Episode 50 – Endodontics and Practice Locations
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Hello. This is Scott McDonald of DoctorDemographics.com and welcome to the perfect place to put a practice podcast.
In this session, we are going to examine Endodontic practice. If you have not listened to the session on Prosthodontics, it is worth a listen as it makes some rather interesting (and bold) statements regarding all dental specialties. What we see in the world of dental, many medical and related practices that are specialists may want to consider what is going on, particularly if you are in a practice that depends upon referrals for your patient base.
As everyone knows, endodontists are involved in doing root canals. When I first started consulting for dentists, it was unheard of for a general dentist to even contemplate offering this treatment. But the techniques of performing a root canal have long been taught in dental school and, at least in theory, any general dentist can perform this service. Practice management consultants have taken up the call to encourage them to refer only those cases that they wouldn’t dare do on their own because the procedures carries some good compensation relative to the time that it takes to perform. The trouble is that the “standard of care” has developed beyond the simple use of files. Now, if you really want to be good at providing this care, having an operating microscope, particularly when treating multi-chamber teeth like molars. But this is an expensive piece of equipment that definitely takes some training and experience to use well. By not offering this standard of care along with these technologies, general dentists are increasingly liable for when the root canals fail. Even endodontists have some cases fall apart, certainly through no fault of their own. But in an increasingly litigious age, general dentists have the potential of being successfully sued when it happens.
Now, let’s go back to the key topic that I usually address: where should you put an endodontic practice. Let’s deal with the first issue which I am asked about most often: how many endodontists are too many or not enough? This once was a simple matter of determining how many general dentists, the primary referral source for endodontists, would there be. Keep in mind, it has never been an issue of coming up with a ratio of population-per-endodontist. I will explain why in a minute. Rather, the theory was that if you had enough general dentists referring their patients to an endodontist, you would have enough demand to place a practice in a particular location. At least that was true back when general dentists would not perform these procedures and, rather, they would refer them over regularly. Now times have changed. So many GPs are doing root canals on front teeth with a single chamber that the traditional number of one endodontist per 25 general dentists does not hold true any more.
Now, I mentioned a moment ago that the population-per-endodontist ratio has never been the issue. That is because of the relationship between treatment and demographics. Perhaps the most obvious example of this is oral surgery. Third molar extraction usually occurs in the age window between 18 and 24. As an aside, some races (no kidding) tend to have some variation in the age of these wisdom teeth eruptions but that is a matter for another session. Let’s just say that if you are in the business of doing lots of wisdom teeth extractions, you want to find a large population of 18 to 24 year olds. In endodontics, the incidence in which root canals are most needed (or tend to occur most often) is over age 50. There is some controversy in this and I leave it to the clinicians to define it. Nevertheless, at some age, the odometer in your mouth turns over. For this reason, you have to place a practice where there are plenty of people of this age. But endodontists also know that there are some other demographic factors that will make one location more desirable than another. Among them are educational attainment and median household income. When one finds a population with limited education (usually below 25% of the population who has a 4 year college degree or more), they tend to favor extraction rather than treatment by endodontics. “Yank it doc!” they will say. This partly a function of not understanding or wanting to understanding the virtue of retraining the tooth in the mouth. They assume a denture, or dental implant, or a bridge will work just as well. If you assume that this conclusion is correct, then you will want to find a population that is moderately well-educated AND will fit the age characteristics we just discussed.
THEREFORE, the idea location is not just a place where there are no other endodontists. In fact, given the demographic character of the population, an endo practice may not even be viable even if there are many people. They have to be the right kind of people. Additionally, there are still many general dentists who don’t want to get into endodontic treatment at all. From experience, we have learned that general dentists who are busy and also who have reached a certain level of success and age just don’t want the hassle. There are other ways for them to make money and they don’t want the headache. So age and success level of the general dentists in an area may also be important indicators of where you want to practice.
The last point has to do with isochrones. As you may recall, an isochrones is a time-distance measurement. These can be expressed in both distance (in terms of miles or kilometers) or in terms of time to travel a given distance. People tend to speak about how long it takes to get from one location to another rather than the actual distance in miles. But how far is “too far” is a subjective measurement. Still, we can measure how far people are willing to travel based upon lots of variables including what their commute looks like, means of transportation, age, shopping, and recreational habits. There is also one additional factor that almost everyone forgets: population density. The more densely populated an area is, the less tolerance residents have to traveling very far. In a suburban area, the “sweet spot” for endodontists is between 10- and 15- minutes to travel. In rural areas, that might be 30 minutes or more. In very urban areas, it may be far less.
It is interesting to note that given the general public’s aging demographic character in many places, we can assume that demand for endodontics will increase. But it should not be assumed that this trend is universal.
This is Scott McDonald. Thanks for listening. Catch us on YouTube, Twitter, FaceBook, and on the web at DoctorDemographics.com. We appreciate your referrals!