Dear Hany,

From my point of view, this topic is very complex because a lot of parameters must be taken into account especially the profitability of the dentists but also the profitability of the manufacturer. Just one exemple with MTA that you know very well. What is the real cost for the manufacturer ? As you know, there is a big gap between it and the price which paid by the dentist due to manufacturer's profitability. However, we should not forget that manufacturer has to invest money in order to create new technologies and products improvement. On the other hand, since the price of MTA is high, the dentist also has to increase his fees...It is a viscious circle and finally the patient is "at the end of the way". From an ethical point of view, i totally agree with you but unfortunatelly business is very present in dentistry and can have a strong influence on the decision making, on the patient treatment and even on advises given in publications or lectures. For underprivileged patients, it is very complicated and it is a pity. In France, we have the social security but it can not reimburse all the fees of an endodontist. two years ago, after around 10 years of endodontics in private practice, i decided to take the full time in hospital and university. In this context, i have the possibility to treat the most underprivileged patients with all the advances you described.

Dear Frederic,

Actually you are raising very important points that always make the discussion interesting with you!

Indeed, I agree that the manufacturer should have a reasonable profit.; however I strongly believe that we are "over-priced". I was in a discussion with some friends dealing with such issues, and they told me that the manufacturing process of NiTi rotary systems is not that expensive (about 10% or less of the commercial price). Indeed, some dentists would charge more than enough, and the ttt would be an expensive one.

- NiTi rotary systems: You should be well trained. Extremely curved canals: single use is recommended. I do not have the ability to use NiTi rotary in many of my cases, because, in addition to the cost, the application of flexible SS hand files/gates glidden burs, copious irrigation, incremental instrumentation technique usually work with me in difficult cases!

- Operating microscope: it is a very important equipment in endodontics. Indeed, its involvement in a private clinic would increase the fees significantly. That is why I usually recommend using the loupes (2.5-4x) without or with (much better) accessory illumination. When the operating microscope is available in schools, the ttt fees would be much less or free!!.

- Apex locators: I usually use apex locators since almost 8 years. I do not think it causes a dramatic increase in the ttt fees. In addition to reduction of X-ray exposure and saving the time, it is an accurate and long lasting device.

That's why, I usually recommend my colleges/ undergraduate students, if you have "some" money and you want to enhance your profession as an endodontist. Buy loupes and an apex locator. 1) Usually these items can be afforded by many dentists. 2)Your ttt procedures will be enhanced. 3) You do not have to increase the ttt fees so much.

- CBCT: In big centers/schools. required only whenever indicated. I do not think it is crucial to have it in a private dental clinic!

- Thermoplastized GP: I believe this innovation is "nice to have" but not "must to have" or even "better to have". Machtou pluggers/heat carriers are avaliable in different sizes and can do a nice work.

- Retreatment: Unfortunately, difficult cases such as broken instruments in the apical third. etc. usually require expensive items. But again, I believe we are over-priced with the CPR tips, IRS and others.

- MTA: Yes, very expensive. Conventional GIC can be an alternative in some limited clinical situations. Hopefully, researchers would be able to find out cheaper formula of Portland cements.

Conclusion: We still have a lot to do. Humanity should be a title in our career as manufacturers/dealers/dentists. Reasonable profit is necessary to survive, but we should remember that bringing happiness to our patients also is one of the great responsibilities in our life.

In full agreement with you Hany but all these issues are also linked to policies of each country. Worldwide globalization concept may contribute to enhance...or to deteriorate this situation.

I am disagree with Dr. Hany....Although Endod is my second specialty, I practiced and taught it over than 10 years during my academic job in the Univ...... From My viewpoint, Successful RCT requires skillful endodontist with good RVG X-ray machine and apex locator..... And all the rest equipment e.g.; Microscope, CPCT , MTA ....etc are optional and accessories...only help the specialist to reduce the treatment time, but don't affect the efficiency of the treatment.

Many thanks Hamdi for your kind opinion.....but when I have read your paragraph, I felt it is in "agreement" with what I have mentioned!!......Apex locators/some sort of magnification(loupes)/RVG(is also a nice option but if you don't have, you also can do a good job) can pave the way for successful endodontics while maintaining a reasonable (slightly higher) cost to the patient.....

- I wish all the best for the coming international dental conference in Mansoura this April.....I was hoping to be there.....

Dear Hamdi,

I don't agree with you. If you analyse the different available papers:

- apex locator is the most reliable tool to determine the working lenght. Radiographs method is approximate depending on many parameters such as apical foramen location and dentists analyse.

- magnification tools clearly increase the number of canal treated...such as MB2.

Thanks Hani for your kind discussion, Also I am whishing them a successful Conference, and I would like also to be there. But now I am in HK doing my PhD.. Hopefully to see you soon in Mansoura.

Dear Frederic ,

I am agree with you about the apex locator and also I have mentioned it in my comment. But regarding to the magnification tools I had a different opinion... May be it the influence of operative dentistry practice on my endodontic work... But also I am totally understand and respect both your and Hani's point of view.

Sorry for the apex locator. I didn't read your comment carefully enough. Having different points of view contribute to animate our discussions on ResearchGate.

Dear Hamdi

I am not sure to understand your point of view. If clearly magnification and sophisticated devices such as ultra sonic tips makes the endodontal treatment less afordable for patients they also allow us to save lots of teeth after file separation, root perforation, contaminated isthmus and many more clinical situation that cannot be resolve otherwise. If one compares with the cost of bone surgery before implant placement ( and implant itself) the treatment cost for a patient is still in favour of keeping the teeth by all means.

Best Regards

Agreed my dear friends. I hope the best for you Hamdi in HK.

Many thanks Thomas for your valuable point of view.....but I guess you also agree with me that we are over-priced from the manufacturers.....If we want to save the tooth, and the patient is keen to save his tooth but he is not able to pay for the fees, then we still are facing the problem.....The only way for those patients with moderate/limited financial support is the university hospitals/clinics of dental schools that should afford for the more sophisticated treatment approaches with reasonable prices, rather than extraction.....

Dear Hany

Thank you for initiating this very interesting topic, i think it's primordial to keep endodontics as any other treatment accessible for all patients but as a matter of facts i'm not in full agreement with you regarding manufacturers, as Dr Bukiet pointed out industry does much effort in research and development and they sometimes show good will producing instruments or devices that does not generate so much profit for them but are still very useful for us clinicians and our patients ( i could mention Profiles that are not much sold in France but are still produced but many better exemples could be found). From my point of view ( but this may only been true in my own country) National Health Systems should reevaluate their position on endodontal treatment since the real cost comes with the failures, be it implants or simply retreatment and making a new crown. I don't have the statistic but I shiver thinking of how many prosthesis are removed and redone on poor endodontal treatment basis

Best regards

Once again, In France, we have to struggle and find solutions to improve quality of initial RCT carried out by general practititioner to avoid indications of retreatment (more issues with diagnosis, technical difficulties, risk increasing, cost for the patient and for the secu, necessity to remove post and crowns...). Unfortunately, endodontist in France is not recognized as an official specialist (the only speciality in France is orthodontics) even if endodontist has real skills and experience. Thus, whatever the complexity of the case, every general dentist can attempt to carry out an endodontic treatment depending on his ability to identify his own limits. Moreover, it is sad to see that business parameters frequently pollute decision making process...The consequence is that endodontist has always to manage only challenging cases with many unfavourable factors (perforation, broken file associated with lesions). This is why the initial consultation is crucial to give all the informations to the patient (risk, advantages, disadvantages by comparing with alternatives) in order to assess if the treatment is possible and if the patient is ready to do it (patient content).

Anyway, the most frequent reason given by general practititioner to explain bad quality of RCT is the discrepancy between the weak fees (fixed by secu) and the complexity of the cares. From my point of view, this argument is not relevant enough to explain all the issues (the fees for crowns can greatly make up for it) . I'm sorry to say it is likely a pretext which gives satisfaction to dentist's conscience and a good means to be in denial.

Therefore, in general practice, most of dentists perform a molar RCT in about 30-45 minutes...with the well-known consequences...

The only possibility to improve the situation would be a hard reboot regarding the vision of endodontics in France and a big change in health policy.

Hi,

to just give an impression of one of the most successful (economically) societies on this earth: the statutory health insurance (covers 90% in Germany) pays for an endo treatment (including radiographs and filling of access-cavity) in a molar around 250 Eur. Maybe some cents more or less.

Running a dental practice costs 200 to 300 Eur (hygiene alone is good for 60 000 Eur/year) - and then there is still no income for the dentist...

A crown is good for 130 to 190 Eur (without/with post), maybe plus some Euro (was too lazy to cover all these prices which could be added) for the dentist.

Concerning private patients we just got a new dentists' fee schedule - the last one was from 1988(!) without any inccrease since then. Now the colleagues are not quite sure if there is an increase of about 3 to 5 %, or even not that. Not bad for 30 years...

I can in some way understand the colleagues out there that there is not much en*tooth*iasm, which is, in my eyes, more important for a good work than any specialist training.

The advantage of the endospecialists is: they can much easier prevail higher prices, up to 1500 to 2000 Eur.

But not from the majority of the German people...

Frédéric, you mention 30 to 45 min, which is obviously much too short. What do you need for doing a good endo? What is that in Euro in France?

Did anybody calculate the costs necessary to "repair" the faults of the first treatment? And compared those to the social costs (for educating the specialists) and the higher prices that have to be paid? Apart from a medical standpoint, these issues get more and more into the foreground...

Dear Yango,

in France:

- for a molar root canal therapy, fees are around eighty euros including all materials, products and clinical steps except radiographs. For exemple local anesthesia is included in this amount.

- Endodontics is not an official speciality even if there are skilled endodontists. Unfortunatelly, endodontist can't take fee more than standard fee (imposed by secu). The only possibility is to get out secu system if you want to be free but in theses conditions the patient is not reimburced (patients are use to being reimburced in france concerning the health). Thus, if you are endodontist in a private dental office, you can only treat privileged patients after getting out secu.

- there is a huge discrepency between the absence

of endodontist recognition and need of the population but also general practitioners request for their patients.

Finally, from my point of view, except for simple treatment (very rare), a well done molar root canal therapy takes around

60-90 min. When you compared required time with fees...you easily figure out the issue.

Hi Yango and Frederic,

Many thanks for raising out these points. I just would like to ask regarding the quality of the RCT performed under the insurance in Germany and France. Is there any advanced utilities (apex locators/any sort of magnification/RVG/etc) used?. In many times an endo treated molar requires a crown. Is the fixed prosthesis also covered?. In my country, this is not covered.

- For me, a single visit endo molar takes a wide range from 45 to 120 min....Usually the MB2 and other accessory root canals, if present, take more time, especially if they are curved and/or narrow.

Hi Hany,

General dentists in France often use advanced technologies but rarely use the rubber Dam...It leads to very astonishing comments such as "My apex localor doesn't work" (LOL)...Unfortunatelly, for most of practitioners, technologies are more important than objectives because it is also a good way to show off front of the patient who thinks "I'm lucky to have this modern dentist"....then, a good means to convince the patient to realize a crown...I exagerate on purpose to show you kind of behavior in France (maybe it is the same around the world and in other jobs) and i apologize to all good dentists who attempt every day to do the maximum for their patients.

Moreover, In France fixed prosthesis is only partially covered by secu but private insurance frequently complete the reimbursement. The profitability is good for the dentist in prosthodontics but quality is quite similar to endodontics' one. It is the reason why i think to increase the fees for RCT would not lead to RCT quality improvement.

Finally, concerning the duration of RCT, i agree with Hany in case of standard to difficult treatments.

Dear Hany

please read the following articles:

The effect of pulpotomy using a calcium-enriched mixture cement versus one-visit root canal therapy on postoperative pain relief in irreversible pulpitis: a randomized clinical trial.

Treatment outcomes of pulpotomy in permanent molars with irreversible pulpitis using biomaterials: a multi-center randomized controlled trial.

One-year results of vital pulp therapy in permanent molars with irreversible pulpitis: an ongoing multicenter, randomized, non-inferiority clinical trial.

Regards

Many thanks Saeed for your kind contribution to the topic. Actually, I am aware of your valuable contribution regarding this treatment approach, and I have cited your work in my publication "Management of third molar teeth from an endodontic perspective". In my opinion, this treatment approach is valid in some clinical situations such as very complex root canal morphology/difficult accessibility/very close proximity to a vital surrounding structure. However, it is not indicated for badly decayed teeth, which is common, that require restoration via post and core. The clinician should be able to select the case carefully because the retreatment of such cases would be extremely difficult.

- By the way, what is the cost of CEM in Iran?. Is it affordable for all patients, and it is covered by the insurance?.

Best regards.

Dear Hany, its a very interesting discussion and its good to see Yango. Hope you are doing fine my friend. My take on the issue is to use manual/hand version of rotary files. e.g. protapers are available in hand file version and this cuts the cost like anything. I our endodontic department we are charging 11.6 euros for endo done by these protaper hand files. I have conducted a research that is yet to be published about the dramatic reduction in iatrogenic damages once we shifitef our students from SS files and stepback to these hand protaper files. I also agree with your statements about the apex locator and loupes. I have been using the locator for the last 8 to 9 years and I dont take radiographs at all. But we must understand that cutting the cost would also make it less lucrative for the profession. I can understand the passion of a few to do a good job for less money. But to ask the majority to cut their fee may prove to be counter productive. Its all about quality. And good quality comes at a price. We can redice the cost at university hospital and dental schools. But to ask for the same at private practices may not be commercially viable. On the other hand it is also difficult to justify the fee endodontist charge in USA, 2000 to 4000 $ if i am not mistaken.

Many thanks Arshad for your valuable inputs, and it is really nice to hear that RCT costs only ~12 euros using ProTaper. However, I believe that this paradigm shift in students education should be planned carefully. After students graduation, they will gonna work in different places not necessarily having these NiTi file systems. Practicing RCT via SS files (also by crown down/hybrid tec.) is essential to be taught in dental schools, besides the adoption of any given innovation. The students should be able to know the indications and limitations of both instrumentation techniques.

- I totally agree with you regarding the application of apex locators; however, the radiographic interpretation is still essential, and the literature indicates that using both techniques has a synergistic outcome.

We teach the SS files at undergraduate level and students perform RCT's with them, but when they come into housejob/internship thats when they are taught to use Niti hand files. Regarding apex locator, I am yet to come across a case where my postop radiograph shows I have made a mistake in length determination. But thats my experience and my experience alone cannot replace evidence based research.

One procedure that really improves the outcome and takes the quality of work to a different level is the use of rubber dam. I am a strict user and and advocate of it. It doesnt cost too much and can improve the quality of restorative and endo job.

In my country endodontics is not expensive but so many of patient don't informed about root canal treatment. A general dentist can do a root canal for a patient that can pay ,the mean cost is 50 us dollars per canal the total cost for a molar is about 150 to 200 us per tooth. I think the best way that we can thing is to do a special services endodontics with all tools and the goverment and the assurance can help the patient to pay the fees .

This is a global problem. In Nepal, the patient wants endodontic treatment but due to its high cost the treatment plan is switched from endodontic treatment to extraction. The best way is public awareness about the dental treatment and the major role should be played by the government. In my country the cost of RCT in a government based hospital is 2000- 3000 NPR( 20- 30$). Although, the price is low as compared to other part of the world but the patients still wants extraction of teeth because of low socioeconomic status.

Dear All,

we all know the scientific requirments for a predicatble, long lasting root canal treatment. Do you really believe that cutting corners is a honest service to your patients? Yes, I fully understand the circumstances and appreciate those. I do ask myself here the question: should the dilemma to save or to extract be different weighted? One may consider the potential ongoing risk from insufficient root canal disinfection and apical aor coronal leackage...

Dear Hany and followers,

The best endo ttt is decay management in order to avoid RCT !!

Just by stopping the decay progression and allow the pulp to recover ...!?