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)
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.
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)