Endodontic Education: Teaching One Standard of Practice
Linda G. Levin, DDS, PhD, for the American Association of Endodontists
As an endodontic educator for more than 20 years, I was involved in clinical and didactic proficiency assessments on many levels. None were as informative as what I experienced in 2005 when I went into full-time clinical practice. It was there that I could observe the real-life competency of my students. I remember reviewing a case for retreatment in which the primary treatment was “less than adequate” and thinking, “Who taught this person that this was acceptable?” Then I had a revelation and realized it had been me who had taught this dentist. How could this be? I had taught at a school accredited by the Commission on Dental Accreditation (CODA). Furthermore, we had a renowned postgraduate program in endodontics with the same faculty. I quickly concluded that we teach two standards of endodontic practice: one to endodontic residents and another, much lower, standard to predoctoral students.
While our endodontic residents were instructed in microscopy and three-dimensional imaging and given a solid underpinning of the literature and biology pertaining to our specialty, predoctoral students were exposed to a minimum number of cases. The faculty had screened the cases for difficulty, so case selection was largely hidden from the students. The amount of time for didactic lecturing at the predoctoral level was shrinking, so more time could be devoted to other disciplines.
In most institutions today, we equip predoctoral students with the same techniques we taught in the 1980s. The exception is that most schools now teach some form of rotary instrumentation, which evolved in the 1990s. We are heavily dependent on two-dimensional radiographs and “feel-o-dontics,” which refers to using an explorer rather than a microscope to find anatomy. There are valid reasons for this, and many institutions suffer from a lack of resources for predoctoral students. But we have to ask ourselves tough questions: Is this in the best interests of the students and the patients they will treat? Are we exposing future general dentists to state-of-the-art endodontics, or are we leaving them with the impression that performing molar endodontics is no more involved than a mesial, occlusal, and distal (MOD) restoration?
The State of the Profession
In a recent American Association of Endodontists (AAE) survey of predoctoral educators, the overwhelming opinion was that our current system of predoctoral education does not provide the resources to educate students adequately to practice state-of-the-art endodontics. Eighty-nine percent of faculty members believed students were not competent to perform molar endodontic procedures. This is concerning because they will be licensed to do so when they graduate—with or without sufficient training.
Can we rely on external controls to ensure adequate endodontic education for the predoctoral student? The revised CODA predoctoral education standards simply state that the student must be exposed to “pulpal therapy,” which allows for a wide range of interpretation by those who develop the curriculum and allocate resources. These nonspecific guidelines have resulted in significant differences in the endodontic competency of dental graduates. The AAE is aware that this is of great concern to stakeholders such as group practices, insurance carriers, dental service organizations, the various branches of government service, and especially patients.
What Can We Do?
First, we must examine how we measure competency. There are several levels of evaluation at the predoctoral and licensure levels. All are fraught with a lack of consistency and validity. Does the ability to perform endodontic treatment on an acrylic tooth equate with the clinical competency required to treat patients? Many schools and boards believe that it is, or they have simply conceded to external pressures to produce licensed dentists. The AAE is taking action to address competency in endodontics, recently appointing a special committee to study this issue and make recommendations as to how we can better judge a student’s ability to be a “safe starter” in endodontics. It is a complex topic that demands our immediate attention.
As specialists in endodontic care, it is our responsibility to lead the charge in making sure our predoctoral students receive a sound and consistent foundation. We must teach one standard of practice to all our students. The present educational system gives the false impression that the student is prepared to practice at the same level as the endodontist. The predoctoral curriculum needs to provide a firmer foundation in the biologic basis of disease, diagnosis, treatment planning, and prognosis. For students interested in clinical competency in simple endodontics, schools must offer “selectives” so the student can have adequate exposure to care.
We must teach students what endodontics in 2017 looks like. We owe it to our students and, most importantly, to their patients.
About the Author
Linda G. Levin, DDS, PhD
President, American Association of Endodontists