14
VIEWPOINT
Endodontic Quality:
At What Cost?
COSTS OF IMPLEMENTING ADVANCEMENTS
As more dentists graduate with training in contemporary
instrumentation and obturation, they are incorporating these
advancements into their private practices. Since many of these
new dentists are associating with a more experienced dentist,
these changes may meet resistance. Many private practioners
he past decade has witnessed an explosive development
are playing a balancing act between technology and cost. The
of endodontic-related technology. The purported goals
dilemma arises between bringing new technology into the ofof these technological advancements are to increase the
fice, which will provide higher quality of care, and keeping overefficacy and efficiency of clinical treatment. While endodontic
head cost to a minimum. Dental practice overhead increased by
treatment goals remain virtually unchanged, the routes to
over 10 percentage points during the 1980s, causing many docclinical success are varied and burdened with subjectivity.
tors to work harder in order to earn less. As of 2001, the average
Numerous manufacturers have entered the endodontic mar- Diwakar Kinra, DDS, MS
overhead in a general dental practice is at 65% and approxiketplace with little independent clinical scientific evidence of
their products’ effectiveness or superiority. None of the latest products come mately 35% percent for specialist (Pindyck). Therefore, minimizing cost is cruwithout added cost. It is incumbent upon a prudent clinician to consider a cost cial to the success of a practice.
The 2 major categories of cost incurred in a practice are fixed and variable.
benefit analysis prior to inclusion of new technology into clinical treatment.
The evidence-based practice of medicine and dentistry is an attempt to pro- Fixed costs are those that do not vary with the number of goods produced. Fixed
vide the best and most predictable clinical treatment outcomes. Unfortunately, costs can be further divided into a number of categories. First, occupancy costs
there is not always solid scientific evidence to support the use of newer endo- are the total cost of the practice facility. These include rent, utilities, repairs,
dontic technologies and techniques. Authors, such as Pettiette, have provided maintenance, depreciation of equipment, and amortization of leasehold imvaluable information regarding the technical superiority of nickel titanium provement. Second, clerical wages include wages, payroll taxes, medical insurfiles relative to the standard stainless steel files. Additionally, numerous in vitro ance and medical reimbursement. Third, nonoperating expenses such as telestudies support the use of thermosoftened gutta-percha techniques to improve phone, legal and accounting, office supplies, dues and subscriptions, and auto
canal obturation thoroughness. Recognizing the benefits of these trends, many expenses fall into the fixed category also (Blair/McGill). Variable costs are a unit
predoctoral programs are now incorporating these instrumentation and obtu- cost that depends on volume (Pindyck). These may include all the consumable
supplies used in the treatment of patients and laboratory fees.
ration technologic improvements into the dental curriculum.
T
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In endodontics, these increases in fixed cost
may be associated with advances in technology, including microscopes, electrically controlled handpieces, and apex locators. The variable costs are single-use consumables used on a daily basis based on
the number of patients seen, such as files, lubricants, absorbent points, gutta-percha, and sealer.
SEARCHING FOR METHODS TO DECREASE
VARIABLE COSTS
These rising costs of providing treatment leave some
practitioners searching for methods to reduce variable cost within their practice. There is an assumption among private practioners that switching to
rotary instruments and thermosoftened gutta-percha
creates such an increase in cost, that it in not cost
effective in the long run to make the change. The author has been unable to locate specific information
regarding the actual variable cost of delivering quality endodontic treatment.
This purpose of the study was to provide the current variable cost associated with the delivery of traditional and contemporary endodontic treatments.
Without such information, it is complicated to make
an informed decision concerning cost. Previously, the
field of dental economics has had difficulty incorporating evidence-based dentistry into this study model.
Without a current body of knowledge on this topic,
there is a void in the research and literature on cost
expenditure in endodontics. Since this philosophy
has become the “gold standard” of research, this article is an attempt to fill that void.
The study included cost analysis of consumables
from the beginning until completion of root canal treatment. Access burs, isolation materials, and disinfectants
will remain constant in the cost analysis for both methods. The supply companies provided information for
cost of the consumables and discounts for bulk purchases were considered. The costs that were differentiated between traditional and contemporary endodontics included shaping instruments, lubricants, absorbent points, sealer, and obturation materials.
Thirty extracted human teeth were divided into 2
groups containing equal numbers of anterior, premolar, and molar teeth. The teeth were selected to represent treatment of a similar number of canals, curvature and calcification. Each tooth group was timed
from access, cleaning/shaping, and to obturate the
canals using 2 different methods described below.
Method 1 used a step back technique with hand files
and lateral condensation. Method 2 used the ProSys-
Table 1. Study Method’s Step-By-Step Process
Method 1: Modified Step Backa
Method 2: Ni-Ti Engine Driven Rotaryb
1. Access and locate canals
1. Access and locate canals
2. Apical enlargement—Enlarge apex
at working length to appropriate size file
for that tooth (recaptiluate)
2. Establish patency
3. Step back—Shorten the next
larger file (from step A) by one mm
until 3 mm of step back is achieved
3. Prepare Glidepath for rotary instrument
with hand files
4. Refine canal with Gates Gliddens to create
funnel and allow taper for a DT-11 spreader
reach one mm from working length
4. Instrument from largest to smallest taper
file, beginning with orifice opener (using
appropriate size file for tooth)
5. Dry with nonstandard paper points
5. Dry with appropriate tapered paper points
6. Apply Roth’s 801 Sealer within
6. Apply thermaseal within canal
7. Lateral condensation with gutta-percha
7. Thermal compaction with obturators
a Unit dose RC Prep and 10 mL of 2.6 % sodium hypochlorite was used with each tooth.
b Unit dose of ProLube and 10 mL of 2.6% sodium hypochl rite was used with each tooth.
Table 2. Study Method’s Costs and Time to Complete
Method 1: Modified Step Back
Method 2: Ni-Ti Engine Driven Rotary
Consumable
Average Cost/Use
Consumable
Average Cost/Use
Hand files
$12.15
Hand files
$2.27
R.C. Prep
$0.83
Prolube
$0.75
Gates Gliddens
$7.64
Rotary Instruments
$27.95
Absorbent Points
(Nonstandardized)
Absorbent Points
(Tapered)
$0.42
$0.13
Gutta-percha
$0.57
GT Obturators
$13.53
Roth’s 801 Sealer
$0.21
Thermaseal
$0.48
Total Cost
$21.53
Total Cost
$45.40
Time
34 min
Time
17 min
tem GT as described by the manufacturer and thermal compaction with GT obturators (Table 1).
Each case was treated bench top by the author and
the data was taken for consumables used in the procedure. A cost was associated with each category and
totaled to reach an average final cost for both methods.
In the present economy, dental practioners must
manage the fiscal aspect of the practice along with the
dental aspect. Most dentists are caught in a balancing
act between providing the highest quality care and
minimizing cost. Endodontics can be very profitable
for the dentist in that it generates high income with
minimal cost. As the trend moves toward engine-driven Ni-Ti rotary systems and heat delivered obturation,
high quality endodontics becomes easier to deliver.
As seen in Table 2, the average cost for a case
using method 1 is $21.53 and the average times takes
34 minutes. For method 2, the average cost for a case
was $45.37 and the average time was 17 minutes.
At first look, many general dentists may assume
that switching from hand filing and lateral condensation to rotary instrumentation and thermal compaction will be an expensive decision. Although upon
further review, the switch may be a cost-effective procedure to increase revenue in the office. Per conversation
in April 2004 with the Levin group, the average fixed
cost to run a general dental practice is $300 per hour ($5
per minute). Therefore, for method 1, which takes 34
minutes, the average cost would cost $21.53 plus the
fixed cost. To perform a case with hand files and lateral
condensation would range in cost from $135.54 to
$261.18, with the average being $191.53. For method 2,
the overall range in cost would be $92.53 to $290.28
with the average being $130.37. For both methods cost
increased from anterior to posterior. There is a significant difference between the 2 methods.
CLOSING COMMENTS
More than 24 million root canals were performed in
2003, and general dentists accounted for 75.2% of
these cases. This accounted for the $8.2 billion generated by these procedures in that year. Therefore, general dentists are providing most endodontic procedures and are also profiting from performing this very
valuable service to their patients. To take this one step
further and apply evidence-based dentistry to practice
management allows dentists to make informed decisions on how they are going to run their practice.
In conclusion, performing endodontics with a
rotary Ni-Ti instrumentation and thermal compaction
allows the dentist to provide high quality care for the
patient, increasing production at the same time. This
can be attained, while keeping costs to a minimum.!
Dr. Kinra received his DDS degree from the University of Michigan
School of Dentistry in 1999. In 2002 he obtained his master’s degree in endodontics at the University of Detroit-Mercy School of
Dentistry. In 2004, he began his solo private practice limited to
endodontics in Flint, Mich. Dr. Kinra is an adjunct professor of graduate endodontics and graduate periodontics at the University of
Detroit-Mercy School of Dentistry and an adjunct professor of graduate endodontics at the University of Southern California. He is a
member of the AAE, MAE, ADA, MDA, and GDDS dental societies.
He also serves as the committee chair for the ADA Committee on
the new dentist. Dr. Kinra has spoken on clinical endodontics and
practice management at more than 20 universities internationally.
Clinically, his lecturing focuses on clean/shape/pack of the root canal system. He can be reached at (810) 235-0100,
[email protected], or kinraendo.com.
Disclosure: Dr. Kinra reports no disclosures.