New Jersey Association of Endodontists

Rearranging the Deck Chairs

(A three part editorial about the state of our specialty as this editor sees it. The opinions stated in this article are solely those of the editor and do not necessarily reflect those of the New Jersey Association of Endodontist’s Board of Directors or membership)

Part I

The Oxford Dictionary of Quotations (5th Ed. 1999), page 533, lists a quotation from the Washington Post, 16 May 1976, by Rogers Morton, American public relations officer: “I’m not going to rearrange the furniture on the deck of the Titanic.”  The context, according to the dictionary, was that Morton had lost five of six primaries as President Gerald Ford’s campaign manager.

 

The tie in for me to this aphorism is that the leadership of the AAE has been rearranging deckchairs on the Titanic for too many years. The membership just received the latest “President’s Message from Dr. Clara Spatafore. I’ve known Dr. Spatafore for many years and I can assure you she advocates as passionately as anyone for our specialty. However, the “Practice Promotion Newsletters” we receive almost monthly on the AAE website and this new President’s Message are essentially well meaning but pat bromides. Do we really need practice promotion tips that tell endodontists how to “Give Referring Dentists the Facts About Implants”? Solipsistic endodontic talking points to general dentists don’t wash particularly well with the economy lying at the bottom of an economic sink hole. Like the deckchairs on the Titanic these futile platitudes will gradually fade to black as they are overtaken by events that render them palpably defensive and irrelevant.

 

Knowledge based governance may be the rage of many for profit and non-profit organizations but its ability to act effectively and rapidly in a crisis situation is sorely wanting. The fact is that knowledge based governance is only as good as the organization that uses it and the AAE seems to find a way to populate its knowledge based governance committees with groups of homogeneous team members. For a knowledge based committee to be truly effective it is paramount to bring abroad committee members with independent and unaligned minds. I am of the opinion that that is not always the case with our colleagues who govern our organization. Many of my colleagues from across the country with past experience in the governance of our specialty organization do not require surveys or knowledge based strategic plans to realize that endodontics has reached a precipitous turning point over the past decade. The waning of our specialty has become well established. There are immutable reasons for this evident marginalization. The culture of referral that we hold near and dear to the core of our very existence is on the critical list. Reduced or no contact time between undergraduate dental students and endodontic faculty is a prescription for disaster. Who is teaching endodontic diagnosis and treatment to these students? How many general dentists under the age of 40 are on your “A” list of referring dentists? What was derigueur in restorative dentistry a decade ago has been eclipsed by the realization that not only can you restore an implant more easily than a natural tooth but you can command higher fees as well. Please don’t misunderstand my intent in this article. Implants are an excellent treatment option particularly for teeth that are pathologically hopeless and must be extracted. However, the most abused and misdiagnosed condition in dentistry today is “a fractured tooth”. The gratuitous condemnation of maintainable and healthy teeth has reached epidemic proportions. As endodontists a decreasing number of you are in the diagnostic loop to determine the diagnosis and treatment of teeth. Consequently incorrectly diagnosed symptoms far too often spell the loss of natural teeth that could have been saved with root canal treatment. Sadly, we are infrequent visitors to the loop that would make us part of a diagnostic team approach. We have essentially been reduced to providers of prescriptive endodontics. Can you imagine my disbelief when a dentist in my professional neighborhood asked me to locate a canal they couldn’t find and seal a perforation that occurred in attempting to find that “obscure” canal. Wait there is more! The referral slip also indicated that after I had accomplished bailing out my “colleague” I was to return the patient so that our industrious generalist could complete the root canal.. 

 

 What future does our specialty have when an ever increasing amount of the endodontic educational contact time our dental students receive is administered by mega departments under the supervision of non-endodontic faculty? If we don’t teach and mentor the next generations of general dentists how will they know what we can do for their patients and why and when it is appropriate to refer their patient’s for endodontic treatment? Do you think post graduate periodontists and oral surgeons graduating over the last few years are familiar with Salehrabi R and Rotstein I; Endodontic treatment outcomes in a large patient population in the USA (an epidemiologic study) . J Endod. 2004; 30:846–850?  More than likely the paradigm shift in their specialty education has left them blind to the reasons for embracing endodontic therapy as the equal of implant dentistry. Incongruously,  many of our colleagues in general dentistry, periodontics and oral and maxillofacial surgery consider root canal therapy “old technology”. How many referrals did you get from periodontists and oral and maxillofacial surgeons last year? When teeth treated endodontically by general dentists goes south do you believe they consider you their first line of referral for diagnosis and re-treatment?  Rather, I suspect the vast majority of endodontic treatment failures in general dental offices are shuffled off to the implantologist for cold steel and sunshine followed by bone augmentation and a titanium accoutrement. I can honestly tell you that many of my previous patients who “self-refer” to my office for a second opinion always have the same refrain……Dr. Balson please save my tooth I want to keep it and Dr. “Smith” said it needs to be extracted because it’s fractured. On occasion Dr. “Smith” is right and the tooth is not salvageable. However, all too often the teeth in question have one or more untreated canals; separated instruments the patient is unaware of; unfiled and unfilled apical canal segments; and a myriad of other treatment misadventures too long to enumerate here. When this ethical dilemma is dropped at your doorstep what do you? There are no easy solutions to a problem of this magnitude. The reality is that many treatment decisions in dentistry are made based on economic exigency, lack of diagnostic and treatment acumen or cost containment required by the patient or a third party payer. Isn’t it time dentistry stopped using implants as an insurance policy for substandard root canal therapy?

 

The inevitable passage of time has brought a perceptible decline to the numbers of full and part time endodontic educators. This year the first of the “Boomers” are reaching 65. As they and their predecessors accelerate their retirements from the hallowed halls of dental academia we will experience a significant decline in the endodontic educator community. What should be equally disturbing to all of us is the question…. who  will teach undergraduate dental students the culture of referral when there are not enough endodontic educators on clinics floors now to mentor and educate our future dentists. Who will educate these young men and women to what an endodontic specialist can do for them and their patients? Do these soon to be dentists appreciate how exacting and technique sensitive our specialty is? In essence we are fighting a battle that will make the Pyrrhic victory at Asculum appear to be a post battle bacchanalian celebration by comparison.  The most dangerous manifestation to the lack of clinical exposure to specialty endodontic education at the undergraduate dental school level is the creation of generations of dental school graduates who don’t even know what they don’t know!

 

Interestingly, the problem discussed above does have a double edged spectral presence in the mirror. Somehow even with the shortage of endodontic educators we still manage to graduate in the neighborhood of 200 post graduate endodontic students yearly. That means every 5 years approximately 1,000 new endodontists enter an already saturated endodontic job market and must compete with another 4,000 plus endodontists already practicing. I do not have attrition rate studies that can predict the number of endodontists that will retire over the next 5 years. Conversely, with the economy stagnating, high unemployment numbers and no end in sight to the sub-prime mortgage debacle I would surmise that many of our more seasoned colleagues will be deferring their retirements for a few more years than originally planned. The economic downturn has had a significant effect on our collective busyness in dentistry. Look at your weekly patient day sheet schedules and then at your yearly gross and net figures for the past few years. Let’s titrate out economic woes we collectively suffer and still the forecast remains far from rosy in many cases. General dentists have to some extent solved their busyness problem. They have changed their business model to accommodate the downturn in the economy. Basically, they have cut their endodontic referrals by whatever percentage they believe is necessary to allow them to keep their schedules full and sustain their bottom line. They have also expanded their business model to employ recently graduated endodontists who cannot afford to open up their own practice or find employment with an existing endodontic practice. This creates more in house income for the general dentist and gives them the cache of being able to promote to their patients… we have an “endodontic specialist” on premises. What do you think this business model does to your referring network? It should make you as comfortable as a long tailed cat in a room full of rocking chairs. After all there is an abundant supply of newly minted endodontists who willingly or unwillingly need to work as indentured serfs in general dentist’s offices to pay for their dental school loans. Your chief competitor for endodontic patients, the general dentist, can now eliminate you from his or her rolodex or data base of specialists.

 

I would venture to say that no matter where you practice the vast majority of periodontists & oral maxillofacial surgeons are convinced that endodontic retreatment creates a more difficult milieu in which to deliver an implant and invariably recommend extractions for teeth that have experienced endodontic failure rather than consider retreatment. Do you remember about 13 years ago when an implant institute from California made an educational CD that warned all dentists the failure to mention implants as a treatment option when discussing treatment options was a potential case of failure to inform. We are always excoriated as a specialty when we fail to consider or mention the implant option. How many of our colleagues in periodontics and oral maxillofacial surgery mention endodontics as a treatment alternative to their usual treatment of choice? You and I will never know the answer to that question because in the vast majority of cases endodontists aren’t even in the treatment loop to help the patients make informed decisions. Do we honestly think “Lunch & Learns” as well intentioned as they are can possibly create enough traction to move the pendulum back to the middle of the meter when it is continuously being pegged toward implants?  Need further proof…..look through continuing education catalogues and the ADA’s annual session CE brochure. Compare the number of courses on implants to endodontics and you will see the direction your specialty is going. The other daunting reality hitting us square in the rubber dam is that implant manufacturing companies have promotional budgets that far outstrip budgetary largess of endodontic manufacturing companies. We will never outspend them in dental schools. Should we capitulate and let them win the hearts and minds of our future dentists?

 

What is needed is a strategic plan to revive our specialty and take it off the critical list. A modern day “Marshall Plan” that tactically moves endodontics back into the mainstream of the dental consciousness for our graduating dental students. We need an independent group of thinkers, not just the same members of the board of directors. Isn’t it time to infuse a heterogeneous group of people into the mix? Perhaps they can produce novel ideas that hopefully germinate fresh and innovative approaches to a burgeoning problem. Has the AAE provided you with any statistics about how many root canals were done over the last 10 years? Which way do you think the graph is going? Did we complete more cases the first 5 years or in the last 5? I’m not certain we would like the answers to that question. Remember the statistical downturn is not just about the economy. How about comparing outcomes studies in root canal treatments done by general dentists versus endodontic specialists or just by endodontists . Are we afraid of the results we might obtain from research assessments of this kind? Dr. Henry Van Hassel, a man of  prodigious intellect, once said at an AAE board meeting when he was editor of the JOE, “be careful of the questions you ask…you may not like the answers”! Have we reached the point that we no longer wish to advance and support the art and science of endodontics with definitive research that will refute the nay Sayers on the other side of that proverbial line in the sand. It is time for the AAE to acknowledge the gravity of the problem we face. We have reached a “Sputnik Moment” in our storied history and we need our leadership to regenerate endodontics before the deck chairs run out of locations to rearrange them.

 

Respectfully submitted,

 

Marc Balson

Editor, New Jersey Association of Endodontists

 

(Part II of this editorial blog will discuss the nominating process of the AAE and how we select the future leaders of our organization)

Us and Them!

Part II

(The second in a three part editorial about the state of our specialty as this editor sees it. The opinions stated in this article are solely those of the editor and do not necessarily reflect those of the New Jersey Association of Endodontists Board of Directors or its membership. To view Part I please link to NJAE’s website at www.njae.org/ )

‘We are discreet sheep; we wait to see how the drove is going, and then go with the drove. We have two opinions: one private, which we are afraid to express; and another one – the one we use – which we force ourselves to wear to please Mrs. Grundy, until habit makes us comfortable in it, and the custom of defending it presently makes us love it, adore it, and forget how pitifully we came by it. Look at it in politics.’
Mark Twain

I found the response to my first editorial…”Rearranging the Deck Chairs” quite interesting. Apparently my perspective resonated with a significant number of my colleagues and people who were not directly posted to. Some shared their opinions openly and others demurred and expressed their comments to me without using the reply to all option. Either way I was encouraged that people thought about what I opined and cared enough to respond or rejoin to this piece. However, what was particularly telling was that with two exceptions no one on the board of directors or the executive committee deigned to respond. Nineteen out of twenty-one members of our governing elite were disinclined to make a comment whether negative or positive. Initially, I thought this strange and somewhat disappointing. Then a knowing smile came across my face because I quickly realized that this was an ‘Omertà’ a code of silence likely initiated by admonition from our executive director or perhaps by edict from our president. I had called Dr. Spatafore a few weeks ago to ask her about some aspect of governance in regards to recent nominating committee activity. I also shared with her that I was planning to write an editorial about it as I felt our nominating process and the committee responsible for its implementation appeared to me to be in need of a major overhaul. This week a reliable source informed me that Dr. Spatafore did send out an email to advise the board, the executive committee and a few of the past-presidents supportive of her agenda that some unnamed individual was going to email them material they should assiduously not respond to. You can’t make this stuff up! It is a strategic and all too common ploy by the AAE leadership to circle their wagons in a defensive posture to marginalize those who elect to openly tender constructive criticism or question any of their deliberations, decisions or management style. Is this the AAE equivalent of shunning which makes me excommunicated vitandus? Daniel Coleman the bestselling author of Emotional Intelligence and Social Intelligence wrote in the latter book about ‘US from Them’. ‘The gulf that divides US from Them builds with the silencing of empathy. And across that gulf we are free to project onto Them whatever we like. As Kaufman adds, “Righteousness, intelligence, integrity, humanity and victory are the prerogatives of Us, while wickedness, stupidity, hypocrisy, and ultimate defeat belong to Them.” ‘As an example last year I asked the AAE’s leadership about the transparency and accountability of their financial reports. I also queried why they felt the public awareness campaign assessment should continue in light of its ineffective 3 ½ year existence. The program plainly never reached its goals or realized its mission? It was clearly an evidenced based disaster. Where has this fiscal year’s assessment gone to since they fired the PR firm last year that has almost 2 million dollars of the AAE’s assessment revenues? The only thing my inquiries produced was silence. Did the executive director or the president that year give me, a past-president, the courtesy of a call to discuss this issue? No call, no email, no communication because I am “Them”. All I received was quiescent indifference.

Does anyone have a comprehensive understanding of the AAE’s finances? How could we when the annual financial report consists of a pie chart for revenue and expenses with a cursory spread sheet? We are advised to call the executive director, the treasurer of the AAE or the AAE’s CFO if we have any questions or concerns. Why should we have to jump through hoops to find out how the AAE spends our money? What the membership needs from the executive director, the treasurer of the AAE and the leadership of this organization is a line item budgetary analysis of expenses and revenues. Maybe then we can find out what happens to the estimated $400,000 annually we are required to pay the AAE for the public awareness campaign. The AAE is a 501 (c) 3 entity. A 501 (c) 3 is an American, tax exempt non-profit organization. According to the IRS “exempt or political organizations (excluding churches or similar religious entities) must make their returns, reports, notices, and exempt applications available for public inspection. The organization’s Form 990 (or similar such public record as the Form 990-EZ or Form 990-PF) is generally available for public inspection and photocopying at the offices of the exempt organization, through a written request and payment for photocopies by mail from the exempt organization, or through a direct Form 4506-A Request for Public Inspection or Copy to the IRS of the exempt organization’s filing of Form 990 for the past three tax years”. Is it unreasonable for the members of this organization to have the right to know how their dues, assessments and foundation donations are utilized?

For our members to restore and maintain our faith with this Board and our Executive Director our leaders need to create a more transparent and open modus operandi. They should be willing to communicate what the objectives of the organization are and how they are to be achieved. Most importantly this shared knowledge must include how the finances of the American Association of Endodontists are handled. Madame President and Mr. Drinan is it not time to tear down that wall of secrecy and not consider every request for financial information as an assault on your integrity and competency. Perhaps our association’s leadership suffers from an acute case of organizational blindness? Is their vision obscured to the reality that exists for vast numbers of our membership? Do we need a survey and a Knowledge Based Governance committee to understand that endodontic busyness amongst our members has seen a decrease of 15% to 50 % over the past 12 months?

With apologies to Abraham Lincoln permit me to modify a quote by him… The AAE will never be destroyed from the outside. If we falter and lose our way, it will be because we have sowed our own destruction.

 

The Nominating Committee

Recently the 2010 – 2011 Nominating Committee completed their charge as outlined in the AAE’s constitution; article XI on Committees. According to Section 6 the nominating committee “shall be composed of the three immediate past-presidents and two sitting members (non-officers) of the Board of Directors. The senior past-president shall serve as committee chair. The two sitting directors shall be elected by closed ballot and they shall serve a term of one year…etc.”

By all accounts Dr. George T. Goodis is a very decent fellow and a dedicated leader of the AAE and organized dentistry in the state of Michigan. He has served this organization well in a multitude of capacities. Dr. Goodis has been a member of several AAE committees; a member of the Board of Directors; a Director and past-president of the College of Diplomates, and he is now the secretary of our association. An informal survey conducted by me with some of his colleagues on the board of directors and the executive committee indicated that he has served our organization well in this position. However, when the Nominating Committee report was sent out to the past and present leadership of the AAE his name was conspicuously missing from the list of AAE sanctioned executive committee candidates for 2011 – 2012.

As the late Paul Harvey was known to say….”and here is the rest of the story”. Dr. Goodis, weeks before the Nominating Committee met, was asked by the Executive Director ED) of the AAE if he was still interested in serving on the Executive Committee (EC). That’s a strange question coming from the ED who also just happens to be an ex-officio member of the Nominating Committee (NC) and would be expected to be more than just an arms-length from any discussions with or pertaining to candidates available to be elected to the EC. I would think if George had any reservations about continuing to serve on the EC he would have spoken to his colleagues on that committee, the EC, or perhaps to this year’s chairman of the NC, Dr. Shepard S. Goldstein.

The two board members serving on the NC now have been on this committee collectively for 5 years. One board member has served his entire term (3 years) on the board of directors as a member of the NC. That is three consecutive years running. The second board member has now completed his second successive year of service on the NC. I wonder if he will match his colleague next year and serve for a third term too. The three immediate past-presidents of our organization also serve three consecutive years running on the NC. Do you begin to understand the inherent structural flaws in our nominating process? This is an incestuous selection activity at best and fundamentally a non-representative governance model at worst. No other specialty organization allows the perpetuation year after year of the same group of people to vet, qualify and decide who comes on the EC, who stays and who gets thrown under the bus. Would anybody who reads this tome be shocked to learn of the jockeying for position, back door politicking and the political capital cashed to make sure their girl or boy get the keys to the executive bathroom? Need some verification of that statement. Let us look at the last decade of past-presidents. With the notable exception of Dr. Mahmoud Torebinejad, a member of the old District VI and Dr. Gerald N. Glickman, a member of District V, we have had 4 presidents from District I; 1 president from District II; and 3 presidents from District III. I could go further and break them down by states but I believe you get the point. The method we now employ to choose our leadership is flawed, susceptible to cronyism and the least representative way to vet our future leaders in a fair and democratic fashion. It is my contention that Dr. George Goodis didn’t lose his position on the EC because he was a poor leader but rather because he didn’t have the right friends in high places. How convenient it is for them to wrap themselves in a ‘cloak of confidentiality’. When the same people are continually placed in a position to select the officers of their organization and the individual who administers to the day to day activities of that association is also the liaison to that committee, then ‘Houston we have a problem’. The Old Boy/Girl network is just chaffing at the bit to influence the outcome of the election and thanks to the structural design of our nominating process they occasionally see some positive wish fulfillment toward that end.

I’m not running for any office, belong to no committees in the AAE and I have no vendetta against the leaders of our specialty organization. What I do have is a strong and abiding hope that the leadership of the AAE will consider what I have penned on these pages and proffer some new governance paradigms that will enfranchise all the members of our organization. Equally important is the wish that they can summon the leadership skills they have been chosen to exercise and cease to consider everyone who has a dichotomous viewpoint as ‘Them’.

If they can’t or won’t change their modus operandi then perhaps Dr. Martin Trope’s statement said in jest may yet come to pass. ‘I tell my friends that this may be one specialty where you could know the founders of the specialty (IB, Seltzer etc.) and also know the ones who closed the specialty all in one career.’

Respectfully submitted,

Marc Balson

Editor, New Jersey Association of Endodontists

(Part III of this editorial blog will discuss the dental operating microscope and why the CODA teaching standard concerning it needs to be changed)

Clueless in Chicago?

Part III

(The third and final editorial about the state of our specialty as this editor sees it. The opinions stated in this article are solely those of the editor and do not necessarily reflect those of the New Jersey Association of Endodontists Board of Directors or its membership. To view Parts I & II please link to NJAE’s website at www.njae.org/ )

  

‘Government without popular information, or the means of acquiring it, is but a Prologue to a Farce or a Tragedy, or perhaps both. Knowledge will forever govern ignorance: And a people who mean to be their own Governors, must arm themselves with the power which knowledge gives.’ – (James) Madison, 1751 – 1836                                          

Does the membership of the AAE have the right to know how their money is being spent?  Do our Executive Committee, the Board of Directors and the Executive Director of our association have an obligation to their stakeholders, to provide meaningful information on staff salaries, budgets, contracts and their governance decisions and make it accessible to you? Does the term” rhetorical” come to mind? Would any rational individual think that their association leadership and executive director should be anything but transparent and accountable? Creating and sustaining a culture of trust requires our leaders to be willing to entertain consequential dialogue with its members even when that exchange of ideas does not evoke unfettered praise for their programs, judgments and philosophies. The “Us and Them” mentality was abundantly in evidence after my second editorial/blog. “Take me off this email list” was the call of the day for several of the leaders of our organization. Some of my fellow past-presidents requested the same status. Their requests have been noted as well as honored. Confidence in leadership is based on open access to critical information and the willingness to have mutually respectful dialogue with your membership. Sadly, some of the email responses from our leadership, past and present, belie that premise. If I was a recent graduate from PG endodontics or was an endodontists under 40 years of age I might now have some concerns about how “bright the future” of my specialty is!

 

Colleagues, my sole reason in writing these editorials/blogs is to ask questions that apparently no one else will. It is definitely not my intention to denigrate those who serve our association whether they are acting in the capacity as a volunteer member of the governing body or as a paid staff member at 211 E. Chicago Avenue. As a past-president of this association I both appreciate and applaud all those who have made significant sacrifices to help govern and guide our organization. However, anyone who is a dues paying member of the AAE has the right to voice their opinions or concerns about how this organization is administered and governed, even members of the Board of Directors.                                      

                                      

 

Do you know how many dental schools in the United States and Canada teach their undergraduate dental students to employ a surgical operating microscope when providing endodontic care for their patients? More significantly, how many endodontic educators are actually qualified to instruct post graduate endodontic students on how to use the endodontic operating microscope and realize its full potential as a cornerstone to careful and thorough endodontic treatment? Utilizing a microscope as an endodontist requires proper training and understanding of how this invaluable armamentarium expands our capabilities to provide “specialty care” for our patients. Shouldn’t a specialist provide something special for his/her patients? To me and many of my colleagues involved in clinical endodontics it is patently clear that a surgical operating microscope draws the proverbial line in the sand that separates serious endodontic clinicians from dentists and other specialist clinicians who dabble in “root canal”.

 

Dr. Gary Carr, my choice as the foremost advocate and early adaptor in endodontic microscopy has been saying for years that ‘endodontists should have made the microscope the standard of care and understood that it actually defines this specialty, instead of just seeing it as another “tool”.’  Don’t misinterpret what I am saying. Installing a surgical operating microscope in your office doesn’t confer competency nor can it impart special abilities or expertise. However, what it does provide, for those that accept the principle that “you can’t treat what you can’t see”, is the deus ex machina to creating the proper clinical environment needed in endodontics. This tenet, when properly encouraged and taught, fosters a meticulous treatment protocol through the application of disciplined and comprehensive microscopy. When it is coupled with a thorough understanding of dental anatomy, pulp biology and pathology you have four of the most essential elements to foundational clinical endodontics.

 

How many of our endodontic faculty know how to par focal a scope; adjust the interpupillary distance; understand why correct operator position is an essential element of endodontic microscopy; be able to teach proper patient alignment as well as the essentials of the assistant’s positioning during an endodontic procedure; and impart on their students a full understanding of the vital elements and skill sets needed to function ergonomically when employing a scope? Is it not time to create and codify a universal microscope syllabus and a teaching standard for our endodontic post graduate students? Have we given our PG’s the proper guidance and direction to integrate the surgical operating microscope into their daily clinical routine? I know the answer to the last question and it is regrettably and unequivocally ….no! The AAE has been pretty sanguine about the use of the operating microscope for a long time. They don’t disagree that it is conceptually important. They do pay tacit lip service to the scope after all they have pictures on their annual roster books showing endodontists using microscopes and have you looked at your membership card lately? They are also publicity savvy on the website with graphics showing microscopes being employed by various practitioners.

 

What you may not know is the AAE leadership and staff had numerous opportunities to put some real traction into the accreditation standards for advanced specialty training in endodontics with regards to the microscope. I tried very hard to change the existing microscope standard we now have when I was president of the AAE from 2005 to 2006. I was shot down by the majority of my colleagues on the Executive Committee and also by a majority of those serving on the Board of Directors that year. I even asked for a survey to be sent out to all the endodontic chair people and program directors around the country only to be informed by a staff member from the AAE that the survey was not sent out so people could take them privately to express their individual views on the microscope standard. What transpired was an open educator forum, a chat room if you will that actually had a future leader of the AAE change their mind from pro to con during the flurry of opinions expressed on line about the 4-9j standard. Knowledge based governance does not work when the informational survey you use to make informed decisions is biased.

 

 By way of explanation The ADA’s Commission on Dental Accreditation (CODA) is the governing body that defines dental specialty educational standards for all the dental specialties. The ADA’s website has a PDF file on the “Standards for Advanced Specialty Education Programs”. Standard 4 in the endodontics program addresses ‘Curriculum and Program Duration’. According to this standard, curriculum is approached via an evidenced based endodontics (EBE) model. The endodontic-specific Standards are based upon EBE,” the integration of the best research evidence, clinician expertise and patient values”. Now going down to the “Clinical Science” curriculum you will see in section 4-9 ‘The educational program must provide in-depth instruction and clinical training to achieve proficiency in the following areas:’ It goes on to list several clinical areas and the last section is j...Use of Magnification Technologies. It does seem pretty innocuous up to this point. But wait, it gets pretty dubious immediately after that. Just below section j is an intent statement used to interpret and define what specifically is meant by section j’s …’Use of Magnification Technologies’. It reads as follows:

Intent: The intent is to ensure that students/residents are trained in the use of instruments that provide magnification and illumination of the operative field beyond that of magnifying eyewear. In addition to the operating microscope, these instruments may include, but are not limited to, the endoscope, orascope or other developing magnification.

 

Many of us supportive of a stricter interpretation of 4-9j realized that the intent statement essentially provided a mandate for every program in the USA and Canada that adhered to CODA’s curriculum dictates to get a free pass on the operating microscope. If you were the chair or program director of an ADA approved endodontic program you could have a microscope collecting dust in some distant corner of your clinic or better still claim that an endoscope or an orascope were suitable alternatives to employing or teaching your PG’s about endodontic clinical microscopy. The fact is, without a definitive intent statement there was never a need to create a departmental teaching syllabus that would concentrate attention on the operating microscope. Let’s review the genesis of this apparent leadership driven attitude that worked to marginalize the importance of the operating microscope in endodontics?

 

A 1999 article in the JOE by Mines, P., Loushine, R.J., et al, Use of the Microscope in Endodontics: A Report Based on a Questionnaire. J Endodontics 1999; 25: 755-758. The authors surveyed 3356 active members of the AAE and received responses from 2061 of them that indicated 52% of the respondents have access to and utilize an operating microscope (OM). The survey also revealed that ‘the frequency of use appeared to be a function of the years since completing endodontic training. The statistics were as follows: < 5yr, 71%; 6 – 10 yrs., 51%; and > 10yrs, 44%.  For those who answered the survey 36% said they did not use the OM as often as anticipated because of the following issues:

 

•   Restricted field

•   Positional difficulties with the microscope

•   Inconvenience

•   Increased treatment time

•   Lack of auxiliary support

 

‘The results of the survey suggest that increased training results in an increased frequency of OM usage for all procedures.’ In addition this article states that ‘There also seemed to be little standardization in the method of training. Some of the methods included self-training, formal courses or seminars and experience garnered from a residency program or research’. Even the casual observer can comprehend what is missing here… formal training given to every endodontic PG, endodontic resident and endodontic educator to insure that the OM is the standard of care in endodontics. Just about all general dentists in this country have drawers and shelves stocked with endodontic supplies and equipment. How many of them have or employ OM’s when they do endodontic treatment? The microscope has a broad range of tasks that can be completed using it….thus…it’s a fundamental skill set that should be afforded to every endodontic PG or resident while they are in their endo programs. For those of us that use the OM from the start to the finish of our endodontic treatment sequence (especially those under 40 years of age that have some formal training) it is not inconvenient to use and whatever time it takes to treat a case properly is time well spent. Every one of the issues enumerated by that article disappears with proper training. One can only ask why in 2011 is 4-9j still in a watered down state left to the interpretation of individual department chairs or program directors.

 

What has the AAE hierarchy and the Executive Director done about this issue since 2005? At every possible opportunity they have acted in concert to be an impediment to realizing a change in the 4-9j standard. Let us look back at the record as it unfolded over the past few years. After doing several crash and burns in an effort to change 4-9j through standard governance procedures I realized that an end around procedure was needed to get past individuals who steadfastly refused to even consider a change in the magnification/microscope standard let alone permit meaningful debate. I can assure you changing the magnification standard would never have seen the light of day by a “Knowledge Based Governance” committee. So my friend and colleague, Joseph Dovgan, an ardent supporter of strengthening 4-9j, with a little editing from yours truly, put together a petition that was signed by over 200 clinicians and a few educators. Included in that petition was a newly formatted intent statement. It read as follows:

 

Revised Standard:

 

          4-9 j Use of magnification technologies:

          Intent: The intent is to ensure that students/residents are trained in the use of the operating microscope in all phases of non-surgical and surgical endodontic treatment. It is necessary to provide magnification and illumination of the operative field beyond that of dental magnifying eyewear to maintain the endodontic standard of treatment. In addition to comprehensive training with the operating microscope, instruments such as the endoscope and orascope as well as other developing magnification technologies may also be included in the curricula.

 

It was our intention to present this petition to CODA which holds a public forum at every annual ADA meeting. That year’s meeting was held in San Francisco. I was not in attendance at this meeting but I have reconstructed events that transpired thanks to the collective memories of Joe Dovgan, Fred Tsutsui (present member of board of directors from District VII) and Mitchell Davich (former treasurer of the AAE 2007-2009), all of whom were present. Mitchell recalls that during the San Francisco Interim Board Meeting (prior to the ADA Annual Session) the Dovgan petition was glanced over and presented as informational to the AAE Board of Directors and the Executive Committee.  Dr. Louis Rossman, the AAE president, objected to it, saying that many members signed it “not really knowing what they signed,” and therefore the petition should be invalidated. The BOD was advised that Dr. Gerald N. Glickman was to prepare a response and testify before CODA. Dr. Glickman apparently could not make that meeting but Dr. Clara Spatafore substituted in his absence with talking points provided by James M. Drinan, J.D.,  the AAE’s Executive Director and an AAE staff member. Fred Tsutsui presented the petition to the CODA committee members and then stood before the committee  and offered the petitioners request for reconsideration on the intent statement of the 4-9j standard. He relayed to me that after his presentation Dr. Spatafore presented the “AAE’s” talking points and stating that 4-9j had just recently been approved (2005) by CODA and the AAE saw no reason to revisit any modifications. What is so completely disingenuous to me is the executive director of our specialty, our administrator, facilitating an agenda in an area he should not be involved in. Article VIII, Section 2 of the Constitution of the American Association of Endodontists clearly delineates the scope and authority of the salaried head of staff. ‘The executive director shall be the chief administrative officer of Association and responsible only for  management functions. This petition was about issues of clinical significance, not about organizational concerns.

 

How about the AAE leadership, what was their throwaway on this issue? What were some of the quotes attributable to our leaders past and present. ‘Long standing endodontic clinicians can’t be expected to incorporate this new technology’; ‘The microscope is a tool not necessary for endodontic procedures’;  ‘He didn’t like the scope because it obstructed his touch and vision of patients while he was working and that it depersonalized the procedure’;  … admitted to not having the necessary advanced skill set and… thought the scope was too hard to use and too expensive to purchase.’; …  said that program directors already had too many requirements, i.e., too many standards and paperwork to comply with. These additional requirements would be too much of a burden on them. For the benefit of these program directors microscope training and proficiency was a red tape hindrance and should therefore not be mandated’. , When an officer of the AGD was at a joint meeting with the AAE hierarchy he asked ‘What’s the story with this microscope petition?’ Obviously there was a buzz going around prior to CODA meeting.  He was answered by a now past-president of the AAE, who assured him…’Oh, the microscope manufacturers are behind it’. These statements are both telling and incomprehensible to me. 

 

A full CODA board met in Chicago for a hearing in January of 2008. Based on the petition tendered to them in San Francisco they referred consideration to change 4-9j to the Endodontic Review Committee (ERC). The ERC is composed of a Chairman, an endodontic educator plus two other endodontic educators as well as a public sector appointee from CODA and a general dentist also appointed by CODA. Dr. Jeffrey M. Hutter, the present Dean of the Henry M Goldman School of Dental Medicine, was the chair of the ERC and kind enough to invite Joe Dovgan and myself to Chicago for that meeting. We came to Chicago on our own dime to have Joe present the argument for a change in 4-9j. Mr. Drinan was at that meeting along with a member of his staff. Was there a reason that the Executive Director of our organization couldn’t even extend some kind of greeting to a past-president of the organization he worked with for 4 years? Apparently, “Us and Them” is very much part of his administrative culture too. Once again our executive director failed to remain at arms- length when issues pertaining to our association came to the fore? Perhaps it might have been better for all concerned if Mr. Drinan demonstrated his neutrality by not supporting a particular side on a clinical issue. Maybe it might be to his and our mutual advantage to create a new culture of transparency and accountability in his administration of our association.     

 

Returning to the microscope it is the conclusion of a sizeable number of clinicians and some educators  that PG’s and residents that do not obtain this operating microscope skill set during their programs are at a significant disadvantage when diagnosing and  treating today’s more demanding referrals from general practitioners. Do you agree with some or all of these statements then perhaps it is time for you to hold our leadership accountable for what some believe is an egregious lack of insight into what defines us as endodontic clinicians.

 

If what I have written about in this 3 part series has no relevance or concern for you then the AAE and its leadership have met your needs for an organization with clarity of thought and a viable governance model. However, if some of what I have penned might be disturbing to you then now is the time for you to question your leadership and our Executive Director and hold them answerable for their actions and agenda. I pass the baton to ‘you’. As Dr. Stephen Schwartz said ‘If there is resonance to the concerns stated, then actions should be taken, if not, the moment will pass.’ Colleagues, the rest is up to you!

 

 

…made weak by time and fate, but strong in will to strive, to seek, to find, and not to yield. Tennyson; ULYSSES

 

Respectfully submitted,

Marc Balson

Editor, New Jersey Association of Endodontists

(Part III of an editorial/ blog published in www.njendo.org/)