Object-Level
What are the key differences between endodontics and dentistry? What does an endodontist do that a dentist doesn’t?
“Dentistry has nine specialties out of which endodontics is one of them. Endodontics deals specifically with diseases of the dental pulp – and our main procedure is root canals. General dentists also do root canals, but we do more difficult cases.”
What is your physical environment like? How is it unlike a dentist’s?
“Endodontic offices are a little different from regular dental offices because we have more advanced equipment. For instance, we have surgical operative microscopes for advanced visualization and we use cone beam imaging. Otherwise, there’s not much of a stark difference.”
What does a normal day in your field look like? Can you give me a “day in the life” kind of run-down?
“In a typical day at my office we see five to seven patients. Most of them are there for non-surgical root canals. I would say maybe 20% of my cases are surgical cases. We do about five consultations a day (where we diagnose patients, but don’t operate on them). It can get fairly busy, but we try to accommodate as many patients as we can. We try not to push patients to future dates because endodontic problems are pretty immediate. If a patient doesn’t get help from you soon, they’ll find someone else.”
How does this differ from the average endodontist?
“Endodontists practice in different types of settings. There are solo practices, large group practices, and health systems. Large group practices are probably the most common ones – they have between five to seven practices and they accommodate a lot of emergencies. I work in a health system and we only have two endodontists. We have to be a little bit more creative with the way we manage the patient flow. Aside from the setting and intensity, there isn’t much variation in an average day for most endodontists.”
What does a bad day for an endodontist look like?
“A bad day for me would be a day filled with emergencies I cannot handle. My lunch hour doubles as auxiliary time for urgent situations. If there is an emergency, that is when I'm taking care of patients. That isn’t that much time – I typically cannot accommodate more than one case. When I have two or three emergency cases, I swiftly run out of time, energy, and space – and that defines a bad day for most endodontists.”
What percent of your time is spent doing administrative work, and how is this different from the average?
“About 25% of my time is spent doing administrivia like writing notes, charting, contacting patients or my referring dentist, and follow-up. This is standard for endodontists. I delegate what I can, but I keep certain things to myself, especially writing notes and calling patients. I like to do that personally. In some offices, it's delegated to the staff, but calling patients yourself builds rapport with them, and helps them heal.”
How does your time split across different kinds of casework? What cases do you get most frequently?
“60% of endodontic work tends to be molar endodontics. For me, a lot of my work consists of redoing procedures done by other dentists.”
What makes endodontic casework difficult?
“A wide swath of things add difficulty to endodontic casework. Sometimes patients can be difficult to handle – especially if they’re anxious. Sometimes we treat teeth that are positioned far in the patient's mouth, like second or third molars. Anatomical variations, like microscopic canals or limited mouth openings make some cases strenuous. There’s a different set of challenges we face everyday, and no two cases are similar, but you get better as you build up intuition.”
What does the road to endodontics entail?
“The road entails two- or three-year residency after dental school. Most of these programs encourage dentists to apply after they have worked as general dentists for a few years. This is important because you learn crucial skills practicing in the real world. Most endodontic programs are clinic-based, but a few are hospital-based. Most programs run you through lots of clinical work, but some are research-heavy. Aside from the clinical component, residency programs have a didactic component. The didactics involves studying more than endodontics. In my two years, I took courses on neuroscience, statistics, immunology, and microbiology. It sounds broad, but you connect the dots later.”
Can you give me an outline of an average day during your residency?
“We would have classes starting at 7:00 AM or 6:30. We would have lectures in the morning, then clinics, then lectures again, and then more clinics. Some days we would have lectures again after clinics. It would be from 4:30 or 5:00 to 7:00 PM. Depending on the time of the year, it would vary. Clinically, we would try to treat two to three patients every day. The casework increased as we got more comfortable with it.”
What has the potential to go most wrong for a newly minted endodontist? How could someone otherwise competent squander their career?
“A danger for any specialist is not being able to accurately gauge how well one knows their subject after residency. When you are a new specialist, you may have a degree, but clinically, you’ve only started. It takes around five years of practicing on your own to get comfortable handling difficult cases. Another mistake I have seen is overshooting. I knew somebody who took out an enormous loan to open a big practice in a busy part of Chicago. She wore herself out, and had to file for bankruptcy. It was the business part of it that unraveled her, more so than any lack of clinical maturity. Holding a certificate doesn't mean you can operate a business. Programs teach you the theory and practice of endodontics, not the business part.”
Sometimes medical students intent on becoming surgeons find out they can’t take the sight of blood. They may shift to a less hands-on speciality, or abandon medicine for that reason. What “deal-breaker” stressors are unique to endodontics and dentistry?
“There are two things that come to mind. One is the constant pressure of doing fine work. I've seen people abandon endodontics because they can't handle the unyielding rigor of it. The other thing is working with patients that are in pain all the time. So if you can’t handle people in pain, having to do extremely fine motor work, and paying a lot of attention to a very specific thing and doing that all day everyday, you probably shouldn't go into this field.”
Are there any hair-raising moments in endodontics and dentistry? What in your work lights up your adrenal glands?
“We use a variety of dangerous chemicals that if handled incorrectly, can land patients in the ICU. I always have to be very, very careful when I'm using these chemicals to avoid putting a patient in the hospital. Another thing that puts me on edge is failure of anesthesia. I have to be 100% sure that my patients are under profound anesthesia before operating. If the anesthesia is not profound, patients will develop trust issues with me.”
Meta-Level
Under what circumstances should a dentist become an endodontist? Under which shouldn’t they?
“It sounds corny, but the calling has to be from within. If you want to become an endodontist for money, you’ll end up justifying unnecessary procedures – you may still be a stellar clinician, but you’ll act cravenly, and defeat clinical work’s true purpose. The other bad motivations, like becoming an endodontist for bragging rights or just for the sake of being a specialist, tend to be proxies for financial ones. But if you have a genuine love for your patients and taking care of them, then the two to three year investment is going to be worth it.”
What is the rate of change of information in endodontics? How does endodontic theory change, and how does the way you practice evolve?
“The rate of change is very interesting. Some things are rock-solid, like basic endodontic theory. Most of that hasn’t changed in 50 years. Now, what’s really changed is our technology. Materials have definitely improved. Microscopy has improved. Imaging has improved. Our chemicals have improved. But the essence of it – what causes endodontic pathology and how we treat that – has stayed the same.”
What recent changes do you think have been significant?
“New imaging technology has been groundbreaking. But newer materials, like bioceramics, are game changers. Procedures that used to take an hour ten years ago will take three minutes today. That’s a 2000% improvement! Material sciences have produced these incredibly advanced nickel-titanium endodontic files, without which I can't imagine how people worked.”
Do you think these new changes have been occurring more rapidly as time goes on?
“Oh yes, the rate of change is increasing.”
Do recent innovations in the field change the way you look upon your specialist education? Did your years in school prepare you for how the field changes?
“One always has to accept advancement with a little bit of trepidation. Yet you have to accept that things are going to dramatically change, and you have to be open to it, because being closed is the dumbest thing to do. (Imagine refusing a 2000% improvement!) My education gave me a good idea of what to accept, and it still helps me to quickly understand new things as they come about.”
If you had to redo your training in endodontics, what would you do differently given what you know now?
“I would spend more time learning the business part of it because that's one part nobody teaches in the program.”
Domain
What traits, talents, or skills does endodontics draw on that regular dentistry doesn’t?
“Compassion is one thing that endodontics pulls on more than dentistry. Endodontics requires a higher level of compassion towards patients because they are almost always in more pain. The procedures we do are pretty challenging, and patients never come to our office looking forward to them. They come with a lot of nervous apprehension, and you need to handle that with finesse. Then there’s attention to detail. An error by a millimeter can ruin your day, and we even redo procedures for millimeter improvements.”
What prevents talented people with a good fit to the specialty from becoming top performers?
“If you don’t have a good fit to the practice you’re working in, you probably won’t thrive. Take, for instance, someone right out of residency taking a job at a large group practice with twenty people. It would be hard for them to find a footing. They wouldn’t get as many difficult cases, and they wouldn’t get better. The same thing might happen if you start a practice somewhere that’s not especially busy. Most holdbacks have to do with situations like that.”
Relatedly, what falsely fruitful activities do other endodontists engage in? Why do people fall into these traps?
“One falsely fruitful activity would be putting too much time, energy, and money into a practice. Most pitfalls in endodontics turn out to have to do not with actions taken at a treatment level, but at a business level. You could be an exceptional practitioner, but do much worse than someone with more business acumen. The field isn’t dominated by those who are best with microscopes or treatment, but rather those who are shrewd with spreadsheets and where they set up their practice.”
Contrarianism
What is something you believe about endodontics that other endodontists don’t?
“Aside from clinical quirks in other people that I don’t understand, I don’t know how to answer that question.”
Aaron Swartz once observed that the smartest people he knew always talked about fine details, and that charlatans always talked about big, fancy abstractions. Are there any tell-tale signs that an endodontist or dentist doesn’t know what they’re doing?
“Making outlandish claims about your casework is a bright red flag. There are people who treat teeth that are untreatable, or do surgeries on teeth that are possibly fractured, and then never follow up on it – all the while claiming that they’ve done something heroic. If you see someone making big claims or doing impossible cases, it means that they’re a hack, not a great dentist.”
Are there things people working in fields of dentistry adjacent to endodontics misunderstand about what you do?
“A lot of general dentists make judgements about endodontic work based on radiographs and images. But if you don’t understand the pulp biology behind endodontics, successful cases can look like terrible root canals. Sometimes, a general dentist thinks a root canal has been so poorly done that the tooth needs to be removed, when I think the same case has been well executed.”
How do you disagree with everyone about the future of your speciality?
“Many in the field believe that endodontics is a dying specialty – they’ll say all root canals are going to be replaced by advanced implants soon. I think they’re wrong for a few reasons, not in the least because there’s more to endodontics than filling root canals. Innovations like regenerative endodontics foreshadow a golden future for the field.”
People who’re tapped into a specific field might take breakthrough innovations for granted because they’ve known what to expect long before results materialized. If you could step back, what in the nearterm might the world find revolutionary coming from endodontics?
“Improvements in regenerative endodontics, where we use stem cells to aid the development of immature root apices or heal infected adult teeth, might be considered revolutionary. There’s a lot of research that still needs to be done, but I suspect we’ll see stem cell treatments come to fruition and become commonplace in about 15 years.”
Conclusion
How might someone figure out more about what being an endodontist involves? What books, interviews, or nontechnical media would you recommend they check out?
“A good resource is the American Association of Endodontists (aae.org). They have material for non-endodontists about what we do. For dentistry, you can check out the American Dental Association (ada.org). I would strongly recommend avoiding videos made by non-dentists or non-endodontists because they are dense with wrong information.”
What parts of the job do you find make up for all the dark, bad, evil things you need to go through? Is there an element of romance or thrill or existential importance to it that you find? What about your job captures the heart?
“Relieving a patient's pain is worth everything. I always thank God for giving me an opportunity to take care of another human being, and I don't take that privilege lightly.”