Career: The root of the problem

AN estimated 14 million root canal treatments are completed in the UK every year and, thanks to advances in new technologies and techniques, treatment success rates can be 85 to 90 per cent or better.

The branch of dentistry concerned with the biology and pathology of the dental pulp and periapical tissues is endodontics. It also involves the prevention, diagnosis, and treatment of diseases and injuries in these tissues.

In the broadest sense, all procedures that maintain the health and the vitality of pulpal tissues can be considered as relevant to endodontology. Once the pulp becomes diseased, practitioners in this field perform a variety of procedures, most commonly endodontic therapy or root canal treatment. They also provide endodontic retreatment, surgery, and treatment of cracked teeth or dental trauma. Patients often present as emergencies seeking relief from pain.

The General Dental Council maintains a specialist list for endodontics and only registered dentists accepted onto this list can use the title “specialist” endodontist.

Entry and training

For those intending to undertake endodontic training leading to specialist status, the GDC’s minimum entry requirement is two years of postgraduate foundation training (or equivalent) which may include a period of vocational training (VT) and may also include a period of training in secondary care in an appropriate specialist environment.

It is useful (but not essential) for budding specialty trainees to hold membership of one of the Royal Colleges including MJDF (Membership of Joint Dental Faculties RCS England), MFDS (Membership of the Faculty of Dental Surgery RCSEd and RCPS Glasg) or MFD (Membership of the faculty of Dentistry RCSI).

The usual training period for endodontics will be three years (4,500 hours) full time but part-time training is also possible. The programme content is flexible but tends to be roughly 60 per cent clinical, 25 per cent academic and 15 per cent research.

Training may be flexibly delivered through a variety of methods including a structured, taught masters/doctorate degree programme or through a work-place based programme (specialty practice or hospital based training). Whichever route is followed, trainees will have to demonstrate certain minimum outcomes in the range and competence in requisite skills. Development of competence will usually take a systematic path progressively building on core skills. This means the learning process has to be carefully tracked and effective guidance provided at each stage.

Specialist training will take place in programmes approved by the relevant postgraduate deanery and under the supervision of a designated lead trainer (educational supervisor). Appraisals will be held every six months, to include self-reflection on progress as well as trainer assessment leading to a personal development plan.

After successfully working through this programme, a certificate of completion of specialty training (CCST) is awarded by the GDC on the recommendation of the deanery in which the training took place. More information on training pathways is available on the British Endodontic Society website.

The job

Endodontic specialists can choose to practise in a variety of settings, including private referral clinics, within general dental practices (offering NHS or private treatment), in a hospital setting or in an academic/research post.

Those looking to set up a practice offering endodontic treatment will require a referral base and the necessary training and will benefit from much experience gained during postgraduate training. Referral endodontic practice works side-by-side within general dentistry, however it is often necessary when patients are being treated for complex restorative work.

The specialty relies on a number of key pieces of equipment including an endodontic microscope, a torque controlled motor for engine driven rotary nickel titanium instrumentation, digital X-ray equipment, an electronic apex locator and obturation devices and systems. These can involve a considerable financial outlay but are advantageous to ensure efficient endodontic treatment – it is well worth seeking advice before making any big decisions. It must be said that a good trustworthy assistant is perhaps the most valuable element of a successful practice, more so than any of these devices and pieces of equipment.

Membership of professional organisations such as the British Endodontic Society offer a chance to maintain your professional skills and keep up-to-date with the latest developments in the specialty, as well as to share ideas and expertise with fellow dentists and specialists.

Useful links:

• British Endodontic Society - www.britishendodonticsociety.org.uk

• GDC specialist lists and curricula - tinyurl.com/lp7s728

Q&A - Mark J Hunter, specialist endodontist, teacher and secretary of the British Endodontic Society

What attracted you to a career in endodontics?

I was encouraged by a teacher who was aware that I had an aptitude for doing endo. I discovered an area of dentistry that was challenging, intriguing and captivating. To save teeth that would otherwise require extraction is matched only by the privilege we have as dentists to relieve a patient of one of the worst pains that can be suffered.

What do you enjoy most about the specialty?

I enjoy treating the person who owns the tooth. It is not just about doing a challenging and intricate procedure, it is about taking an often frightened patient and delivering them through the process with a positive experience. Winning the trust of another is where the greatest return is to be had.

What do you find most challenging?

Gaining sufficient experience to be confidently effective is one of the early challenges we all face. Once this has been achieved, the biggest continual challenge is to gain and maintain the patient’s trust. If a patient is struggling to let you get on, it can prevent you from performing at your best. This is why endodontics is very much a team effort with you, the patient and your assistant. I can’t over-emphasise the value of a good assistant. Sure, there are technical challenges such as sclerosed canals, 90 degree curvatures with a small arc of radius, previous misadventures, fractured instruments, ledges and blockages. These can be overcome, but not if the patient is unwilling to let you get on with it.

Have you been surprised by any aspect of the job?

I have learned that complacency can teach one a harsh lesson. Positive outcomes cannot be assumed and you should always expect the unexpected. When you see a lateral canal filled very nicely, ask yourself how much skill really went into filling this and how much was down to good luck? Doing endo can be a humbling experience. When things don’t go according to plan, don’t try to cover up, always keep the patient informed, be open, honest and realistic.

What personal attributes do you feel are important in endodontics?

The most important attribute for achieving good outcomes is patience, both with the patient and yourself. If you are performing urgently or under pressure, then this tends to give a poorer outcome. A better outcome can often be had by returning to a case at a later date rather than trying to complete it in a hurry. Missing or difficult to negotiate canals one day can seem much easier to manage when one is refreshed at a subsequent visit. The other great attribute for doing good endo is empathy. Letting patients know they can stop treatment if the need arises helps them to feel more relaxed and in control.

What advice would you give to a student or trainee considering the specialty?

Total commitment is required for endo as it can be tough. Don’t specialise too soon – I feel I’m a better endodontist because I have a facility and ability in other areas of dentistry. (It relates back to the idea that we treat the person who owns the tooth, not just the tooth.) A good endodontist will have a range of early dental experience such as extracting teeth, making dentures, recognising and treating soft tissue disorders as well as treating difficult uncooperative children to name but a few. You also have to be good at giving local anaesthetic, as well as restoring the tooth for the referring practitioner with a core or perhaps a post-retained core foundation. It helps to be a good diagnostician which means being able to listen and, when things don’t make sense, to stand back and admit that we don’t quite know what is going on. Endo is a wonderful, challenging area of medical expertise and intrigue, with ongoing scientific advances on many fronts, and countless gadgets and gizmos to help you on your way.