Every 4 years the American Dental Association Survey Center publishes a review of all aspects of dentistry including a report entitled ‘‘The Economics of Endo- dontics’’. In this report, the Survey Center covers endo- dontic services and utilization, growth of the specialty, location of endodontists, characteristics of endodon- tists, finances, referrals, and ‘‘A Look at the Future.’’ The latest report was published in 2003 covering the years through 1999 with a few references in the years 2000 and 2001.10Portions of the report were published in the Journal of Endodontics in 2006.11
The report paints a rather pleasant picture of the present but voices some concerns about the distant future. Some concerns had not developed by 1999, such as the impact implants would have on the prac- tice of endodontics. The report also predicted that the population of the United States would not reach 300 million until 2010 when in reality this figure was reached in October of 2006. On the whole, however, their concerns for the future bear review and atten- tion.
One changing relationship arising is between the specialty and general practitioners. For instance, the ratio between general dentists and endodontists is dropping; in 1982, there were 50.3 possible referring general dentists to each endodontist. But by 2002, the
ratio was down to 34.5 and falling (Figure 3). Although general dentists perform about 75% of all endodontic procedures, they still refer 25% to endo- dontists; whether this will change is open to specula- tion.
The number of endodontists has grown at a faster rate than any other dental specialty. Between 1982 and 2002 ‘‘the number of professionally active endodon- tists had increased by 85%.’’ In contrast, ‘‘[g]eneral practitioners grew at a rate of 33% from 1982 to 2002.’’10,11In 1989, there were 2,500 endodontic spe- cialists in the United States.18 By the year 2003, the number had risen to 4258 practicing endodontists.19 Between 1982 and 2003, the number of endodontists grew 107.9%, faster than any other specialty, well exceeding the rate of the growth of general practi-
tioners (38.4%).20 By November of 2006, according to the AAE, the specialty had grown to 4,859 endo- dontist members (personal communication, AAE).
There is no question that the greatest share of endodontic procedures is carried out by America’s general practitioners (Table 1). On the other hand, the specialty of endodontics is growing as well. For example, only 5% of those patients who had had root canal therapy in 1986 were treated by a specialist.12 By 1999, however, endodontists were providing 4.4 million procedures, which was 20.3% of the 21.9 million total endodontic procedures provided by all dentists, endodontists included (see Table 1).10
In 1999, there were over 1 billion dental services rendered. Only 1.7% of these procedures were endo- dontic. It is interesting to note, however, that while Figure 3 Ratio of general practitioners to endodontists, 1982–2002. Source: American Dental Association Survey Center, 1982–2002 Distribution of dentists in the United States by region and state.
Table 1 Distribution of Endodontic Procedures by Specialty, 1990 and 1999
Type of Dentist 1990 1999
General practitioners 15,758,100 76.1% 16,493,200 75.2% Endodontists 3,860,700 18.6% 4,459,900 20.3% Pediatric dentists 942,200 4.5% 721,300 3.3% Oral and maxillofacial
surgeons
108,800 0.5% 188,900 0.9% Orthodontic and dentofacial 0 0.0% 0 0.0% Orthopedists
Periodontists 31,800 0.2% 50,700 0.2% Prosthodontists 25,400 0.1% 18,800 0.1% Total 20,754,000 100.0% 21,932,800 100.0% Source: American Dental Association Survey Center, 1990 and 1999 Surveys of Dental Services Rendered.
<2% of the total services were endodontic, 15% of the total dental expenditures in 1999 went for endodontic treatment at a cost of 8.2 billion dollars.10
On a per capita basis, 6% of the total population received endodontic services in 1999. On the other hand, 9% of all dental patients received some form of endodontic treatment. In this same vein, general prac- titioners performed 16.5 million root canal procedures in 1999 compared to 4.5 million by endodontic specia- lists (see Table 1). However, endodontists performed 24.7 procedures a week compared to only 1.9 by gen-
eral practitioners (Figure 4). The average number of endodontic procedures in 1999 by a general practitioner (94.6) versus each endodontic specialist (1263.3) is striking (Figure 5).10
It is interesting to note the differences in the type of procedures performed by specialists versus general den- tists. Endodontists performed 61.9% of the molar root canal treatments and general practitioners did 29.6% of the molars—less than half. The remainder was probably done by oral surgeons. By the same token, general dentists did 20.1% of the anterior root canal procedures Figure 4 Total root canal treatments per week per dentist, 1999. Source: American Dental Association Survey Center. 1999 Survey of Dental Services Rendered.
and 9.8% of the pulp cappings, whereas the specialists treated only half as many anterior teeth and performed only 0.4% of the pulp cappings (Table 2).10,11 Molar
endodontics fairly well defines the difference in endo- dontic treatment performed between general dentists and endodontists.
Another consideration by the ADA survey group concerned amalgam versus resin restorations being placed, particularly in the posterior teeth. They pointed
out the age old record of amalgams protecting the pulp over long periods of time. In the year 2000, the jury was still out on the life span of posterior resins, so they were speculating on how failing resins in the future would impact the amount of endodontics to be done. They pointed out that amalgam restora- tions had declined from 100 million to 80 million between 1990 and 1999, a 20% decline, whereas resin restorations increased from 47.7 million in 1990 to 85.8 million in 1999, an 80% increase (Figure 6).10
Failing resins impacting an increase in endodon- tics may not be predictable at this time, whereas the age of patients in the future is predictable. Most root canal treatment is performed for patients between the ages of 25 and 64, particularly molar endodon- tics, done mostly by endodontists (Figure 7). Unfortunately, projected future change in the US population shows a severe drop off in the very age groups most prone to endodontic therapy (Figure 8). So this population shift may reduce the number of patients seeking endodontic services; at the same time the number of referring general dentists is decreasing.10,11 It is possible that the aging popula- tion (<64) will provide an increasing pool of patients needing endodontic services.
The present good news is that in the years 1997–1998, endodontists enjoyed an average net income of $230,000, second only to oral surgeons, a surprising figure considering average gross
Table 2 Endodontic Procedures Completed by General Practitioners and Endodontists, 1999
Endodontic
Procedures General Practitioners Endodontists
Molar root canals 4,887,500 29.6% 2,761,900 61.9% Biscuspid root canals 3,501,600 21.2% 908,500 20.4% Anterior root canals 3,317,600 20.1% 438,000 9.8% Pulpotomy 1,802,800 10.9% 158,700 3.6% Pulp cap 1,609,200 9.8% 16,400 0.4% Bleaching 1,237,600 7.6% 23,900 0.5% Apicoectomy 136,900 0.8% 152,500 3.4% Root amputation 0 0.0% 0 0.0% Total 16,493,200 100% 4,459,000 100%
Source: American Dental Association, Survey Center, 1990 and 1999 Surveys of Dental Services Rendered.
Figure 6 Number of amalgams and resins, 1990 (blue) and 1999 (red). Source: American Dental Association, Survey Center. 1990 and 1999 Surveys of Dental Services Rendered.
Figure 7 Root canal treatments by age. Source: American Dental Association, Survey Center. 1999 Survey of Dental Services Rendered.
endodontist billings of $491,550 (Figure 9). Only general practitioners and pediatric dentists reported lower billings. The reason is endodontic office expenses were exceptionally low—$237,320, lowest of all dentists. The average endodontic office
employs only 5.6 nondentist staff (Figure 10).10But remember, these figures, even though they are the latest available, are nearly 10 years old.
In spite of many encouraging figures for the present practice of endodontics, the future may not be as Figure 9 Average net income of specialists, 1990 and 1997–1998. Source: American Dental Association Survey Center. 1993 Survey of Dental Practice Specialists in Private Practice and 1998/1999 Survey of Dental Practice.
Figure 10 Average Practice Expenses per Owner, 1992 and 1997/1998. Source: American Dental Association Survey Center. 1993 Survey of Dental Practice Specialists in Private Practice and 1998/1999 Survey of Dental Practice.
‘‘rosy.’’ For example, the rate of dental caries is declining precipitously, and to a great extent, pulpal disease, leading to endodontic treatment, is driven by the index of dental caries.
Early in the 1970s, only 28% of the permanent teeth of American children were caries-free. Then, in 1988, the National Institute of Dental and Craniofacial Research (NIDCR) proudly announced that half of all children in the United States aged 5–17 years had no decay in their permanent teeth. None!21 Then again, between 1999 and 2002 the National Health and Nutri- tion Examination Survey (NHANES) reported that 62% of children and adolescents aged 6–19 years were caries- free in their permanent teeth.22And as reported in the NHANES between 1974 and 1994, the number of decayed-missing-filled (DMF) permanent teeth in the children, not caries-free (aged 6–18) decreased from 4.44 to 1.90 (57.2%). The number of DMF permanent surfaces also decreased, from 8.64 to 3.56 (58.8%) dur- ing this period.23In the year 2003, however, tooth decay was rising, reported as 78% of adolescents, perhaps indicating an emerging problem for older children con- suming ‘‘junk food’’ and sugary drinks.24
As far as older adults are concerned, the NIDCR reported a remarkable decline in edentulism as well, particularly in the middle-aged, a group in which ‘‘total tooth loss has been practically eliminated.’’25 Indeed, during the 1999–2002 survey, adults older than 20 years retained an average of 24 of 28 natural teeth, and only 8% were edentulous.22 The elderly (age 65 and older), however, ‘‘are still in serious trouble,’’ root caries and periodontal disease being the primary offen- ders.25 A recent study of 398 elderly women showed 36.4% were edentulous and 80.7% of the dentate women had periodontal disease.26It is likely that endo- dontists will share a greater part of the burden, carrying for our aging population. In addition, as the growing immigrant population in the United States becomes more affluent, it will increasingly seek care.
All of these encouraging figures suggest greater pre- ventive measures and higher use of dental services by the public. Part of the improvement can be credited to a healthier economy and lifestyle, part to the national water supply and dentifrice fluoridation programs, part to the dental profession’s efforts, and part to dental insurance. A research has shown that third-party pay- ment has increased the dental use and has improved oral health.27–29By 1995, the ADA estimated that 63% of all US citizens were covered by a private insurance program and another 5.3% by public assistance. The remaining 31.4% were not covered by any insurance program.30
Regardless, costs are high: in 2003, 43.1% of dental expenditures were paid by private insurance and 48.2%
were paid out of pocket. Government programs such as Medicaid and Medicare paid the remaining 8.2%.30How- ever, for endodontics in particular, approximately 70% of patients were covered by a private insurance program.31
In providing these burgeoning services, the dental profession has fared well financially. From 1986 to 1995, the net income of dentists increased by 30.7%.32 In 2003, the ADA reported that dentists annually averaged $177,340 net, a 31% increase from 1986 (when adjusted for 2003 dollars.33
Dental expenditures by the public have also increased, from $3.4 billion in 1967 to $10 billion in 1977, to $25.3 billion in 1987, to $47.5 billion in 1996, and to $67 billion in 2003.30 The expenditure for dental services has increased by 509% from 1975 to 2005.34 After all this expenditure and care, one is hard-pressed to explain why 15.1 million workdays are lost annually because of dental pain.35
ENDODONTICS CASE PRESENTATION
All of these improvements notwithstanding, many patients still must be convinced that root canal ther- apy is an intelligent, practical solution to an age-old problem—the loss of teeth. The ‘‘case for endodontic treatment’’ must be presented to the patient in a straightforward manner. The patient with the correct ‘‘oral image’’ will be anxious to proceed with therapy. ‘‘Is this tooth worth saving, doctor?’’ This senti- ment is voiced more often than not by the patient who has been informed that his or her tooth will require endodontic therapy. Superficially, this appears to be a simple question that requires a direct, uncomplicated answer. It should not be interpreted as a hostile or as a challenge to the treatment recommendations presented for the reten- tion of the tooth. Psychologically, however, this initial question is a prelude to a Pandora’s box of additional queries that disclose doubts, fears, appre- hensions, and economic considerations: for exam- ple, ‘‘Is it painful?’’ ‘‘Will this tooth have to be extracted later?’’ ‘‘How long will this tooth last?’’ ‘‘Is it a dead tooth?’’ ‘‘Will it turn black?’’ and ‘‘How much will it cost?’’
Following the first question, the dentist should anticipate such a series of questions. These may be avoided, however, by including the answers to anticipated questions in the presentation. In turn, the dentist will gain a decided psychological advan- tage. By this apparent insight into his or her pro- blems, the patient is assured that the dentist is cognizant of the very questions the patient was about to raise or possibly was too reticent to ask.
Most of the patient’s fear and doubts can be allayed by giving a concise answer to each question.
In today’s world, the patient may have been offered the choice between saving the tooth by root canal treat- ment and extracting the tooth and replacing it with an implant. Unless the tooth is hopeless, the dedicated dentist, one who believes in root canal therapy, should be able to make a positive case for retaining the tooth.
To answer patients’ questions, the ADA has pro- duced two inexpensive pamphlets entitled: Root Canal Treatment—Following up on your dentist’s recommen- dations and Understanding Root Canal Treatment*. The AAE also publishes a number of pamphlets for patients: the Your Guide To series: Endodontic Treat- ment, Dental Symptoms, Cracked Teeth, Endodontic Retreatment, Endodontic Surgery, Endodontic Post- Treatment Care, and Dental Symptoms†. Although this approach is somewhat impersonal, it is a tangible reference, particularly when the patient returns home and tries to explain to an interested spouse what endodontic therapy involves.
Based on previous experiences in the office, the average patient has sufficient confidence in the dentist’s ability to help. The patient is ready to accept the professional knowledge and advice offered but likes to have some part in evaluating the reasonableness of treatment. The professional person and the staff must spend time and thought necessary to understand the patient’s initial resistance, which is sometimes based on false assumptions and beliefs in matters dealing with pulpless teeth. However, once the patient is secure in the thought that this is the correct treatment, most of the fears and apprehensions related to unfamiliarity with endodontic therapy will be dissipated.
A dental appointment is still associated with fear in the minds of many people (Figure 11).36–38 The mere thought of treating the ‘‘nerve’’ of a tooth implies pain. Patients require reassurance, supported by all available psychological and therapeutic meth- ods of relaxation and pain control. The patient must be reassured that endodontic therapy need not be painful and usually requires no more than a local anesthetic.
All too often we hear negative remarks about root canal therapy: ‘‘Trying to do anything positive in Tacoma is akin to getting a root canal without Novo- cain.’’ Or, ‘‘Whew! What you just heard was a collective
sigh of relief following 7 months of agonizing root canal’’—remarks made following President Clinton’s ‘‘confession’’ on television. In contrast to these com- monly heard excoriations, LeClaire et al.38reported that 43.9% of endodontic patients reported a decrease in fearfulness after having root canal therapy. Further- more, 96.3% said that ‘‘they would have root canal therapy again to save a tooth’’. It should be explained to the concerned patient that root canal therapy is a specialized form of dental procedure designed to retain a tooth safely and comfortably. The tooth, when prop- erly treated and restored, can be retained as long as any other tooth. It is not a ‘‘dead tooth’’ as long as the roots of the tooth are embedded in healthy surrounding tis- sues. Although teeth do not turn ‘‘black’’ following root canal therapy, a slight change in color owing to reduced translucency may occur. Discoloration associated with pulp necrosis and leakage around restorations can be managed successfully (see Chapter 38). Most often, retention of the tooth and bleaching, veneering, or crowning (Figure 12) are preferable to extraction and/ or an implant and replacement with a prosthetic appli- ance.12
There is a little doubt that economic considerations play an important role (and for some a supreme role) in the final decision. Some patients ‘‘think finan- cially,’’ and even though they are able to afford treat- ment, they allow financial considerations to govern decisions that should logically be made on a physio- logical basis only. It is necessary to point out to these people the financial advantage of retaining a tooth by endodontic therapy rather than by extraction and prosthetic or implant replacement. In addition, it Figure 11 Rash (possibly hives) occurred in this terrified patient who was merely sitting in the dental chair prior to root canal treatment. The patient’s apprehension was allayed by sympathetic management, allowing successful completion in a four canal molar. Courtesy of Dr. Norbert Hertl.
*American Dental Association, 211 E. Chicago Ave. Chicago IL 60611
†American Association of Endodontists 211 E. Chicago Ave. Suite 1100,
should be mentioned in all honesty that any vital tooth prepared for a bridge abutment might even- tually become a possible candidate for future endo- dontic therapy.
Also, the patient who says ‘‘Pull it out’’‘ should be informed of the problems that will arise if a space is left unfilled, that is, tilting, reduced masticatory effi- ciency, future periodontal problems, root caries, and cosmetic effects. Another commonly heard statement by the patient is, ‘‘It’s only a back tooth, anyway,’’ or ‘‘If it were a front tooth I would save it, but no one sees it in back.’’ This patient thinks cosmetically. The disadvantages of the loss of any tooth, let alone a posterior one, so essential for mastication, must be explained.
Fortunately, today’s patient is becoming more sophisticated, too ‘‘tooth conscious’’ to permit indis- criminate extraction without asking whether there is an alternative. Extraction contributes to a crippling aber- ration from the normal dentition. There is no doubt that a normally functioning, endodontically treated, and well-restored natural tooth is vastly superior to the best prosthetic or implant replacement.
INDICATIONS
The indications for endodontic therapy are legion. Every tooth, from central incisor to third molar, is a potential candidate for treatment. Far too often the expedient measure of extracting a pulpless tooth is a short-sighted attempt at solving a dental problem. Endodontic therapy, on the other hand, extends to the dentist and the patient the opportunity to save teeth.
The concept of retaining every possible tooth, and even the healthy roots of periodontally involved teeth, is based on the even distribution of the forces of mastication. The final success of any extensive restorative procedure depends on the root surface area attached through the periodontal ligaments to the alveolar bone. Like the proverbial ‘‘horseshoe nail,’’ root-filled teeth may often be the salvation of an otherwise hopeless case.
To carry this concept one step further, the importance of retaining even endodontically treated roots, over which a full denture may be constructed, the so- called overdenture, is recognized.39 On some occa- sions, attachments may be added to these roots to provide additional retention for the denture above (Figure 13). At other times, the treated roots are A
B
Figure 12 Fractured premolar restored by endodontics and post and core crown. A, Tooth immediately following fracture. B, Restoration and periapical healing at 3-year recall. Note spectacular filling at trifurcation and apex (arrows). Courtesy of Dr. Clifford J. Ruddle.
Figure 13 Four locator overdenture attachments (Zest anchors) ensure adequate retention for mandibular full denture. Courtesy of Dr. A.L. Schneider.
merely left in place on the assumption that the