Endodontist vs. General Dentist - Who should perform your tooth's root canal work?

- Advantages that a specialist can offer. | Is the expertise of an endodontist always needed? What does research suggest? - statistics | Additional factors and differences associated with the services of each.

Endodontist or Dentist - Which makes the right choice?

When it comes to having root canal treatment, the field of dentistry offers two options. Either your regular dentist can perform your work, or else a specialist. The formal term for a root canal specialist is "endodontist."

The main difference between the two lies in the level of expertise they have to offer. And as this page outlines, while you can't go wrong with choosing to have an endodontist perform your tooth's treatment, their level of training and skill isn't needed in every case.

a) Advantages endodontists offer.

Having a specialist perform your work has some basic advantages associated with it. They typically include:

  • Greater expertise and clinical skill. - An endodontist has: 1) All of the same schooling as your regular dentist. 2) Plus additional years (2 or 3) of training in graduate school that's entirely focused on just performing endodontic therapy. 3) And then however many years of being in practice where they only provide this type of work.

    That generally means that an endodontist has a lot of knowledge about, and is quite expert in doing, that which they do. (More details about differences in training.)

  • More advanced equipment. - The kinds of equipment that an endodontist utilizes in their practice typically lies at a full level above that of a general dentist. As examples, most use a surgical microscope and possibly even 3D x-ray imaging.
  • A higher level of diagnostic skills. - Along with greater expertise and the use of more sophisticated equipment generally comes a greater ability to diagnose difficult cases.
  • Shorter/fewer appointments. - Since as a specialist they only perform endodontic procedures, you can anticipate that an endodontist will be quite adept in providing treatment. And that should translate in to shorter and/or fewer appointments.
  • Higher treatment success rates. - Research studies suggest that work completed by endodontists, especially for certain kinds of teeth, tends to have a higher success rate.
  • More expert pain management. - It's only logical to assume that a practitioner who's "seen it all before" will be more likely to be able to anticipate and manage their patient's pain-related problems.

b) Advantages offered by general dentists.

The benefits associated with choosing an endodontist to perform your work won't play a significant role in all cases. As we discuss below, not all root canals pose a great challenge. And in the case where your own dentist is more than capable of performing your work, there are certain advantages that having them do so can offer.

  • Lower fees. - There's usually a financial premium attached to an endodontist's services. In most cases you'll find that their fee is higher than your regular dentist's.
  • A familiar environment. - Having your own dentist perform your work has the advantage that your treatment will be performed in an office you're already familiar with, by a person you already know.

    And because your dentist and their staff already know you too, they may be more accommodating with scheduling, billing, and insurance issues than an endodontist's office would be.

  • Convenience. - In some parts of the country just finding an endodontist may be relatively difficult. Getting to one may require a trip to a nearby metropolitan area. Or if one travels to your town, it may just be on selected days.
  • Treatment continuity - Having just one person perform all of the different procedures your tooth requires might offer some benefit in terms of scheduling.

General dentists vs. endodontists. - Treatment success rates.

When it comes to your tooth's work, there's no factor that's more important than its ultimate success. And it seems logical to speculate that the added expertise that a specialist has to offer will favorably influence the outcome of the treatment they provide.

Statistics from the following research studies seem to confirm this, at least to some degree, and for some types of teeth more than others. [page references]

Alley (2004)

This small study (350 cases) found a success rate of 98% for therapy performed by endodontists vs. 90% for cases completed by general practitioners.

Ibqal (2016)

Using a sample of 90 failed root canal cases, this study found that 79% of them represented work that had been performed by general dentists. This paper also cites a study (Weiger 1998) that determined that the success rate of endodontic therapy performed by general dentists generally runs on the order of 65% to 75%. For specialists this number was 90%.

Lazarski (2001)

This study investigated the outcome of over 100,000 root canal cases by way of evaluating an insurance company database. Each tooth was followed over a time frame of at least 2 years.

  • The study found a similar success rate for work completed by both specialists and general dentists (94% at 3.5 years).
  • The paper noted however that the specialist group treated a substantially greater percentage of molars (multi-rooted teeth often having a very complex root canal system) whereas the generalist group more single-rooted, typically easier to treat, teeth.
Burry (2016)

Also mining an insurance company database, this study monitored the outcome of almost one-half million root canal cases, broken into groups of 1, 5 and 10-years following the completion of their work.

  • Molars - At 5 years, molars treated by specialists had a 2% higher survival rate. At 10 years this difference expanded to 5% (84% vs. 89%).
  • Incisors, Canines, Premolars - For these types of teeth at 5-years, no statistical difference was found in survival rates for cases performed by endodontists vs. dentists. At 10 years, a 1% difference in success was reported (around 91%).

Does that suggest that some types of teeth are best treated by specialists?

Possibly. To recap the study just mentioned (Burry 2016), it suggests that:

  • As far as 10 years out, relatively little difference is found in the success rate of cases completed by endodontists vs. general dentists for incisors, canines (cuspids, eyeteeth) and premolars (bicuspids).
  • But for molars a survival difference is apparent at longer durations (5% at 10 years out).

Those findings seem to correspond pretty well with the data in our "root canal failure rates by tooth type" tables which seem to suggest that:

  • Treatment failure is more frequent with molars (possibly more so with upper ones) than incisors and canines.
  • Root canalled premolars (more so upper ones) tend to fail at a rate greater than that for front teeth (incisors and canines) but less than molars. (This is in contrast to the Burry study above which found the failure rates for incisors, canines and premolars to all be about the same.)

Formulating rules of thumb about opting for treatment by a general dentist.

Using the information above, you could draw some broad conclusions about which types of teeth are generally the easiest to treat and therefore the best candidates for treatment by a general dentist.

It's important to keep in mind however that the following statements are simply our conjecture, and that of course exceptions always exist.

a) Incisors, Canines, Lower Premolars.

The level of skill needed to successfully treat upper and lower incisors, upper and lower canines and lower premolars generally seems to lie within the capabilities of general dentists in the vast majority of cases.

As an explanation, these are single-rooted teeth that most commonly just have a single relatively large (and therefore comparatively easier to treat) root canal.

b) Molars.

While the long-term failure rate of molars treated by general dentists is relatively low (16%), the added expertise that an endodontist can provide apparently provides a benefit (11% case failures), especially when the long term is considered (both statistics cited here involve a 10-year interval). (Burry 2016)

Additional factors that favor considering having an endodontist perform your tooth's work.

  • Of all of the different kinds of teeth, molars are the type most likely to experience failure. (Per our tables link above, likely comprising 46% to 58% of all failed cases).
  • Per the Lazarski study cited above, it seems that molars are the type of tooth most commonly referred by general dentists to specialists for treatment.

    [It would be our conjecture that this implies that endodontists typically treat more difficult cases (the cases that general dentists refer out), and therefore their overall failure rate of 11% mentioned above might be lower if it only included cases having a similar level of difficulty as those treated by general dentists.]

  • Per our reference below, choosing a dentist who is a recent dental school graduate may not make the best choice of providers for molar endodontics.

As an explanation, molars have the most complex root canal anatomy. That includes the greatest number of roots and the largest number of individual root canals, many of which are characteristically small and often branched thus making them difficult to locate and treat.

All things considered, and in the sense of erring on the side of caution, electing to have an endodontist complete your molar's work seems to make a reasonable first choice. Although from a strictly statistical standpoint, either type of provider (specialist or general dentist) is likely to create a successful outcome.

c) Upper Premolars

Determining the necessity of a specialist's care for upper premolars is somewhat difficult to weigh.

  • Our Burry reference above found no statistical difference in outcome for premolars in general (upper or lower) when treated by either type of practitioner (and actually calculated a slightly lower success rate for specialists, 90% vs. 91%).
  • However two of our failure-by-tooth-type tables linked to above suggest a higher failure rate for premolars in general, and one of them for upper premolars in particular.

As an explanation: 1) upper premolars may have one or two roots and 2) one, two or more root canals. This variability makes treating them less straightforward.

Just like for molars, in the case of upper premolars it seems that electing to have an endodontist complete your tooth's work makes a reasonable first choice (for erring on the side of caution). Although from a strictly statistical standpoint, either type of provider is likely to be able to produce a successful outcome.

Special circumstances.

a) Troublesome teeth.

Of course none of the above rules of thumb should apply to teeth where your dentist has identified factors that suggest that the level of skill needed to complete your tooth's work lies beyond their capabilities. Whether or not this fact is identified before or during treatment, it only makes sense that the tooth's work should be referred to an endodontist for completion.

b) Strategically important teeth.

We'd also suggest that in cases where a tooth is vitally important from a standpoint of associated dental work, and that tooth's root canal treatment seems even remotely challenging (probably more likely in cases involving upper premolars or any molar), that referral to an endodontist as a way of helping insure the most predictable outcome makes sense.

As examples, this type of scenario might include teeth that (currently do or are planned to) support a dental bridge or removable partial denture. Or teeth whose replacement by an implant might be esthetically challenging.

c) Retreatment success rates.

Beyond just cost and inconvenience, the importance of weighing the above considerations is supported by the fact that success rates for root canal retreatment are somewhat lower than for a tooth's original work.

Rates run lower on the order of 6 to 8% for conventional retreatment (just redoing the tooth's original work, the method used with most cases) and 22% when surgical intervention is needed (Elemam 2011).

At least a part of the difficulty associated with retreatment is that in some situations its outcome may be hampered by previous mismanagement of the case (iatrogenic factors). So with a vitally important tooth, completing its treatment to the highest standards the first time may make all the difference. (Either by making the need for retreatment less likely, or if needed, more likely successful.)


Endodontists typically use more advanced equipment.

A part of the difference in treatment success suggested above, especially with difficult to treat teeth like molars, may have to do with the more sophisticated equipment that an endodontist typically has. Two examples that stand out are:

  • A surgical microscope. - This instrument is used to scan the interior of the tooth in search of tiny root canals or cracks.

    Since missed canals and cracks in roots are two of the most common reasons for endodontic failure, the use of magnification can enhance case outcome. (A study by Hoen [2002] suggests that 42% of failed cases involve missed canals.)

  • Cone Beam Computed Tomography (CBCT) - This method of taking x-rays gives a 3D representation of the patient's teeth, which can aid in evaluating, diagnosing and treating them.

General dentists usually have trouble justifying the cost of this type of specialized high-end equipment.

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Additional considerations in deciding between the two.

a) Shorter appointments.

All other issues being equal, it only stands to reason that a practitioner that specializes in providing one kind of treatment will be more adept at completing it than one who only performs that type of work occasionally.

Even beyond operator skill, the economy of scale associated with specialization means that certain kinds of equipment that can expedite the treatment process will be a must-have for an endodontic office whereas for a general dentist purchasing them may not be cost effective.

A study by Wong (2015) found that the amount of time needed for a tooth's treatment correlated (decreased) with: 1) greater operator experience and 2) the use of optical magnification. Both of these are factors associated with treatment provided by specialists.

A general dentist may be able to offer better treatment continuity.

It shouldn't be overlooked that just having one person perform all of your tooth's work may offer the advantage of their being able to combine some of your needed appointments. As examples:

  • Your dentist might be able to begin your tooth's root canal treatment during the same appointment that its need for it has been diagnosed.
  • At the completion of your endodontic procedure, your dentist might be able to place, or at least begin the process of placing, your tooth's final restoration. The advantage being that there would be less risk of coronal leakage occurring or in the case of a fragile tooth, tooth fracture.

b) Pain management.

While there's no real reason why any dentist shouldn't be able to control a patient's discomfort, since handling "hot" (painful) teeth is such a routine matter for an endodontist, they might be better in anticipating or have more experience in taking any additional steps needed to insure adequate pain control.

Additionally, a specialist's office might be more likely to offer a wider range of anxiety control and sedation techniques that can be used during your procedure.

c) Your dentist's recommendation about the need for a specialist.

No doubt, most patients simply follow the advice of their dentist in deciding who will perform their tooth's root canal work. But this requires that they have been objective in weighing the quality of care they can provide vs. what is required for the satisfactory completion of your case. So if you have questions, you should ask them.

Terms that come into play when making a decision are "standard of practice" (technical details about how your procedure is performed) and "standard of care" (a comparison to what other practitioners would do).

A major tenet of the latter is that the dentist must provide a level of treatment that serves their patient’s best interest and protects their health. And while that doesn't necessarily mean that the treatment provided must be successful, their decision to take on a case must conform with what other general practitioners within the same community would choose to do. As examples:

  • These terms would be defined differently for localities where the services of an endodontist are readily available vs. those where they are not.
  • There would be less latitude involved in interpreting these terms in cases where the dentist simply did not want to refer out cases that could generate income for their practice, or where the dentist chose not to use a protocol that conforms with modern endodontic standards.

What does it take to become an endodontist?

Exactly what it takes to be credentialed as a root canal specialist varies by state and/or country. The usual requirements are that the person has:

  • Completed a dental degree. - Which means that an endodontist has the same formal training as your general dentist.
  • Completed an advanced training program. - This typically involves 2 to 3 years of additional schooling.

Usually an endodontist must limit the scope of their practice to just performing root canal (and associated) procedures. (As an example, that means they can't be the one to place a new dental crown on your tooth after it's endodontic work has been completed.)

Board Certification

Being "board certified" is a separate credential. It's issued by a country's governing association for that specialty. In the USA, it means that the endodontist has passed a set of examinations (oral, written, case presentation) overseen by the American Board of Endodontists.

Comparing the level of training of endodontists vs. general dentists.

a) Dental school training.

The amount of experience that a new dental graduate (DDS, DMD) has in performing root canal treatment might be less than you'd expect.

One study (Woodmansey 2015) polled the directors of US and Canadian dental school (predoctoral) endodontic programs. 60% of the schools provided a reply.

  • On average, the total number of root canal cases completed by students before graduating was just 6. (It would be our conjecture that these would tend to be simpler, more straightforward cases.)
  • When asked if they felt their graduating students were competent to treat molar cases, 36% of directors responded "yes," 36% "no," and 28% were uncertain.
b) Graduate program training.

We ran across a position paper written by the European Society of Endodontology stating what they considered the minimum criteria they felt appropriate for specialists training. (Gulabivala 2010)

It stated that its recommendation was that a graduate student should spend 60% of their training in clinical activity, with a minimum of 180 cases (teeth) treated during the course of a 3-year program.

A 2007 standards paper published by the American Dental Association states that 40 to 60% of a student's training should involve clinical practice, although no set number of treated teeth is mentioned. We should also state that this paper states that a period of 2 years training is adequate.

Either way, the level of training and experienced accumulated by endodontists during their schooling far exceeds that provided to general dentists.

 
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