WORKSHOP OF ADVANCED ENDODONTIC PROGRAMS The W o r k s h o p of A d v a n c e d E n d o d o n t i c P r o g r a m s w a s h e l d in C h i c a g o , Feb 21-22, 1975. T h e objectives of the W o r k s h o p w e r e to e s t a b l i s h c l e a r l y d e f i n e d criteria a n d g u i d e l i n e s that will en.able e v a l u a t o r s to distinguish a m o n g the varieties of p r o g r a m s currently b e i n g offered a n d those in the p l a n n i n g s t a g e s . P r o c e e d i n g s of G r o u p 5, led b y J a c o b B. F r e e d l a n d , is the final in a series of position p a p e r s . F e a t u r e d a r e A: W h e r e a r e w e a n d w h e r e a r e w e g o i n g ? a n d B: Discussion.. Three introductory p a p e r s a n d p r o c e e d i n g of G r o u p s 1 a n d 2 a p p e a r e d r e s p e c t i v e l y in the O c t o b e r N o v e m b e r , a n d D e c e m b e r 1975 issues of the Journal. P r o c e e d i n g s of G r o u p s 3 a n d 4 a p p e a r e d r e s p e c t i v e l y in the J a n u a r y a n d F e b r u a r y 1976 issues.
Jacob B. Freedland, DDS
It would be both timely and appropriate to avail ourselves of this opportunity to celebrate the tenth anniversary of the formal implementation of endodontics .as a specialty area of dental practice. It was over ten years and two days ago (March 1, 1965) that .the American Board of Endodontics met with the American Dental Association's Council on Dental Education to implement the action of the A D A House of Delegates after it had recognized endodontics as a specialty area of dental praotice and approved the constitution of the board. The A D A reference committee of the House of Delegates, in recom-
mending approval, said that it appeared that "an increased interest by practitioners, teachers, and research workers in endodontics had resulted in the preservation of many more teeth than in the past, and that it was not possible for the qualified practitioner to preserve the large majority of all permanent.teeth with pulpal involvement. 'u The A D A House said that recognition of endodontics as a specialty area of dental practice will improve the capabilities of the profession to serve the public3
WHERE ARE WE GOING IN 19757 I would like to recommend to you to read the .articles in the November
1974 issue of the Journal o/ Dental Education on advanced endodontic education--especially the papers by Harrington and Van Hassel and by Schilder, which were sent to you because they relate in substance to my assigned subject. To achieve some resource information for this presentation, a questionnaire was devised and mailed to 42 directors of advanced endodontic programs. Although there are 52 such programs listed in the Jialy 1974 Accredited Advanced Dental Education Programs by the A D A Council on Dental Education,Z some are no longer viable and some of the directors are responsible for more than one
JOURNAL OF ENDODONTICS [ VOL 2, NO 3. MARCH 1976
program. The questionnaire and tabulation are appended to this report. Some references to this survey are embodied in the text.
Distribution of Diplomates and Limited Practitioners As of this date, the 1974-1975 Roster o/ Diplomates 4 indicates a total of 430 endodontic specialists. Of this group, 30 are either deceased or inactive. Nineteen live beyond the continental limits of the United States, 33 ,are in full-time ,teaching, and 17 are in the federal services. The 19741975 Directory o/ Dental Educators 5 indicates 112 full-time teachers of endodontics in US dental and nondental institutions. This figure provides no information as to certification or educational qualification. There are 216 endodontic diplomates on faculty rosters of US dental schools. With 85.7% of the questionnaires completed and returned, 55.5% of the respondents indicated an adequate number of faculty members to achieve optimum teaching values for an advanced program. On the question of how many full-time teachers came from these programs, the sum total was 31. Indiana led the list with eight teachers; Pittsburgh had seven; and the Navy had four. The remaining ten came from the remaining 33 programs. The 1973 survey by the A D A Bureau of Economic Research and Statistics on the distribution of dental specialistsG shows a total of 638 endodontic practitioners out of a total of 11,555 specialists. In percentages (of 100% of specialists), the breakdown speaks for itself: orthodontists, 40.23%; oral surgeons, 24.8%; pedodontists, 10.8%; periodontists, 9.7%; prosthodontists, 6.8%; endodontists, 5.5%; oral pathologists, 1.2%; and public health dentists, 1.0%. Our ranking is sixth among the
clinical disciplines. When you compute the availability of endodontists to the national population, the ratio is 1:352,664. When you study the geographic distribution, you find ten states with no endodontic practitioners and 11 states with only one; 52% of the endodontists are found in five states that contain only 26% of the population.
A d v a n c e d Proqrams In the 1973-1974 listing of advanced programs by the A D A Council on Dental Education, 7 52 include endodontics, with an enrollment of 259 graduate students of a total of 2,788. Once again, we are in sixth position in regard to enrollees in advanced programs.
A Clinical Discipline As a clinical discipline, five points should be considered in evaluating where we are: - - i n limited practitioners, lowest in number of specialists; - - i n enrollees in advanced programs, lowest in number; - - i n qualified full-time faculty, in obvious short supply; - - i n training full-time faculty, in obvious short supply; and - - i n availability to population, 1:352,664. Concerning the question--"Do you think that we are training too many endodontists?"--60% of the respondents answered in the negative.
Continuinq Education In the listing of continuing education courses in the September 1974 issue of the Journal of the American Dental Association, 8 five programs indicated some design for the endodontic practitioner; one had no restriction on attendants, and the other four could accommodate a total of 64 attendants.
Publications At the time of our recognition, there were only five texts devoted to endodontics published in this country. Today, we have nine texts available, with only one of the former group in a currently revised edition. An article by T. M. Graber in .the June 1974 issue of the Journal of the American Dental Association 9 provides an observation but-no accolade: "Endodontics has relatively little publishing activity for a clinical specialty. However, good books are already available and endodontics has not seen much innovation." As a component of the Journal o/ Oral Surgery, Oral Medicine, and Oral Pathology, we had been allocated about 25 pages per issue. In January of this year (1975), we initiated our own independent journal. It is of special interest to note that the questionnaire brings out that 60% to 72% of the advanced education programs should require students to write a paper eligible for publication.
Endodontic Objectives The constitution of the American Association of Endodontists, Article II, Section 1, stipulates that this association has been organized with this objective: to promote the interchange of ideas on methods of pulp conservation and endodontic therapy. There are no explanatory references or modifications that this objective is limited to the ambulatory patient who has achieved the eruption of the permanent dentition. When one scans the endodontic literature in texts, journals, and technical manuals, there is little or no reference to the problems of the primary dentition, or to the care for the young, the chronically ill, the handicapped, or the nonambulatory patient. One is perplexed to review the indices and not find much beyond the reference to pulpotomies.
JOURNAL OF ENDODONTICS [ VOL 2, NO 3, MARCH 1976
In the Workshop on the Biologic Basis of Modern Endodontic Practice, 1~ Torneck, in his synthesis report of pedodontic-endodontic practices says "despite our apparent sophistication in resoarch, much of what we do clinically .is still based on empirical .and biased opinion. It is evident in this area of pedodontic endodontics that much is to be learned and much must change." In translating the objective in the A A E constitution, the questionnaire provided some provocative data. Multidiscipline communication was higher in the non-dental school programs, and the differential is significant. Panacea Endodontics-Biologic P r i n c i p l e s Demosthenes observed in the first century that "man will believe what he wants to believe." The disciples of the panacea concept reflect favorably that his observation is equally accurate for the 20th century. We have been alerted and cautioned by biochemists, toxicologists, publications, and editorials that the everchanging contents of N2 contain enough lead and phenyl mercury to be considered potentially hazardous in endodontic therapy. 1~ In a written communication from Irving M. Shapiro in November 1974, he stated that "it is conceivable that lead introduced through the root canal could add significantly to the body burden of this element. Obviously, in a population risk, any increased exposure to lead is undesirable." He further said that "what is currently needed is an assessment of the importance of leadcontaining agents in endodontic therapy and carefully controlled studies to determine the contribution that these formulations make to the lead burden of children and adults." Kay, 12 in a recent publication, indicated two specific requirements that we need to assess for such toxic materials and
their breakdown: to establish the concentration levels and to follow the course of the metabolism; and to identify target organs and measure functional changes of tissue damage to the target organs. A reminder of an historic admonition for all therapies might be in order: P r i n u m non nocere--First, do no harm.
was the responsibility of dental educators to initiate the debate to better define what the clinical disciplines were today and what they might be for the future. It was also his view that the major issues confronting specialties in the near future would not be of a scientific but more of a social, political, and economic nature.
WHERE ARE W E G O I N G ?
It requires no crystal ball set in either silver or gutta-percha to envision the winds of change emanating from our government, dental educators, third party programs, and the American Dental Association. The report of the Advisory Committee on Dental Health to the Secretary of Health, Education, and Welfare is states, in part, "that dental care is an essential part of total health care and that every person has the right of .access to necessary dental services; and it should establish national health goals .and formulate a plan and programs essential to their achievement." Morris, 14 in his paper to the Conference on Oral Health, Dentistry, and the American Public, provided some insight into the future with the statement "It is not current demand for dental care, but existing need for dental care, which must form the basis for manpower planning." Ackerman, 15 in a presentation at the Conference-Workshop for Orthodontic Teachers of Postgraduate and Graduate Programs, held in Chicago, June 1973, made a number of observations for the future that are relevant to all denfal disciplines: "It is my conviction that the course for the future is chartered under a much broader definition than now ,accepted, the practice of orthodontics is on a collision course with the country's emerging concept of health care as a human right rather ,than a privilege." He also expressed the belief that it
In the first decade of our recognition, advanced programs increased in number from 10 to 52. A closer look would reveal that some of these programs are no longer active. In papers recently presented by Harrington and Van HasseP 6 and by Schilder, 17 they raised the question of the quality and quantity of existing programs. This issue of quality also has been raised by nonendodontic educators. The survey showed that over 50% of the programs had no full-time faculty, and it should be of significance to .this workshop that the programs have produced so few graduates devoted to full-time teaching. The recent approval by the A D A House of Delegates of the Revised Requirements for Advanced Specialty Programs 18 stipulates that faculty members must have certification and high professional standing; must possess the attributes of a teacher; must be selected on the basis of ability, aptitude and interest; and that in all instances it is imperative that the director of the program must be available to assume full responsibility for supervision of the specialty program. With the new structure of the A D A Council on Dental Education, more frequent site inspections, and more stringent criteria for approval, we should anticipate an improvement in the quality of advanced programs. The survey reflected that 39% of the schools and 44% Of ,the nondental schools considered the accreditation requiremerits too lenient, and 22% of each
JOURNAL OF ENDODONTICS l VOL 2, NO 3, MARCH 1976
group also believed that they were unsatisfactory. 9 Reassessment. Coady, 19 in his presentation to an endodontic workshop, expressed three pertinent references to the future of endodontics: that the profession would ask for a reassessment of all specialties ,to determine if they will meet the criteria for specialty recognition; that there would be a lessening of endodontic problems related to caries--however, problems related to injuries of the teeth resulting in endodontic problems will ensure a continued need for the endodontist; and that he would opt for less than eight specialties in the future. 9 Perio-endo programs. Subsequent to this workshop, I. B. Bender, then president of the AAE, arranged for a conference with the representatives of the American Academy of Periodontology ,at the University of Pennsylvania. 2~ The objective was to inquire into the considerable body of knowledge relevant to both disciplines, and to explore the commonality of background in the advanced education curriculums. The next year, the University of Pennsylvania School of Dental Medicine enrolled its first gradu.ate student in a three-year combined perio-endo program. 9 Expanded duties auxiliaries in endodontic practice. Although there has been much debate on the issue of expanded duties for auxiliaries, it was of special interest to see the response from the survey. The vast majority of the respondents believed that auxiliaries could place a rubber dam, take cultures after the seal had been removed; and place the final seal after therapy. Sixty percent of the nondental school responses showed that ,auxiliaries could inject anesthetic for endodontic procedures. I n all other categories, the favorable responses for expanded duties were less than in the 50-percentile range. There was a special interest in
this particular question in view of the fact that about 50% of the dental schools have T E A M grants. 9 Shortage o/ dentists. The National Health Service Corps surveyed the ratio of health-care personnel to population in 1972. In December 1974, this information was released for general publication.21 All areas having a dentist-patient ratio of 4000:1 were designated as critical-shortage areas. Congress is considering bills authorizing loans to students who volunteer to practice in underserved areas. For each year of practice in such areas, the government would forgive a part of their loans. Dental schools may be required to reserve 25% of new admissions for such volunteers. It would be realistic to anticipate that bold steps will be taken to improve the distribution of health care personnel, and this certainly will include both dental and medical specialties. Tomorrow's
The demand for dentistry to meet the need for dental care will be overwhelming. Every discipline and every resource will be challenged for years to come. If there is a fear to concern us, it may well be that expediency, economics, and bureaucracy may dilute the ultimate goal of dentistry: the retention of the natural dentition for the normal life span. For too long we have permitted the concept that extraction and prosthetic replacement are acceptable services while prevention and retention therapies are considered luxury services. If there is merit to the premise that teeth are lost because of only two reasons--disease or accidental i n j u r y - - t h e n we need not fear for the future of endodontics as a clinical discipline. It is also reasonable to anticipate that preventive dentistry and a strong emphasis on periodontics and endodontics will become increasingly more significant if dentistry is determined and dedicated
to achieve its ultimate goal. The anthropologists tell us that their studies reflect that primitive man suffered dental diseases but did not lose his dentition in his normal life span. Is modern man entitled to less? The Bible tells us in Exodus 21:27 the significance of the value placed on a human tooth: "And, if he smite out his bondsman's tooth, or his bondswoman's tooth, he shall let him go free for his tooth's sake." A second reference is a n admonition from Matthew 19:6: "Quod ergo Deus conjunxit, homo non extrahat"--"For the flesh is no more twain, let no man put [pull] asunder that which God has joined together." Reference 1. American Dental Association. Reference Committee report. Read before the ADA House of Delegates, Atlantic City, Oct 1963. 2. American Dental Association. Annual session, House of Delegates, San Francisco, Nov 1964. 3. American Dental Association Council on Dental Education. Accredited advanced dental programs. Chicago, American Dental Association, July 1974, pp 4-38. 4. American Board of Endodontics. Roster of diplomates 1974-75. 5. American Associat.ion of Dental Schools. Directory of dental educators. Washington, American Association of Dental Schools, 1974, pp 75-229. 6. American Dental Association. Reports of Councils and Bureaus, Bureau of Economic Research and Statistics. Chicago, American Dental Association, 1973. 7. American Dental Association Council on Dental Education. Annual report. Advanced dental education. Chicago, American Dental Association, 1974, p 3. 8. American Dental Association Council on Dental Education. Continuing education course listing for September 1974 through February 1975. JADA 88:657 Sept 1974. 9. Graber, T.M. Books for the dentist. JADA 88:1324 June 1974. 10. Torneck, C.D. Pedodontic-endodontic practices: a synthesis. In Siskin, M., ed. The biology of the human dental pulp. St. Louis, C. V. Mosby, 1973, p 375. 67
Dental schools 1. Do you have an adequate number of faculty to achieve optimum teaching values for an advanced program?
13. D o you feel that it requires two years of postdoctoral training to produce a clinically competent endodontist? 14. What is the ratio of applications to admissions in your program?
2. If faculty is in short supply would you indicate which of the following causes are most significant: a. availability b. salary levels c. interest in teaching
28% 60% 24%
14% 57% 29%
3. Do you require your students to write a paper digible for publication in a scientific journal?
4. Do you feel that all students in advanced programs should be required to write a paper acceptable for publication?
5. Do you feel that we are training too many endodontists?
6. Do you feel that those that have been trained and currently in practice are fulfilling the objectives and goals set forth in your p r o g r a m ?
7a. Do you have the cooperation of the other disciplines of dental practice in your clinical training program? a. periodontics b. pedodontics c. oral surgery d. prosthodontics e. orthodontics f. oral pathology g. public health dentistry
92% 54% 75% 54% 33% 79% 29%
100% 100% 100% 78% 45% 89% 1%
7b. Is such cooperation scheduled
8. Is there an organized plan to provide endodontic therapy for the chronically ill, handicapped, and nonambulatory patient?
9. Are your students required to serve the therapeutic needs of primary teeth in their clinical experiences?
10. Are you a full-time director? H o w many days per week? 1 1 1/2 2 2 1/2 3 4 5
14% 6% 9% 9% 14% 18% 46%
28% 14% 57%
11. H o w many full-time members of the endodontic faculty?
12. How many graduates of your program devote full time to teaching
15. Do you feel that the undergraduate training of your advanced students was a. excellent b. adequate c. inadequate
29 % 67% 4%
11% 67% 22%
16. Do you believe that all endodontically treated teeth should be restored with full crowns or onlays? a. all multi-rooted teeth
64% 20% 8% 50%
18. D o you believe that the administrative heads in your school believe that endodontics will maintain itself as one of the special areas of dental practice?
19. D o you think that undergraduate endodontic training can achieve the desired level of competency in this clinical discipline?
91% 48% 74% 26%
75% 44% 88% 60%
21. D o you feel that the A A E and the A D A should encourage and support endodontic therapy as an essential dental therapy in third party programs?
22. D o you feel that accreditation requirements for advanced programs are: a. too severe b. too lenient c. unsatisfactory d. satisfactory
-39% 22% 39%
11% 44% 22% 22%
17. What do you think is the most significant motivating factor for a student to seek advanced training in endodontics: a. economics b. psychic income c. ease of clinical practice d. postdoctoral identification in a specialty (Some respondents provided more than one answer to this question)
20, D o you feel that auxiliaries can be trained to do the following: a. place a rubber d a m b. adequately instrument a canal after the initial opening has been accomplished by the endodontist c, take cultures after the seal has been removed by the endodontist d. prepare the trial cone e. place the final seal after therapy f. inject the anesthesia
JOURNAL OF ENDODONTICS I VOL 2, NO 3, MARCH 1976
I1. Nygaard-Ostby, B. Is N2 an acceptable method of treatment? In Grossman, L.I., ed. Transactions of the 5th International Conference on Endodontics. Philadelphia, University of Pennsylvania Press, 1973, p 196. 12. Kay, K. Instrumentation in toxology: assessing toxic materials and products in the body. Trans NY Acad Sci 36:511 June 1974. 13. Young, W.O. Dentistry looks toward the twenty-first century. In Brown, W.E., ed. Oral health, dentistry, and the American public. Norman, University of Oklahoma Press, 1974, p 27. 14. Morris, A.L. Training and utilization of dental manpower, oral health, dentistry, and the American public. In Brown, W.E., ed. The need for an ~improved oral care delivery system. Norman, University of Oklahoma Press, 1974, p 289. 15. Ackerman, J.L. Orthodontics: art, science, or transscience. Angle Orthod 44:243 July 1974. 16. Harrington, G.W., and Van Hassel, H.J. Postdoctoral endodontic education: current problems. J Dent Educ 38:610 Nov 1974. 17. Schilder, H. Endodontics: present status and future prospects. Read before the Workshop for Teachers in Advanced Education, San Diego, Calif, April 1974. 18. American Dental Association Council on Dental Education. Annual reports .and resolutions. Chicago, American Dental Association, 1974, p 29. 19. Coady, J. The future of dental specialties. Read before the Endodontic Workshop on Advanced Education, Chicago, 1973. 20. American Association of Endodontics. Report of preliminary conference on relationships between periodontics and endodontics. Philadelphia, University of Pennsylvania, Feb 1973. 21. King, W. Charlotte Observ, Dec 26, 1974.
Discussion Jacob B. F r e e d l a n d , DDS, L e a d e r D a n i e l B. G r e e n , DDS, R e c o r d e r
This group agreed that it is essential, if not imperative, that we require continuing evaluation to ensure the quality and competence of advanced programs in endodontics. It is the belief of this group that the numbers of specialists in endodontics did not exceed the need or ,the demand for expert care. There was evidence that there was an imbalance .in the distribution of endodontic specialists, who tend to congregate in the more populated states and in their metropolitan areas. There was concurrence with the remarks by Dr. William E. Brown that predoctoral endodontic t r a i n i n g should provide an adequate level of competence for the average graduate from dental school to handle routine endodontic cases. It was also the opinion of this group that consultants to the American Dental Association's Council on Dental Education, serving on site inspections, should monitor predoctoral endodontic programs so that the level of competence of the general practitioner is achieved during his learning experiences ~n the dental school. A minimal requirement would be that he be competent to oare for an endodontic case that did not show undue complications visually, clinically, or radiographically. It was the consensus of our group that every advanced student should be capable of writing ,a paper eligible for publication. A n advanced endodontic program should provide for the training and competency of the advanced student
to manage the endodontic requirements of primary teeth as well as the care of the handicapped, chronically ill, and nonambulatory patient.
The P r o q r m n A d m i n i s t r a t o r The individual responsible for the day-to-day implementation of an advanced program should have a fulltime commitment of four days a week. The reference to full time has been a variable, and our group believed that four days was a minimal definition of the full-time commitment. On page 2 of the Requirements For Advanced Specialty Education Programs, 1 under the paragraph titled "Program administrator," it was recommended that the first two words of this sentence, "If not," be deleted. This sentence would then read, "There must be evidence that sufficient time is devoted to the program by the director so that the educational and administrative responsibilities can be met." It should be understood that this means that the director be on the premises and available at .all times. It also should be understood that such an appointment as director of an advanced program would, in all instances, be a primary responsibility of the individual and not secondary to his private practice or administrative duties. In the desire to maintain the minimal level of the quality of an advanced program, it would be both desirable and preferable that at least two consultants be utilized for a site inspection. I n the event that the