably over a 100 hours this semester. Majority of our class has never done a single endo procedure, fixed or removable procedure, or extraction. Also our dean announced today he is quitting at the end of this year.

 

[Cold Front]

Also our dean announced today he is quitting at the end of this year.

Ha! He probably sees the writing on the wall. I wouldn’t be surprised if he lost a loved one to covid. He knows his decision to run a dental school contributes to covid community spread. 100s of patients walk through a dental school clinic every day. They are not being probably covid tested by the schools; just a questionnaire and temperature checks. Covid is in every dental school building like an invisible fly on the wall.

I lost 2 relatives to covid. I have been inside of a covid ICU unit. This virus is a fake disease to many, and indifferent to almost everyone else. Almost 2,000 people dying daily nationwide will eventually take a toll on the nation - even for the first 6-12 months of a vaccine distribution.

 

[William M Buttlicker]

D3 here in a private school from the northeast, and clinic has been closed since march for D3s and D4s. I have yet to see my first patient. Life sucks

 

[MLC45]

DS3 here. Our 4th years started back in May and everyone else came back in June. The first couple months was a challenge finding an empty chair to claim since it was a free for all with a 55% reduction. However, the school has done a good job at making sure everyone has a fair shot at clinic time. Come spring semester we've been told they will open up more chairs and we should be working at about 75% capacity. The school also opened up some old clinics that weren't used any more so we can have better social distancing. I have 6 patients scheduled for next week so I get to feel like I'm actually becoming a dentist. No endo though. All endo gets passed to the 4th years because that's hard to find. Most people just have the tooth extracted because of financial issues this year.

 

[AONLINE]

D3 at UNC - clinics have been TERRIBLE. The school was completely shut down from March to August - then only D4s saw patients in August. We've been at 50% clinic capacity this whole time. Only in September D3s got to see patients, and we'd only get to see 1, maybe 2 if we're lucky, patients a week. Some weeks we got ZERO patients. They've made our D3 class assist D4s and residents for probably over a 100 hours this semester. Majority of our class has never done a single endo procedure, fixed or removable procedure, or extraction. Also our dean announced today he is quitting at the end of this year.

I feel you. The D3's at our school are probably in the same boat in term of having to assist several times a week. Faculty shortage has been a big problem at our school as a lot of people have retired in the past several months, and the school is refusing to hire new people due to budget issues. It's just a mess.

 

[TanMan]

I agree with you. My post is about the idea that all molar RCTs should be referred out because general dentist is not equipped to do them.

I am a new grad and have heard many other new grad don't do molar RCT because they take longer, nervousness, etc. At least for me, my molar RCT is getting to 40-50min including the BU.

May be I am fortunate enough to go to a dental school where endo prof teaches the most current endo technique (waveone gold, protaper gold, etc)

Although we were all slow in the beginning, if we have a gap in our schedule and have a willingness to learn, I would encourage a young developing dentist to take the case so that he/she may learn how to do molar endos. If you refer all molar RCT, you'll never learn to do them efficiently and profitably. As I've alluded to, there are some killer combos in private practice such as the rctbucrn (+ CL), ext/graft/membrane/immediate implant + custom abut/crn, ortho/veneer for cosmetic practices, etc. Not having molar endo is a huge loss in the rctbucrn sequence and loss of a quick and profitable combo. One of the things I've been doing to streamline rctbucrns recently is to make sure all my preps can accept a rubber dam clamp after prep. So I can prep all teeth now, then come back and finish the rct while the crown is being milled.

 

[frozenicecreamDMD]

Although we were all slow in the beginning, if we have a gap in our schedule and have a willingness to learn, I would encourage a young developing dentist to take the case so that he/she may learn how to do molar endos. If you refer all molar RCT, you'll never learn to do them efficiently and profitably. As I've alluded to, there are some killer combos in private practice such as the rctbucrn (+ CL), ext/graft/membrane/immediate implant + custom abut/crn, ortho/veneer for cosmetic practices, etc. Not having molar endo is a huge loss in the rctbucrn sequence and loss of a quick and profitable combo. One of the things I've been doing to streamline rctbucrns recently is to make sure all my preps can accept a rubber dam clamp after prep. So I can prep all teeth now, then come back and finish the rct while the crown is being milled.

I think I see some pictures of this style (prep the crown then do RCT but for some patient, the caries is so extensive (either DO or MO) that this is unrealistic and some offices are not digital but I agree with you RCT/BU/Crown is very profitable.

 

[P7898]

DO you all think that CODA will change graduation requirements for the D3s?

 

[Jshilkof]

Yeah but do you think D3s should be doing molar endo? I don't. Dental students in general probably shouldn't be doing molar endo. It's another thing if someone does it in a GPR, or gets into it after plenty of experience in private

 

[Jshilkof]

I think this issue comes down to proper mentorship. I agree that complicated endo procedures are not for the faint hearted. However, if a student is genuinely interested in the speciality, and has decent hands with the ability to learn, I see no reason for a D3 or D4 to refrain from more involved procedures under the guidance of adept faculty. This is your time to learn. If you are told that you should never apply yourself to these more difficult situations while in school, you will surely have a difficult transition while attempting such procedures in private practice.

 

[P7898]

^ in addition it is time to find out what you like and dislike doing during your D3 and D4 years and see what you are good at and not good at. All of these are important things to explore during this time. So apply yourself and try to do everything under the sun with supervision and guidance. But always remember that patient safety is #1, during a difficult procedure if you are not comfortable just ask for guidance and help -> this is the beautiful thing about school.

 

[TXftw]

Yeah but do you think D3s should be doing molar endo? I don't. Dental students in general probably shouldn't be doing molar endo. It's another thing if someone does it in a GPR, or gets into it after plenty of experience in private practice.

Dental students in general shouldn’t be doing molar endo?? Dude... good luck in the real world. I believe dental students should be doing a lot more molar endo. At least that way they’ll have a bail out when they need it. Everyone has to start somewhere and learning anything comes through the school of hard knocks. When you do it outside of school your license is on the line. In the real world you eat what you kill. Of course there are those cases that should be referred out, but if you refer every molar endo out because you never learned how to do it because you’re scared, it’s very limiting. Especially during the times we’re currently in. I guarantee you’re not gonna fill your schedule full of veneers and Gucci dentistry. If you as a dentist can’t get people out of pain and get paid for it, you’re gonna have a hard time. If you’re still uncomfortable doing molar endo after school get a bunch of extracted molars and practice a lot. Also probably take a CE course.

 

[PerioDont]

Dental students in general shouldn’t be doing molar endo?? Dude... good luck in the real world. I believe dental students should be doing a lot more molar endo. At least that way they’ll have a bail out when they need it. Everyone has to start somewhere and learning anything comes through the school of hard knocks. When you do it outside of school your license is on the line. In the real world you eat what you kill. Of course there are those cases that should be referred out, but if you refer every molar endo out because you never learned how to do it because you’re scared, it’s very limiting. Especially during the times we’re currently in. I guarantee you’re not gonna fill your schedule full of veneers and Gucci dentistry. If you as a dentist can’t get people out of pain and get paid for it, you’re gonna have a hard time. If you’re still uncomfortable doing molar endo after school get a bunch of extracted molars and practice a lot. Also probably take a CE course.

Pain is the great motivator in dentistry. Veneers and implants, even crowns many times are not priorities for most people in my experience.

IMO Endo and Exo are the #1 thing needed to be learned well by dental students and new grads.

 

[Screwtape]

Dental students in general shouldn’t be doing molar endo?? Dude... good luck in the real world. I believe dental students should be doing a lot more molar endo. At least that way they’ll have a bail out when they need it. Everyone has to start somewhere and learning anything comes through the school of hard knocks. When you do it outside of school your license is on the line. In the real world you eat what you kill. Of course there are those cases that should be referred out, but if you refer every molar endo out because you never learned how to do it because you’re scared, it’s very limiting. Especially during the times we’re currently in. I guarantee you’re not gonna fill your schedule full of veneers and Gucci dentistry. If you as a dentist can’t get people out of pain and get paid for it, you’re gonna have a hard time. If you’re still uncomfortable doing molar endo after school get a bunch of extracted molars and practice a lot. Also probably take a CE course.

I’m curious, where are you in your dental career? Also what general location? I did molar endo in dental school, I did molar endo in residency, I even did it in PP in the beginning, now I don’t. And I am plenty busy. Referring every molar endo is not “very limiting” in a lot of practices. I would guess that most general dentists in my area refer most or all molar endo out. Why? Because there are more profitable, predictable, and easier things to do. I have never worked in a Medicaid clinic so this may not apply in that type of practice setting. I also have not worked in a crazy saturated locale where you have to offer every service under the sun to keep busy and paid. But I also don’t practice in the sticks. YMMV

 

[frozenicecreamDMD]

Dental students in general shouldn’t be doing molar endo?? Dude... good luck in the real world. I believe dental students should be doing a lot more molar endo. At least that way they’ll have a bail out when they need it. Everyone has to start somewhere and learning anything comes through the school of hard knocks. When you do it outside of school your license is on the line. In the real world you eat what you kill. Of course there are those cases that should be referred out, but if you refer every molar endo out because you never learned how to do it because you’re scared, it’s very limiting. Especially during the times we’re currently in. I guarantee you’re not gonna fill your schedule full of veneers and Gucci dentistry. If you as a dentist can’t get people out of pain and get paid for it, you’re gonna have a hard time. If you’re still uncomfortable doing molar endo after school get a bunch of extracted molars and practice a lot. Also probably take a CE course.

I agree with you wholeheartedly. Extractions and molar endo have been saving my schedules. it is just not realistic for the pt to show up with a bombed out borderline restorable tooth - to be referred to endo, who decides its not restorable, then referred to OS. Some pts just leave and go to another office. GPs have limitations and should not do some retreat cases or super calcified cases.

since most new grads will start somewhere experienced grads do not (medicaid, heavy medicaid/PPO), extractions and RCT/BU/Crown are all you need to save your schedule. if you are lucky enough to land cushy associate job that you do 10 fillings a day and make 3k or 1-2 crown a day to make 3k a day consistently, kudos to you.

these tend to be limited exams. then they come back for comp exam where the fun dentistry begins (multiple crowns, smile make over, etc)

 

[Screwtape]

I agree with you wholeheartedly. Extractions and molar endo have been saving my schedules. it is just not realistic for the pt to show up with a bombed out borderline restorable tooth - to be referred to endo, who decides its not restorable, then referred to OS. Some pts just leave and go to another office. GPs have limitations and should not do some retreat cases or super calcified cases.

since most new grads will start somewhere experienced grads do not (medicaid, heavy medicaid/PPO), extractions and RCT/BU/Crown are all you need to save your schedule. if you are lucky enough to land cushy associate job that you do 10 fillings a day and make 3k or 1-2 crown a day to make 3k a day consistently, kudos to you.

these tend to be limited exams. then they come back for comp exam where the fun dentistry begins (multiple crowns, smile make over, etc)

I am not sure why one would send a non-restorable tooth to endo ? But yes molar endo skill set can definitely be helpful in the right clinic. My first job was a PPO heavy place, but I ended up phasing out my molar endo because I would produce more with other “easier” procedures given the same amount of time. All I’m saying is that molar endo is not the end all be all procedure out there. Far from it honestly. I don’t like comments like “good luck in the real world” from the poster I initially replied to. The real world is very diverse. I am just offering a different part of that real world.

 

[frozenicecreamDMD]

I am not sure why one would send a non-restorable tooth to endo ? But yes molar endo skill set can definitely be helpful in the right clinic. My first job was a PPO heavy place, but I ended up phasing out my molar endo because I would produce more with other “easier” procedures given the same amount of time. All I’m saying is that molar endo is not the end all be all procedure out there. Far from it honestly. I don’t like comments like “good luck in the real world” from the poster I initially replied to. The real world is very diverse. I am just offering a different part of that real world.

some teeth are "borderline" restorable. By that I mean we as clinicians are not sure how long the RCT/Crown will last the pt but the pt wanna save the tooth at all cost. you probably have some of the pts.

you are very lucky you end up at a PPO heavy place as most new grads (myself included) will start with medicaid somewhat heavy. and in this type of practice, yes endo and ext are end all be all

 

[TXftw]

I’m curious, where are you in your dental career? Also what general location? I did molar endo in dental school, I did molar endo in residency, I even did it in PP in the beginning, now I don’t. And I am plenty busy. Referring every molar endo is not “very limiting” in a lot of practices. I would guess that most general dentists in my area refer most or all molar endo out. Why? Because there are more profitable, predictable, and easier things to do. I have never worked in a Medicaid clinic so this may not apply in that type of practice setting. I also have not worked in a crazy saturated locale where you have to offer every service under the sun to keep busy and paid. But I also don’t practice in the sticks. YMMV

Im a new grad and practice in a metropolitan city. Personally I have a lot of PPO patients that skip a lot of appointments and don’t prioritize getting their crowns and fillings done. When I get those holes in my schedule the endo/BU/CRN combination saves my ass. If you have a nice cushy practice where you can fill your schedule with stress free profitable dentistry that’s great. My motto is make as much money as possible while exerting the least amount of effort and taking on minimal amounts of liability. Your experience is more atypical, especially for new grads. Too bad that’s not a reality for a lot of us and when **** hits the fan people will always pay to get out of pain. Even if they can’t pay, they’ll borrow the money from someone else. I’m guessing you own your own practice. If you’re an associate, being proficient at molar endo makes you much more marketable in today’s job market.

 

[frozenicecreamDMD]

Im a new grad and practice in a metropolitan city. Personally I have a lot of PPO patients that skip a lot of appointments and don’t prioritize getting their crowns and fillings done. When I get those holes in my schedule the endo/BU/CRN combination saves my ass. If you have a nice cushy practice where you can fill your schedule with stress free profitable dentistry that’s great. My motto is make as much money as possible while exerting the least amount of effort and taking on minimal amounts of liability. Your experience is more atypical, especially for new grads. Too bad that’s not a reality for a lot of us and when **** hits the fan people will always pay to get out of pain. Even if they can’t pay, they’ll borrow the money from someone else. I’m guessing you own your own practice. If you’re an associate, being proficient at molar endo makes you much more marketable in today’s job market.

being proficient at molar endo and surgical extractions are the key now.

when you get them out of pain, they will remember you and come back for comprehensive care.

 

[Screwtape]

some teeth are "borderline" restorable. By that I mean we as clinicians are not sure how long the RCT/Crown will last the pt but the pt wanna save the tooth at all cost. you probably have some of the pts.

you are very lucky you end up at a PPO heavy place as most new grads (myself included) will start with medicaid somewhat heavy. and in this type of practice, yes endo and ext are end all be all

So it seems that we are discussing different things here. The majority of dental practices don’t take Medicaid. Even then, some states’ Medicaid programs don’t allow molar endo or heavily limit it. I have no experience in clinics that take Medicaid so my words do not apply to that clinical setting. The majority of my classmates went into offices/clinics straight from school that did not take Medicaid (we took a poll). I would think that’s the case for the majority of new grads but I may be geographically biased. Anyone have a stat?

Im a new grad and practice in a metropolitan city. Personally I have a lot of PPO patients that skip a lot of appointments and don’t prioritize getting their crowns and fillings done. When I get those holes in my schedule the endo/BU/CRN combination saves my ass. If you have a nice cushy practice where you can fill your schedule with stress free profitable dentistry that’s great. My motto is make as much money as possible while exerting the least amount of effort and taking on minimal amounts of liability. Your experience is more atypical, especially for new grads. Too bad that’s not a reality for a lot of us and when **** hits the fan people will always pay to get out of pain. Even if they can’t pay, they’ll borrow the money from someone else. I’m guessing you own your own practice. If you’re an associate, being proficient at molar endo makes you much more marketable in today’s job market.

PPO practices are so varied it’s hard to compare them. I was in a heavy PPO practice my first job out. Again, I was able to phase molar endo out because I was able to be kept busier doing other things (this continued to my second associateship and now as an owner). Same day Endo/BU/crown by a minimally experienced general dentist on symptomatic molars that don’t come in for regular recalls is potentially not doing the patient an optimal service. Symptomatic molars have the highest failure rate even if done by the most experienced endodontist. So now they just maxed out their insurance (and paid a fair amount out of pocket) for the year to save one tooth, when they could have 10 other things going on. And hopefully it worked. And hopefully it was more than “borderline restorable” as mentioned above for long-term prognosis. I am speaking in generalities here, not attacking anyone as a provider. You very well could be doing amazing work and providing an optimal service for your patients. But I’m sure you follow my train of thought.

I may be getting a bit into the weeds here, but my point is that in the practice setting you are in you believe molar endo is saving your schedule. I am not denying that. I was just stating my perspective where molar endo wasn’t necessary to save my schedule. And I know that was the case for most of my friends in DS as new grads and as the new grads came in every year into the group practice I started out at. It would be interesting to see what % of new grads routinely do molar endo their first, second, etc year out. And compare their production.

In the right practice doing a good job at molar endo can be beneficial no doubt. But I believe in the majority of practices out there, molar endo is one of the first procedures given up by general dentists. For a reason.

We do all agree that proficiency in extractions is very important!

 

[TXftw]

So it seems that we are discussing different things here. The majority of dental practices don’t take Medicaid. Even then, some states’ Medicaid programs don’t allow molar endo or heavily limit it. I have no experience in clinics that take Medicaid so my words do not apply to that clinical setting. The majority of my classmates went into offices/clinics straight from school that did not take Medicaid (we took a poll). I would think that’s the case for the majority of new grads but I may be geographically biased. Anyone have a stat?


PPO practices are so varied it’s hard to compare them. I was in a heavy PPO practice my first job out. Again, I was able to phase molar endo out because I was able to be kept busier doing other things (this continued to my second associateship and now as an owner). Same day Endo/BU/crown by a minimally experienced general dentist on symptomatic molars that don’t come in for regular recalls is potentially not doing the patient an optimal service. Symptomatic molars have the highest failure rate even if done by the most experienced endodontist. So now they just maxed out their insurance (and paid a fair amount out of pocket) for the year to save one tooth, when they could have 10 other things going on. And hopefully it worked. And hopefully it was more than “borderline restorable” as mentioned above for long-term prognosis. I am speaking in generalities here, not attacking anyone as a provider. You very well could be doing amazing work and providing an optimal service for your patients. But I’m sure you follow my train of thought.

I may be getting a bit into the weeds here, but my point is that in the practice setting you are in you believe molar endo is saving your schedule. I am not denying that. I was just stating my perspective where molar endo wasn’t necessary to save my schedule. And I know that was the case for most of my friends in DS as new grads and as the new grads came in every year into the group practice I started out at. It would be interesting to see what % of new grads routinely do molar endo their first, second, etc year out. And compare their production.

In the right practice doing a good job at molar endo can be beneficial no doubt. But I believe in the majority of practices out there, molar endo is one of the first procedures given up by general dentists. For a reason.

We do all agree that proficiency in extractions is very important!

I don’t cement the crown the same day. I don’t have Cerec or any of that fancy stuff. I’m still doing it old school and sending PVS impressions to a lab. I monitor the problematic teeth I RCT before delivering a crown. On many teeth I’ll let CaOH sit in the canal for a week before obturation.
I don’t completely disagree with you. However, you likely graduated during an easier time. 2020 was the worst year in the history of dentistry to be a new grad and pickings were slim. The more you know how to do the more versatile you are and the better you get by when times are tough. Like I said before, from a simplicity and stress standpoint I’d be happy just doing the easy stuff, but I’d be doing a whole lot of sitting around. If I’m not seeing any patients due to cancellations I’m practicing molar endo on extracted teeth so I can be a better provider.

Also, I completely agree that EXTs are very important to be proficient at. Lowest overhead procedure in dentistry.

 

[frozenicecreamDMD]

I don’t cement the crown the same day. I don’t have Cerec or any of that fancy stuff. I’m still doing it old school and sending PVS impressions to a lab. I monitor the problematic teeth I RCT before delivering a crown. On many teeth I’ll let CaOH sit in the canal for a week before obturation.
I don’t completely disagree with you. However, you likely graduated during an easier time. 2020 was the worst year in the history of dentistry to be a new grad and pickings were slim. The more you know how to do the more versatile you are and the better you get by when times are tough. Like I said before, from a simplicity and stress standpoint I’d be happy just doing the easy stuff, but I’d be doing a whole lot of sitting around. If I’m not seeing any patients due to cancellations I’m practicing molar endo on extracted teeth so I can be a better provider.

Also, I completely agree that EXTs are very important to be proficient at. Lowest overhead procedure in dentistry.

yea 2020 is the worst worst year to be a dentist, let alone a brand new grad (I am 2020 year grad). hopefully things take a turn for the better

 

[Screwtape]

I don’t cement the crown the same day. I don’t have Cerec or any of that fancy stuff. I’m still doing it old school and sending PVS impressions to a lab. I monitor the problematic teeth I RCT before delivering a crown. On many teeth I’ll let CaOH sit in the canal for a week before obturation.
I don’t completely disagree with you. However, you likely graduated during an easier time. 2020 was the worst year in the history of dentistry to be a new grad and pickings were slim. The more you know how to do the more versatile you are and the better you get by when times are tough. Like I said before, from a simplicity and stress standpoint I’d be happy just doing the easy stuff, but I’d be doing a whole lot of sitting around. If I’m not seeing any patients due to cancellations I’m practicing molar endo on extracted teeth so I can be a better provider.

Also, I completely agree that EXTs are very important to be proficient at. Lowest overhead procedure in dentistry.

Yes 2020 will hopefully be a major outlier. It was a very atypical year.

In regards to 2-stepping root canals with CaOH, you should call your local endodontist and see how often they do that. I’m not bashing your clinical judgement here, I was taught the same in school.

 

[FutureDent020]

Yes 2020 will hopefully be a major outlier. It was a very atypical year.

In regards to 2-stepping root canals with CaOH, you should call your local endodontist and see how often they do that. I’m not bashing your clinical judgement here, I was taught the same in school.

CaOH is ineffective unless it is contacting bacteria. It does create an unstable environment for bacteria but it’s main function is breaking down the bacterial membrane. Honestly, it’s great for trauma cases, stopping types of resorption, and killing gram (-) bacteria it can come into contact with. For a SIP/SAP molar, it’s really pointless to use. Most important thing to do is find all the canals (we find a clinical MB2 in 1st molars that we can instrument between 75-90%), instrument them properly and irrigate sufficiently. If we don’t feel like we have had enough time to irrigate the tooth, we’ll 2 step, or if we can’t get it dry (exudate/ heme). Otherwise most endo will always 1 step. Symptoms don’t play a part believe it for not. For us at least. If they do, it’s purely preference and anecdotal. And always remember, it’s what you take out of the tooth that generally predicts root canal success, not what you put in. You could do a beautiful #14 with perfect lengths and obturation, but if you leave a MB2 with its own POE, it’s going to fail at some point. If you don’t instrument and irrigate properly, but your obturation looks nice and dense (usually a carrier) it’s probably going to fail too.

We understand GP’s do majority of the root canals, just use a rubber damn, clean the hell out of it, and know your limits.

 

[TXftw]

CaOH is ineffective unless it is contacting bacteria. It does create an unstable environment for bacteria but it’s main function is breaking down the bacterial membrane. Honestly, it’s great for trauma cases, stopping types of resorption, and killing gram (-) bacteria it can come into contact with. For a SIP/SAP molar, it’s really pointless to use. Most important thing to do is find all the canals (we find a clinical MB2 in 1st molars that we can instrument between 75-90%), instrument them properly and irrigate sufficiently. If we don’t feel like we have had enough time to irrigate the tooth, we’ll 2 step, or if we can’t get it dry (exudate/ heme). Otherwise most endo will always 1 step. Symptoms don’t play a part believe it for not. For us at least. If they do, it’s purely preference and anecdotal. And always remember, it’s what you take out of the tooth that generally predicts root canal success, not what you put in. You could do a beautiful #14 with perfect lengths and obturation, but if you leave a MB2 with its own POE, it’s going to fail at some point. If you don’t instrument and irrigate properly, but your obturation looks nice and dense (usually a carrier) it’s probably going to fail too.

We understand GP’s do majority of the root canals, just use a rubber damn, clean the hell out of it, and know your limits.

This is good information. I use CaOH and do 2 step endo mostly for necrotic teeth because from what I understand there is a layer of bacterial biofilm in the canal. From what I understand in vital cases most of, if not all the root canal system is sterile and at that point it’s just about keeping it sterile. I do have a question. How often do you feel like you see Endodontic failure from a long obturation (last the apex)? Considering the sanitization aspect of the root canal was done well. I definitely understand that if you obturate short and your endo failed there was obviously probably an issue with failure to sanitize the full extent of the root canal system.

 

[Screwtape]

CaOH is ineffective unless it is contacting bacteria. It does create an unstable environment for bacteria but it’s main function is breaking down the bacterial membrane. Honestly, it’s great for trauma cases, stopping types of resorption, and killing gram (-) bacteria it can come into contact with. For a SIP/SAP molar, it’s really pointless to use. Most important thing to do is find all the canals (we find a clinical MB2 in 1st molars that we can instrument between 75-90%), instrument them properly and irrigate sufficiently. If we don’t feel like we have had enough time to irrigate the tooth, we’ll 2 step, or if we can’t get it dry (exudate/ heme). Otherwise most endo will always 1 step. Symptoms don’t play a part believe it for not. For us at least. If they do, it’s purely preference and anecdotal. And always remember, it’s what you take out of the tooth that generally predicts root canal success, not what you put in. You could do a beautiful #14 with perfect lengths and obturation, but if you leave a MB2 with its own POE, it’s going to fail at some point. If you don’t instrument and irrigate properly, but your obturation looks nice and dense (usually a carrier) it’s probably going to fail too.

We understand GP’s do majority of the root canals, just use a rubber damn, clean the hell out of it, and know your limits.

Yup this agrees with what I’ve been told by my local endo’s. I don’t mess with resorption cases so unfamiliar about that. If you shape and clean well and get a clean and dry paper point at length, then obturate that sucka!

 

[FutureDent020]

This is good information. I use CaOH and do 2 step endo mostly for necrotic teeth because from what I understand there is a layer of bacterial biofilm in the canal. From what I understand in vital cases most of, if not all the root canal system is sterile and at that point it’s just about keeping it sterile. I do have a question. How often do you feel like you see Endodontic failure from a long obturation (last the apex)? Considering the sanitization aspect of the root canal was done well. I definitely understand that if you obturate short and your endo failed there was obviously probably an issue with failure to sanitize the full extent of the root canal system.

That’s a good question. The classic literature shows higher failure rates with over extension, but it’s not black and white. If you clean the tooth and conserve the apical anatomy, meaning don’t zip, perforate, or blow out the apex. But your cone is a little long or you extrude more sealer than just a puff, this doesn’t mean imminent foreign body reaction that will lead to failure. It’s more about carefully instrumenting the apex and not extruding a bunch of bacteria and debris. The body has much more difficulty dealing with this than some sealer and gutta percha. Other lit suggests that instrumentation and obturation within 2mm of apical constriction generally leads to success. But if within those 2mm is an inflamed pulp stump or necrotic tissue then this will probably result in failure as well. If it’s vital tissue in that 2mm then you’d probably be ok.

As Endodontists, some of the steepest learning curve is learning how to instrument the last apical couple of mm’s conservatively enough to preserve the anatomy, but sufficiently enough to irrigate and clean. And then do it quickly and consistently. And we’re also considering microbiology, irrigation dynamics, and patient’s immune status. It’s a delicate combination of tooth engineering and microbiology/ immunology. If those are handled properly, that’s when you see the 90+% success rates. Proper diagnosis as well. A lot of necrotic/ SIP teeth that are treated have unnoticed cracks. These prognoses go way down. Microscope helps here.

Sorry- just realized I completely high jacked this thread. Forgot what the topic at hand even was. PM me if you have other Endo questions