by Dennis Brave, DDS, and Kenneth Koch, DMD
Endodontic education begins first and foremost in dental schools. However, undergraduate endodontic education has changed significantly in the past 10 years. The change has occurred not so much in the didactic component, but more in the clinical experience. Many dental school graduates now have only limited exposure to clinical endodontics.
This is particularly a challenge in institutions that have large postdoctoral programs that devour endodontic cases. The undergraduate students need to have more clinical experience, and it is getting harder and harder for them to acquire it.
In addition, with the increasing emphasis on cosmetic and reconstructive dentistry in dental schools, clinical areas - such as endodontics - have a more difficult time competing for student time.
But endodontics and oral surgery are unique because patients often present with pain! Students need to become better educated, particularly in diagnosis and emergency treatment. Consequently, in dental institutions, philosophies must be established that not only allow the graduate residents in endodontics to meet their requirements, but also give undergraduate students clinical endodontic experience. A common excuse is: “We don’t have enough endodontic cases to give more than a few to the undergraduate students.”
Here are two suggestions that may alleviate this problem for undergraduate students.
Before a graduate student can treat a case that is assigned to an undergraduate student (such as an apicoectomy or a difficult molar), the endodontic resident must find a replacement case and give it to the undergraduate student. This is easy to accomplish, and generally requires the postdoc to spend only an hour or so in the emergency clinic. This is important because it maintains the continuity of endodontic education for the undergraduate student.
The second way to generate more cases for the entire endodontic program is straightforward. Senior residents need to be assigned time in undergraduate clinics where they can review panoramic X-rays and full-mouth series. It is not uncommon for students to see patients needing endodontic intervention (especially apicoectomies), but often undergraduate students are reluctant to send the cases to postdoctoral endodontics. They fear the cases will not be returned or the patients will be lost.
This is especially a concern with patients who need prosthodontics. Students live in fear they won’t complete their crown-and-bridge requirements, and thus delay their graduation. This thinking has existed for many years. However, this can be changed by endodontic departments reassuring students that cases will be returned to them.
There are plenty of endodontic cases in dental schools. Most are in the patients’ charts. It goes without saying that a graduate program in endodontics is still the best bet for anyone who wants to bcome an expert in endo. Graduate endodontic programs, and the quality of their residents, continue to improve each year.
But this article is directed toward the general practitioner. So the question remains, “How can general dentists increase their knowledge in endodontics, and what is the best way to meet this challenge?” Certainly there are a number of options - online CE courses, endodontic lectures at dental meetings or schools, and hands-on courses.
Real World Endo continues to be a strong proponent of hands-on courses. If you want to take endodontic expertise to a higher level, you should enroll in courses with a hands-on component. Hands-on experience is critical. It is also important for participants to do some preparation before attending a course.
Make certain, to the best of your ability, that access is properly prepared on the teeth that will be used for the hands-on course. It is wise to become familiar with any new rotary file system before you try it on a patient. Be sure that any hands-on course director allows you to try multiple file systems so you can make a fair comparison between systems. These suggestions will help create a more complete experience.
If you have attended numerous hands-on courses and still want to improve your expertise, the next option is an institute course. There are a number of institute courses around the country, and most will satisfy your need for more in-depth training. Before you sign up for a course, speak with someone who has attended it to confirm that the course will meet your requirements.
We believe continuing endodontic education has two other factors that must be considered.
The first is efficiency in endodontics. The second is performing endodontics in a way that will increase the long-term retention of the tooth.
First, let’s take a look at efficiency. There are programs designed to help the practitioner (specialist or general) not only perform good endodontic procedures but also accomplish them in an effective, effecient manner.
One person who immediately comes to mind is Dr. Ace Goerig. An endodontist, Dr. Goerig’s speciality is teaching a philosophy that will allow the practitioner to not only produce quality endodontics but to become more productive in his or her practice. His course can benefit clinicians regardless of their experience level. Dr. Goerig has been doing this for many years, and has hundreds of clients. It’s not just practice management with him. Rather it’s endodontic management from an endodontist’s point of view.
The second factor is the most important. You must learn an endodontic technique that allows you to perform a root canal so that you don’t destroy a tooth during the process.
If you unnecessarily remove radicular dentin (particularly in the coronal third) during the procedure, the tooth will not stand up long term to the stress of a functioning dentition. This is especially true for teeth that require a post.
We are seeing more and more fractured roots as the result of excessive removal of vital root structure. Consequently, we believe that both doctor and patient are better served when the doctor learns a constant taper preparation rather than a variable taper one. With a variable taper preparation, one often unnecessarily weakens the tooth in the coronal third of the canal. Ultimately, this compromises its long-term retention.
In fact, we now see many teeth that could be treated endodontically but are condemned quickly for extraction and an implant. This happens because so many teeth with an extra-wide preparation in the coronal part of the canal are not standing up long term.
As previously mentioned, this is often observed in teeth that require a post. Practitioners should begin performing endodontic procedures so that they not only solve the endodontic problem but also increase the long-term (15 to 20 years) retention of the tooth.
If you are not performing endodontics in such a manner, implants will continue to replace more of those teeth that could be treated conservatively with good endodontics.
As endodontists, we believe in saving the natural dentition and giving a patient the option of maintaining his or her natural tooth. Your endodontic education begins in dental school, but requires continuing education to keep up with all the advances and improvements.
Real World Endo intends to keep delivering “Just the facts, nothing but the facts” to keep you up to date and acquainted with the latest techniques in clinical endodontics.
Dr. Dennis Brave is a diplomate of the American Board of Endodontics and a member of the College of Diplomates. In endodontic practice for 27 years, he was the senior managing partner of a group specialty practice. Dr. Brave, formerly an associate clinical professor at the University of Pennsylvania, currently holds a staff position at The Johns Hopkins Hospital.
Dr. Kenneth Koch is the founder and past director of the new program in postdoctoral endodontics at the Harvard School of Dental Medicine. In addition to having maintained a private practice limited to endodontics, he has written numerous articles on endodontics and is a co-founder of Real World Endo.
They can be reached at Real World Endo at (866) 793-3636, or through www.realworldendo.com.