The Changing Face of Endodontic Practice—Where Have We Been and Where are We Headed?

“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change”—Charles Darwin

“At the most basic level, competition in healthcare must take place where value is actually created”—Michael Porter

I know that I have said this many times before, but as I look back on my life, my educational experience, and on my career, one word always comes to mind—change. I grew up in the San Fernando Valley section of Los Angeles, a suburban haven for lower to middle class families and even a cultural desert. It was a simple place where kids rode their bicycles to school, where we played in the streets, and where parents seldom knew where their children were from minute to minute. My group of public-school friends were socioeconomically, racially, religiously, and academically diverse. We were aware of our diversity, but somehow it never really mattered; we were all friends with similar goals, dreams, and interests and we supported each other unconditionally despite our differences– what a simple world it was. Today, things there are different there. In a sprawling community which on its own could be the fourth largest city in the United States, children are sequestered private schools which lack diversity, socioeconomic differences differentiate the classes, and urban blight has spilled over into the streets which were once filled with playful children. How could this have happened?

My father was an attorney and an executive at a large aerospace company. We had health insurance which enabled us to go to whatever doctor we wanted, and which adequately covered our healthcare expenses. Those less fortunate than us were often relegated to large “healthcare systems” which were anecdotally deemed to be inferior. No one really wanted to be there, including the doctors who were reported to be underpaid or worse, substandard. Today, these healthcare systems have not only grown to dominate the healthcare industry, but they deliver more than adequate care by physicians who are happy (for many reasons) to practice in these settings and are well compensated. And when I see my own “private practice” doctor, I invariably receive a bill from an entity that does not have his or her name on it. This world has changed also.

I finished my undergraduate and dental school education with no debt (through a lot of challenging work and personal sacrifice). The messages we received in dental school were those of quality, autonomy, and service to our patients and we were encouraged to open private offices where we could accomplish these goals. For my first job in general dentistry (1986) I was paid $150 per day and was introduced to the capitation system where there was a financial incentive to not treat patients and where dentists were discouraged from referring to specialists for the purpose of cost containment. HMO dentistry was evolving at that time and the consensus was that this was the first stage of the downfall of our profession. Later, as I completed my endodontic residency and entered private endodontic practice, it was hypothesized that the traveling endodontist would poorly redefine how specialty endodontics would be practiced and would pose an existential threat to our specialty. And yet, for good or for bad, our profession and specialty has survived.

The point of these stories is to illustrate that everything changes and that the way we respond to these changes can have a great bearing on the future. The dental profession continues to change. According to a recent ADA Health Policy Institute report, the “U.S. dental workforce is changing and with it, the practice paradigm.” As dentistry grows younger and more diverse, fewer clinicians will own practices. Based on data, they also predict solo practices will continue to wane as more dental professionals “flock” to dental service organizations. They further state that “Dentistry is heading exactly down the path of every other healthcare occupation that’s gone through this transition of business owner/solo practice to working in groups.”

The question on many AAE members’ minds is how these changes will affect the future and wellbeing of our specialty and what stance should our organization take considering these current changes in endodontic practice. These are certainly valid yet tough questions. The AAE has a long and rich tradition of supporting quality care, the art and science of endodontics, and all its members as they make personal decisions regarding their professional careers. Our thrust is to provide balanced information to be used in the decision-making process. So, is it within the purview of the association to make comment or otherwise dictate how a member decides to practice endodontics if they adhere to the exacting standards which define excellent endodontic care? Will they be able to deliver the highest quality of care in these new practice models? These are difficult questions to answer.

It is always easy to pass judgement, so perhaps the best approach is to understand the motivations for why some practitioners enter the corporate world. Residents today often graduate with significant, sometimes stifling student debt. Many aspire to practice in specialty settings but do not have the means to purchase or startup endodontic practices, especially in an era of expensive technology and increasing practice overhead. Alternative practice settings provide them with the opportunity to work in a specialty environment. Some of them may continue to work in these settings and yet others may move on to private practices once it becomes more economically feasible for them. My personal communications with endodontic residents reveals their overall desires to practice in specialty settings but a reluctance to purchase or open their own practices—certainly economically driven.

We all know of those practitioners who have used alternative practice models as exit strategies, but what about those practitioners who are no longer equipped to run a private practice but still want to maintain quality and have a degree of autonomy? I recently had a conversation with a solo endodontic practitioner who joined a DSO. She was a mother whose life had changed, and she no longer had the time to professionally manage her practice, but she cared about her patients and her referrals and still wanted to provide a high level of care. She relies now on her organization for management of her practice and enjoys the autonomy which they allow her.

And speaking of technology, those of us that have practiced for a substantial amount time all understand that its use has significantly increased the overhead of our practices. In an era of inflation, reduced insurance reimbursements, and other economic factors which affect us and our patients, I often worry about the cost of our treatment and patient acceptance should the cost of a root canal rise beyond what the market care bare. Although I am not an advocate of any practice model, consolidation may be a means to make our treatment more affordable and profitable. Of course, the quality of treatment will always be of paramount importance.

For those private practitioners who wish to continue practicing in their current settings, did you ever consider the fact that perhaps corporate dentistry is making your practice more valuable? There will always be a segment of the population who values your practice model, and a segment of endodontic practitioners who will seek your type of practice as they either matriculate from their residency or exit other alternative practice models.

As a leader of the AAE I have the moral and ethical responsibility to make decisions that not only affect the individual members of our organization but also assure the long-term well-being or our profession. Rest assured; it is a huge responsibility. The question that continually runs through my mind is how you reconcile change that affects both individuals and the specialty. How corporate dentistry will affect our specialty is yet to be seen. But the American Association of Endodontists will continue to shoulder its responsibility to be fair, to provide our members the information which will allow them to make the proper decisions for themselves, and to interact with corporate entities and stress upon them the value of quality endodontic care regardless of the practice setting or economic model. To this end, we will continue our efforts to support all our members, regardless of their personal decisions, and to promote the expertise of endodontists and the quality of work they deliver in order to make endodontics relevant, no matter what changes may occur in the future.