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Strategic Priorities Update: Partners in Patient Care

I have always believed that “we are all members” of the same team, probably because of my playing full contact football from the  third grade on in Houston! (No, I don’t have CTE!) The coaches were all volunteers who loved football and all were WWII vets who knew a few things about teamwork. The concept of being unified for a common goal was always emphasized (along with a 2-inch-thick binder with offenses and defenses that were state of the art in 1956!) The coaches said that in order to be successful, we had to work together and each do our part if we were to be successful in both our offense and defense. My experiences in both the United States Navy and later the Army National Guard were also all about teamwork.

This theme of the dental team carried over to the operatory. The dental assistants provided support for the dentist with four-handed dentistry and chairside efficiency improved by 50 percent! Well, it is time for us to remind our general dentists that we are part of the overall dental team and WE are the partners with advanced expertise in all things in endodontics. If you have not read our two papers on Treatment Standards and Endodontic Competency, download them from right here.

We recognize that 75 percent of all nonsurgical endodontic procedures are done by general dentists, but argue that general dentists should know their comfort level and send more complex cases to endodontists. The general dentist must also recognize that “the standards of practice are constantly changing based on new evidence and technology.” Very few general dentists have microscopes, CBCT, ultrasonics or any of the newer technologies and materials developed over the past four or five years that we routinely use in our practices. Again, our biggest challenge for us as endodontists is to get general dentist to do the introspection needed to know their own limitations. This is also discussed in the Treatment Standards whereby, we point to the AAE Case Difficulty Assessment Form as a template to be used to evaluate individual cases. This is an instrument that can be shared one-on-one with a referring dentist to help them in their decision-making process. It could be sent back as part of a referral sheet. I think this works best at the grassroots level. When we educate our referring dentists about our expertise and our unique knowledge set, they will respect that we spent the time and effort to help them and will utilize our skills more appropriately. By the way, did you know that we will soon be releasing an app version of the Case Difficulty Assessment Form, called the EndoCase App? Stay tuned for more details on that.

In terms of changing landscapes over the past few years, is the recognition by periodontists and others that implants are failing at a rate greater than previously thought. To quote Dr. William Giannobile, former editor of Journal of Dental Research, in the January 2016 JDR:

“The erroneous belief of implants yielding a better long-term prognosis has now clearly been rejected in several comparative studies and systematic reviews. Teeth even compromised because of periodontal disease or endodontic problems may have a longevity that surpasses by far that of the average implant”.

He further advances the argument that studies have shown that maintenance of even a portion of the tooth can have better results than implants. This all translates to “let us try to preserve any/or all of the natural tooth for as long as possible”. It is almost like he read about our Worth Saving campaign!

When I started in my residency in 1981, periodontists still did root amps and hemisections. Interestingly, many times these were done while the tooth was still vital! Periodontist did not have widespread training in the use of titanium implants for tooth replacement. Consequently, the longevity studies for tooth maintenance that are cited by Dr. Giannobile are from that era. The first 25 years of my practice, I saw a lot on endo-perio combined cases. The last five years of private practice, I saw very few periodontal referrals as my referring periodontist retired and younger periodontist arrived, changing practice dynamics with very few endodontic consultations and more implants being placed. I think this is the time to rejuvenate our relationships with periodontists we know personally and have the discussions Dr. Giannobile is talking about for greater tooth preservation for the sake of overall oral health. Maybe it’s time to “take a periodontist to lunch/dinner and discuss it one-on-one” and rekindle teaming together to full fill the best treatment for the patient. As an aside, Dr. Giannobile will be speaking to all of us in Nashville at AAE20!

My first year in full-time practice, 29 percent (N=358) of cases were retreatments with 21 percent being treated surgically. My last year of full-time private practice, 49% (N=866) of my cases were retreatments. Twenty percent of these cases were treated surgically. Clearly, there had been a recognition by my referring dentists that teeth were worth saving and my track record warranted a try. Many of these patients had undergone extractions and replacements with implants with varying degrees of success. Many simply didn’t want to spend the time and money if there was an alternative with a good prognosis.

In a slight twist on this, a recent paper in the February JOE entitled “A Retrospective Comparison of Outcome in Patients Who Received Both Nonsurgical Root Canal Treatment and Single-tooth Implants” by Seyed Vhadati, etal (JOE, 2019, Feb.99-103) really illustrates that given the time, money, complications and outcomes of implants versus nonsurgical root canal treatment, root canal treatment and restoration should remain a very high option even for “implantologists”.

In a final note, as endodontists, WE are all partners with other oral health care providers. Now, WE need to insure, WE are recognized as the ones that have advanced expertise in endodontics. To do this effectively, I think it will need to be a grassroots effort. There are tools such as the AAE Case Difficulty Assessment Form to help you enable a dental professional to decide on the need for a referral. There are talking points about preservation of the natural tooth that were not developed by us, but by respected dental professionals in other fields. These can be used with our talking points from the two white papers to strongly argue that endodontists should be consulted/used in moderate to complex cases. Now, the only thing left to do is make the call!