the economics of endodontics - American Association of Endodontists

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THE ECONOMICS OF ENDODONTICS
(DRAFT 8/12/2003)
L. Jackson Brown, DDS, PhD
Associate Executive Director
Health Policy Resources Center
American Dental Association
Kent D. Nash, PhD
Economist
President, Nash & Associates, Inc.
Beverly A. Johns, PhD
Research Analyst
Matthew Warren, MA
Manager, Electronic Claims
TABLE OF CONTENTS
EXECUTIVE SUMMARY.................................................................................1
THE CURRENT PICTURE ..................................................................................1
Services And Utilization.................................................................................................... 1
Growth In The Specialty Of Endodontics ......................................................................... 1
Location Of Endodontists ................................................................................................. 2
Endodontic Graduates...................................................................................................... 2
Characteristics Of Endodontists ....................................................................................... 2
Market Segmentation ....................................................................................................... 3
Referrals ........................................................................................................................... 4
A LOOK AT THE FUTURE .................................................................................4
U.S. Population................................................................................................................. 5
Disease Trends ................................................................................................................ 5
Treatment Trends ............................................................................................................. 5
Workforce Trends ............................................................................................................. 5
Workforce Projections ...................................................................................................... 6
Productivity ....................................................................................................................... 6
Number Of Endodontists .................................................................................................. 6
Endodontists Relative To The U.S. Population And General Practitioners ..................... 7
FUNDAMENTAL TRENDS TO FOLLOW ................................................................8
CONCLUSION .................................................................................................9
INTRODUCTION ...........................................................................................10
SOURCES OF DATA....................................................................................11
DISTRIBUTION OF DENTISTS BY REGION AND STATE ........................................11
SURVEY OF DENTAL FEES .............................................................................11
SURVEY OF DENTAL PRACTICE ......................................................................11
SURVEY OF DENTAL SERVICES RENDERED .....................................................12
ELECTRONIC DENTAL CLAIMS DATABASE .......................................................12
U.S. BUREAU OF THE CENSUS ......................................................................13
NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY I AND III ..................13
1999 AAE SURVEY OF ENDODONTISTS AND ENDODONTIC PRACTICE...............13
POTENTIAL MARKET FOR ENDODONTIC SERVICES .............................14
U.S. POPULATION TRENDS ...........................................................................14
NEED FOR ENDODONTIC SERVICES ................................................................17
i
OVERALL MARKET FOR ENDODONTIC SERVICES ................................21
DEMAND FOR ENDODONTIC SERVICES ...........................................................21
TRENDS IN UTILIZATION AND EXPENDITURES FOR ENDODONTIC SERVICES ........22
Overview......................................................................................................................... 22
National Expenditures For Endodontic Services............................................................ 23
Trends In Total, Per Capita, And Per Patient Utilization Of Endodntic Services ........... 23
Age Distribution Of Endodontic Patients ........................................................................ 24
Age Of Patients Receiving Root Canals ........................................................................ 26
SEGMENTATION OF THE ENDODONTIC SERVICES MARKET ...............27
PROVIDERS OF ENDODONTIC SERVICES .........................................................27
Total Production Of Endodontic Services By General Practitioners
And Endodontists ........................................................................................................... 27
Relative Importance Of Endodontic Services Among General Practitioners
And Endodontists ........................................................................................................... 29
PROVISION OF ROOT CANALS ........................................................................34
The Predominance Of Root Canals ............................................................................... 34
Distribution Of Root Canals By Type Of Tooth And Type Of Dentist............................. 35
Ages Of Root Canal Patients Among General Practitioners And Endodontists ............ 37
Provision Of Root Canals Per Practitioner ..................................................................... 40
FINANCIAL SEGMENTATION OF THE MARKET .......................................43
FEES FOR ALL ENDODONTIST PROCEDURES ...................................................43
NATIONAL EXPENDITURES FOR ROOT CANALS ................................................48
BUSINESS ASPECTS OF ENDODONTIC PRACTICE ................................49
NET INCOME ................................................................................................49
GROSS BILLINGS PER OWNER .......................................................................50
PRACTICE EXPENSES PER OWNER .................................................................51
PRACTICE CHARACTERISTICS OF ENDODONTISTS..............................52
TIME IN PRACTICE ........................................................................................52
TIME TREATING PATIENTS .............................................................................55
TIME BY PATIENT VISITS AND ENDODONTIC PROCEDURES ...............................58
ENDODONTIC WORKFORCE......................................................................66
NUMBER OF ENDODONTISTS..........................................................................66
NUMBER OF ENDODONTISTS RELATIVE TO THE NUMBER OF GENERAL
PRACTITIONERS ...........................................................................................73
LOCATION OF ENDODONTISTS .......................................................................74
REFERRAL PATTERNS...............................................................................77
IMPACT OF THE GENERAL PRACTITIONER-TO-ENDODONTIST RATIO
ON REFERRAL PATTERNS ..............................................................................77
PATIENT REFERRALS ....................................................................................80
ii
APPENDIX I: SUPPLEMENTARY ANALYSIS ............................................86
COMPARISON OF NON-ENDODONTIC SERVICES AMONG GENERAL
PRACTITIONERS AND ENDODONTIST ...............................................................86
Clinical And Oral Evaluations ......................................................................................... 86
Radiographs And Diagnostic Procedures ...................................................................... 90
Restorative Procedures.................................................................................................. 94
Lab Tests And Exams Procedures................................................................................. 98
Apicoectomy And Periradicular Procedures................................................................. 102
STATE ANALYSIS USING THE ELECTRONIC CLAIMS DATA ...............................106
Distribution Of Endodontists By State .......................................................................... 106
Endodontist Fees For Root Cananls By State ............................................................. 108
General Practitioner Fees For Root Cananls By State ................................................ 109
Differences In Fees For Root Cananls By State .......................................................... 111
APPENDIX II: SUPPLEMENTARY ANALYSIS—DETAILED DESCRIPTION
OF PROCEDURES PROVIDED BY ENDODONTISTS ..............................114
APPENDIX III: METHODOLOGY...............................................................126
iii
LIST OF FIGURES
FIGURE 1: CHANGE IN THE U.S. POPULATION FROM 1980 TO 2000, BY AGE GROUP................... 16
FIGURE 2: PROJECTED CHANGE IN THE U.S. POPULATION FROM 2000 TO 2020 ......................... 16
FIGURE 3: NUMBER OF AMALGAMS AND RESINS, 1990 AND 1999 .............................................. 21
FIGURE 4: ROOT CANAL TREATMENT BY AGE, 1999 .................................................................. 27
FIGURE 5: ROOT CANAL TREATMENTS PERFORMED BY GENERAL PRACTITIONERS AND
ENDODONTISTS, 1999 ...................................................................................................... 36
FIGURE 6: ROOT CANALS PER DENTIST, 1999........................................................................... 41
FIGURE 7: TOTAL ROOT CANALS PER WEEK PER DENTIST, 1999 ............................................... 42
FIGURE 8: AVERAGE NET INCOME OF SPECIALISTS, 1990 AND 1997/1998 ................................. 49
FIGURE 9: AVERAGE GROSS BILLINGS PER OWNER, 1992 AND 1997/1998 ................................ 50
FIGURE 10: AVERAGE PRACTICE EXPENSES PER OWNER, 1992 AND 1997/1998 ....................... 51
FIGURE 11: PRACTICE EXPENSES AS A PERCENT OF GROSS BILLINGS, 1992 AND 1997/1998 .... 52
FIGURE 12: PERCENTAGE DISTRIBUTION OF ENDODONTISTS, BY HOURS PER WEEK
SPENT IN THE PRACTICE AND GENDER, 1999..................................................................... 53
FIGURE 13: AVERAGE HOURS ENDODONTISTS SPENT IN THE PRACTICE, BY AGE GROUP
AND GENDER, 1999.......................................................................................................... 54
FIGURE 14: AVERAGE HOURS ENDODONTISTS SPENT IN THE PRACTICE, BY NUMBER OF
PATIENT VISITS PER WEEK AND GENDER, 1999 ................................................................. 55
FIGURE 15: PERCENTAGE DISTRIBUTION OF ENDODONTISTS, BY TREATMENT HOURS
PER WEEK AND GENDER, 1999 ......................................................................................... 56
FIGURE 16: AVERAGE TREATMENT HOURS AMONG ENDODONTISTS, BY AGE GROUP AND
GENDER, 1999................................................................................................................. 57
FIGURE 17: AVERAGE TREATMENT HOURS AMONG ENDODONTISTS, BY NUMBER OF PATIENT
VISITS PER WEEK AND GENDER, 1999 ............................................................................... 58
FIGURE 18: PERCENT OF ENDODONTISTS, BY AMOUNT OF TIME (IN MINUTES) SPENT PER
PATIENT VISIT AND GENDER, 1999.................................................................................... 59
FIGURE 19: AVERAGE AMOUNT OF TIME (IN MINUTES) SPENT PER PATIENT VISIT, BY
AGE GROUP AND GENDER, 1999 ...................................................................................... 60
FIGURE 20: NUMBER OF PROFESSIONALLY ACTIVE AND PRIVATE PRACTICE ENDODONTISTS
IN THE UNITES STATES, 1982-2000 .................................................................................. 67
FIGURE 21: PERCENT OF ENDODONTISTS IN PRIVATE PRACTICE, 1982-2000 ............................. 68
FIGURE 22: NUMBER OF PROFESSIONALLY ACTIVE ENDODONTISTS BY AGE AND GENDER,
1993 AND 2000................................................................................................................ 69
FIGURE 23: NUMBER OF DENTISTS IN SPECIALTY AREAS, 2000 ................................................. 70
FIGURE 24: GROWTH IN THE NUMBER OF PRIVATE PRACTITIONERS BY SPECIALTY, 1982-2000... 70
iv
FIGURE 25: GRADUATES FROM ENDODONTIC TRAINING PROGRAMS, 1974-2001........................ 72
FIGURE 26: RATIO OF GENERAL PRACTITIONERS TO ENDODONTISTS, 1982-2000 ...................... 73
FIGURE 27: NUMBER OF PRIVATE PRACTICE ENDODONTISTS, BY STATE, 2000........................... 74
FIGURE 28: U.S. POPULATION AGED 35 YEARS AND OLDER PER ENDODONTIST,
BY STATE, 2000 ............................................................................................................... 75
FIGURE 29: NUMBER OF GENERAL PRACTITIONERS PER ENDODONTIST, BY STATE, 2000 ........... 78
FIGURE 30: PERCENT OF ANTERIOR ROOT CANALS PERFORMED BY ENDODONTISTS,
BY STATE, 2001 ............................................................................................................... 79
FIGURE 31: PERCENT OF MOLAR ROOT CANALS PERFORMED BY ENDODONTISTS,
BY STATE, 2001 ............................................................................................................... 80
FIGURE 32: PERCENT OF PATIENT REFERRALS TO ENDODONTISTS, BY SOURCE OF
REFERRAL, 1999.............................................................................................................. 81
FIGURE 33: PERCENT OF PATIENTS REFERRED TO ENDODONTISTS BY GENERAL
PRACTITIONERS, 1999...................................................................................................... 82
FIGURE 34: PERCENT OF REFERRALS BY GENERAL PRACTITIONERS TO MALE AND FEMALE
ENDODONTISTS, 1999 ...................................................................................................... 83
FIGURE 35: PERCENT OF PATIENTS REFERRED TO ENDODONTISTS BY GENERAL
PRACTITIONERS, BY U.S. CENSUS REGION OF THE PRACTICING ENDODONTIST, 1999......... 84
FIGURE 36: AVERAGE NUMBER OF NEW CASES AND RETREATMENT (PER WEEK) REFERRED
TO AN ENDODONTIST BY GENERAL PRACTITIONERS, BY U.S. CENSUS REGION, 1999.......... 85
FIGURE A1-1: PERCENTAGE DISTRIBUTION OF CLINICAL AND ORAL EVALUATION
PROCEDURES AMONG GENERAL PRACTITIONERS AND ENDODONTISTS, 2001 ..................... 88
FIGURE A1-2: AVERAGE FEES FOR CLINICAL EXAM AND EVALUATION PROCEDURES AMONG
GENERAL PRACTITIONERS AND ENDODONTISTS, 2001 ....................................................... 90
FIGURE A1-3: PERCENTAGE DISTRIBUTION OF RADIOGRAPHS AND DIAGNOSTIC PROCEDURES
AMONG GENERAL PRACTITIONER AND ENDODONTISTS, 2001............................................. 92
FIGURE A1-4: AVERAGE FEES FOR RADIOGRAPHS AND DIAGNOSTIC PROCEDURES AMONG
GENERAL PRACTITIONERS AND ENDODONTISTS, 2001 ....................................................... 94
FIGURE A1-5: PERCENTAGE DISTRIBUTION OF RESTORATIVE PROCEDURES AMONG GENERAL
PRACTITIONER AND ENDODONTISTS, 2001 ........................................................................ 96
FIGURE A1-6: AVERAGE FEES FOR RESTORATIVE PROCEDURES AMONG GENERAL
PRACTITIONERS AND ENDODONTISTS, 2001 ...................................................................... 98
FIGURE A1-7: PERCENTAGE DISTRIBUTION OF LAB TEST PROCEDURES AMONG GENERAL
PRACTITIONER AND ENDODONTISTS, 2001 ...................................................................... 100
FIGURE A1-8: AVERAGE FEES FOR LAB TEST PROCEDURES AMONG GENERAL
PRACTITIONERS AND ENDODONTISTS, 2001 .................................................................... 102
FIGURE A1-9: PERCENTAGE DISTRIBUTION OF APICOECTOMIES AND PERIRADICULAR
PROCEDURES AMONG GENERAL PRACTITIONERS AND ENDODONTISTS, 2001 ................... 104
FIGURE A1-10: AVERAGE FEES FOR APICOECTOMIES AND PERIRADICULAR PROCEDURES
AMONG GENERAL PRACTITIONERS AND ENDODONTISTS, 2001 ......................................... 106
v
LIST OF TABLES
TABLE 1: U.S. POPULATION (MILLIONS) IN 1980 AND 2000, AND PROJECTIONS FOR
2010 AND 2020 ........................................................................................................................ 14
TABLE 2: NUMBER OF TEETH PRESENT AND NUMBER OF SOUND, FILLED, DECAYED
TEETH AND SURFACES .............................................................................................................. 18
TABLE 3: TRENDS IN THE PLACEMENT OF RESTORATIONS, BY TYPE OF RESTORATIVE
MATERIAL, 1990 AND 1999 ....................................................................................................... 20
TABLE 4: ENDODONTIC PROCEDURES AND ALL DENTAL PROCEDURES, 1990 AND 1999 ............. 24
TABLE 5: ENDODONTIC PROCEDURES PER CAPITA AND PER PATIENT, 1990 AND 1999 ............... 24
TABLE 6: SDSR DATA, AGE DISTRIBUTION OF PATIENTS WHO RECEIVED AT LEAST ONE
ENDODONTIC PROCEDURE, BY AGE OF PATIENT, 1999............................................................... 25
TABLE7: ELECTRONIC CLAIMS DATABASE, AGE DISTRIBUTION OF PATIENTS WHO
RECEIVED AT LEAST ONE ENDODONTIC PROCEDURE, 2001........................................................ 26
TABLE 8: DISTRIBUTION OF ENDODONTIC PROCEDURES BY SPECIALTY, 1990 AND 1999............. 28
TABLE 9: PROPORTION OF COMMON ENDODONTIC PROCEDURES PROVIDED BY GENERAL
PRACTITIONERS AND ENDODONTISTS, 1999 ............................................................................... 29
TABLE 10: ENDODONTIC PROCEDURES COMPLETED BY GENERAL PRACTITIONERS
AND ENDODONTISTS, 1999 ........................................................................................................ 30
TABLE 11: SDSR DATA, ENDODONTIC PROCEDURES AND ALL PROCEDURES COMPLETED
AMONG GENERAL PRACTITIONERS AND ENDODONTISTS, 1999.................................................... 30
TABLE 12: ELECTRONIC CLAIMS DATABASE, ENDODONTIC PROCEDURES AND ALL
PROCEDURES COMPLETED AMONG GENERAL PRACTITIONERS AND ENDODONTISTS, 2001........... 31
TABLE 13: PROCEDURES MOST COMMONLY PERFORMED BY ENDODONTISTS, 1999 ................... 31
TABLE 14: ELECTRONIC CLAIMS DATABASE, CDT PROCEDURES WHICH ACCOUNTED
FOR 95% OF ALL ENDODONTISTS PROCEDURES, 2001............................................................... 33
TABLE 15: SDSR DATA, ROOT CANALS AND OTHER ENDODONTIC PROCEDURES
AMONG GENERAL PRACTITIONERS AND ENDODONTISTS, 1999.................................................... 34
TABLE 16: ELECTRONIC CLAIMS DATA, ROOT CANALS AND OTHER ENDODONTIC
PROCEDURES AMONG GENERAL PRACTITIONERS AND ENDODONTISTS, 2001 ............................. 34
TABLE 17: ROOT CANAL TREATMENTS COMPLETED BY GENERAL PRACTITIONERS AND
ENDODONTISTS, 1999............................................................................................................... 35
TABLE 18: ANTERIOR, BICUSPID, AND MOLAR ROOT CANALS AMONG GENERAL
PRACTITIONERS, ENDODONTISTS, AND ALL DENTISTS, 2001....................................................... 37
TABLE 19: NUMBER OF PATIENTS WHO RECEIVED AT LEAST ONE ENDODONTIC
PROCEDURE, BY AGE OF PATIENT, 2001.................................................................................... 38
TABLE 20: NUMBER OF PATIENTS WHO RECEIVED AT LEAST ONE ANTERIOR ROOT CANAL
TABLE 21: NUMBER OF PATIENTS WHO RECEIVED AT LEAST ONE BICUSPID ROOT CANAL
vi
TABLE 22: NUMBER OF PATIENTS WHO RECEIVED AT LEAST ONE MOLAR ROOT CANAL
TABLE 23: SDF DATA, AVERAGE FEES FOR ENDODONTIC PROCEDURES, 1999.......................... 43
TABLE 24: ELECTRONIC CLAIMS DATABASE, AVERAGE FEES FOR ROOT CANALS, 2001.............. 43
TABLE 25: AVERAGE FEES FOR OTHER PROCEDURES, 1999 ..................................................... 44
TABLE 26: SELECTED FEE STATISTICS FOR ALL ENDODONTIC PROCEDURES, 2001 .................... 44
TABLE 27: SELECTED FEE STATISTICS FOR ALL ENDODONTIC PROCEDURES EXCLUDING
PULPOTOMY AND PULP CAPPING, 2001 ..................................................................................... 45
TABLE 28: SELECTED SUMMARY FEES AMONG ENDODONTISTS AND GENERAL PRACTITIONERS,
BY CDT PROCEDURES WHICH ACCOUNTED FOR 95% OF ENDODONTIST FEES, 2001 ..................
47
TABLE 29: ESTIMATED NATIONAL EXPENDITURES ON ROOT CANAL THERAPY, 1999 ................... 48
TABLE 30: AVERAGE TIME SPENT BY ENDODONTISTS PER PROCEDURE (IN MINUTES), 1999 ....... 62
TABLE 31: AVERAGE TIME SPENT BY CHAIRSIDE ASSISTANTS PER PROCEDURE
(IN MINUTES), 1999................................................................................................................... 63
TABLE 32: RATIO OF AVERAGE ENDODONTIST TIME TO CHAIRSIDE ASSISTANT TIME
(IN MINUTES), PER PROCEDURE, 1999....................................................................................... 65
TABLE 33: ENDODONTISTS AS A PERCENTAGE OF ACTIVE PRIVATE PRACTITIONERS .................... 71
TABLE 34: NUMBER, PERCENT, AND CUMULATIVE PERCENT OF ENDODONTIC STUDENTS,
BY STATE, 2000........................................................................................................................ 76
TABLE A1-1: CLINICAL AND ORAL EVALUATION PROCEDURES AMONG GENERAL
TABLE A1-2: AVERAGE FEES FOR CLINICAL AND ORAL EVALUATION PROCEDURES AMONG
GENERAL PRACTITIONERS AND ENDODONTISTS, 2001................................................................ 89
TABLE A1-3: RADIOGRAPHS AND DIAGNOSTIC PROCEDURES AMONG GENERAL
TABLE A1-4: AVERAGE FEES FOR RADIOGRAPHS AND DIAGNOSTIC PROCEDURES
AMONG GENERAL PRACTITIONER AND ENDODONTISTS, 2001...................................................... 93
TABLE A1-5: RESTORATIVE PROCEDURES AMONG GENERAL PRACTITIONERS AND
ENDODONTISTS, 2001............................................................................................................... 95
TABLE A1-6: AVERAGE FEES FOR RESTORATIVE PROCEDURES AMONG GENERAL
TABLE A1-7: LAB TEST PROCEDURES AMONG GENERAL PRACTITIONERS AND
ENDODONTISTS, 2001............................................................................................................... 99
TABLE A1-8: AVERAGE FEES FOR LAB TEST PROCEDURES AMONG GENERAL
PRACTITIONERS AND ENDODONTISTS, 2001 ............................................................................. 101
TABLE A1-9: APICOECTOMIES AND PERIRADICULAR PROCEDURES AMONG GENERAL
PRACTITIONERS AND ENDODONTISTS, 2001 ............................................................................. 103
TABLE A1-10: AVERAGE FEES FOR APICOECTOMIES AND PERIRADICULAR PROCEDURES
AMONG GENERAL PRACTITIONERS AND ENDODONTISTS, 2001.................................................. 105
vii
TABLE A1-11: DISTRIBUTION OF ENDODONTISTS IN THE ELECTRONIC CLAIMS DATABASE,
BY STATE, 2001...................................................................................................................... 107
TABLE A1-12: ELECTRONIC CLAIMS DATA, AVERAGE FEES FOR ROOT CANALS AMONG
ENDODONTISTS, BY STATE, 2001 ............................................................................................ 108
TABLE A1-13: ELECTRONIC CLAIMS DATA, AVERAGE FEES FOR ROOT CANALS AMONG
GENERAL PRACTITIONERS, BY STATE, 2001............................................................................. 110
TABLE A1-14: AVERAGE DIFFERENCES IN FEES FOR ROOT CANALS BETWEEN GENERAL
PRACTITIONERS AND ENDODONTISTS, BY STATE, 2001............................................................. 112
TABLE A2-1: DISTRIBUTION OF DENTAL PROCEDURES AMONG ENDODONTISTS BY CDT
PROCEDURE FOR THE TOP 50 CDT CODES AMONG ENDODONTISTS, 2001............................... 114
TABLE A2-2: DISTRIBUTION OF DENTAL PROCEDURES AMONG GENERAL PRACTITIONERS
BY CDT PROCEDURE RANKED BY FREQUENCY OF THE TOP 50 CDT PROCEDURES
PERFORMED BY ENDODONTISTS, 2001 ....................................................................................
117
TABLE A2-3: SELECTED SUMMARY FEE STATISTICS BY CDT PROCEDURE FOR THE TOP
50 CDT CODES AMONG ENDODONTISTS, 2001 ....................................................................... 120
TABLE A2-4: SELECTED SUMMARY FEE STATISTICS BY CDT PROCEDURE AMONG GENERAL
PRACTITIONERS, FOR THE TOP 50 CDT CODES AMONG ENDODONTISTS, 2001......................... 123
viii
EXECUTIVE SUMMARY
The Current Picture
endodontic services peaked later in life.
Almost 14% of patients aged 65-74
years received endodontic services.
Since dental patients are a little younger
than the overall U.S. population, this
effects the age distribution of
endodontic patients. Fifty percent of all
endodontic patients are between ages
of 35 and 54 years.
SERVICES AND UTILIZATION
In 1999, endodontists provided 4.4 million
high quality endodontic services to their
patients. These services represented 20.3%
of the total of 21.9 million endodontic
services provided. General practitioners
were able partners in the provision of high
quality endodontic care. They provided
75.2% of all endodontic services. Various
specialists, primarily pediatric dentists,
provided the remainder of the services.
GROWTH IN THE SPECIALTY OF
ENDODONTICS
Endodontics is one of the smaller clinical
specialties of dentistry. Only
prosthodontics is smaller. In the U.S., in
2000, 3,816 endodontists were
professionally active and 3,408 were in
private practice. Over the previous two
decades, the number of endodontists has
grown faster than any other specialty and
faster than general practitioners. The
next largest growth over that time period
was for periodontists. During the second
half of the 1990s, the number of
orthodontists increased about as fast as
endodontists. Since 1982, the number of
endodontists increased by 84%, compared
to a 33% increase in the number of
general practitioners.
While important to the oral health of the
U.S. population, endodontic services
comprised only 1.7% of the over 1 billion
dental services provided in 1999. This
percentage was a slight decline from the
2.1% of dental services that endodontic
services represented in 1990. Although
endodontic services comprised less than
2% of total dental procedures, root canal
therapy alone accounted for over 15% of
total dental expenditures in 1999, totaling
an estimated $8.2 billion in 1999.
On a per capita basis, approximately 6%
of the population received an endodontic
service in 1999, about the same
percentage as observed in 1990. Overall,
about 9% of all dental patients received an
endodontic service. This was a small
decline from about 10% in 1990.
Two consequences of this rapid growth
can be discerned. First, unlike the overall
population-to-dentist ratio, the populationto-endodontists ratio has been declining.
Thus, the density of endodontists in the
population is increasing. Second, the ratio
of general practitioners to endodontists
has been declining steadily. There were
50.3 general practitioners per endodontist
in 1982. In 2000, this ratio had declined to
36.4. The result is that there are fewer
general practitioners to refer patients to
endodontists compared with earlier years.
Utilization of endodontic services varies
markedly by patient age. These
services rarely occur among children.
Among persons aged 18-24 years,
3.8% of individuals and 6.3% of patients
received endodontic care. Utilization of
endodontic services increase with age.
The percentage of all individuals who
received endodontic services reached a
peak of about 8.2% among persons
aged 35-54 years, then declined slightly
among older individuals. On a patient
basis, the percentage received
Over the past several decades,
endodontics has emerged from a primarily
academic discipline, which it was in its
early days, to a true community-based
1
specialty similar to oral surgery and
orthodontics. In 1982, 83.7% of
endodontists were in private practice. This
was a lower percentage than for general
practitioners. By 2000, 89.3% of
endodontists were in private practice,
which is relatively close to the percentage
of general practitioners in private practice.
This shift towards private practice is likely
to continue, at least in the foreseeable
future, because the current level of
graduates from endodontic programs will
ensure continued growth in the number of
endodontists while at the same time dental
schools will not be able to accommodate
more endodontists as faculty members
due to the budgetary crises confronting
most schools.
Mississippi, and Arkansas are states with
the highest population-to-endodontist
ratios. The populations in these states do
not have the per capita income levels of
perhaps some of the more industrial
states.
ENDODONTIC GRADUATES
One hundred and eighty-eight students
graduated from accredited endodontic
training programs in 2001. The number
represents a substantial overall expansion
of the size of the endodontic training
program. In 1974, 101 students graduated
from endodontic training programs. As
recently as the mid-1980s, the class size
of graduate endodontic programs ranged
between 123 and 139. In the first half of
the 1990s, class size averaged about 160.
Between 1974 and 2001, class size
expanded by 86%. Class size has grown
by close to 20% since the early 1990s.
LOCATION OF ENDODONTISTS
Like most specialists, endodontists are
often located in urban areas. States with
large urban population tend to have a
larger number of endodontists.
Approximately one-third of endodontists
are located in three states: California
(523), New York (314), and Florida (227).
At the other extreme, Alaska and North
Dakota each have 5 endodontists and,
according to ADA data, Wyoming has just
one. As a general rule, endodontists are
concentrated in the Northeast and the
West Coast. Rural states, especially in the
plains and the mountain regions, have few
endodontists.
Huge interstate variation is apparent with
the number of graduates from endodontic
training programs. Five states account for
over 50% of endodontic graduates. These
states also exhibit very high densities of
endodontists for their populations.
CHARACTERISTICS OF ENDODONTISTS
◪Demographics. The average age of
practicing endodontists in 1999 was 47.3
years. Almost 22% were 55 years of age
or older. Another 19% were under 40
years of age. Female endodontists
comprised 6.7% of all independent (i.e.,
owner) endodontists in 1997. The
percentage of female endodontists has
been growing. Females accounted for
only 5.2% of independent endodontists in
1992. On average, female endodontists
were younger (43.1 years) than male
endodontists (48.1 years).
Of course, states with large populations
are expected to have more health
professionals. The population over 35
years of age per endodontist provides a
better assessment of the endodontic
workforce per state. Using this population
cohort, there are very large variations in
the population-to-endodontist ratios among
states. California and New York, the
states with the most endodontists, are
among the states with the lowest
population-to-endodontist ratios. Both
states are relatively affluent and that partly
explains why these states can maintain a
higher concentration of endodontists for
their populations. In contrast, Wyoming,
◪Workload. Endodontists averaged 45.9
visits per week in 1999. Endodontists in
private practice reported spending an
average of 36 hours per week in practice.
About 16% spend less than 30 hours per
week and, therefore, are considered to be
practicing part-time. Another 17%
2
reported spending more than 45 hours per
week in practice. Practicing endodontists
spent about 32 hours per week treating
patients. On average, endodontist visits
lasted about one hour. The longest visit
length (over 100 minutes) occurred among
endodontists who were less than 35 years
of age.
908,000 bicuspid, and 438,000 anterior
root canals.
However, on a per dentist basis,
endodontists provided many more
endodontic services than general
practitioners. On average, endodontists
provided 1,236 endodontic procedures in
1999, compared to 94.6 provided by
general practitioners. Endodontists
provided 831 molar root canals per
endodontist, compared to 39.5 molar
canals provided per general practitioner.
They completed 273 bicuspid per
endodontist, compared to 28 by general
practitioners, and they completed 132
anterior canals, compared to 26.8 for
general practitioners.
◪Finances. The specialty of endodontics
is doing very well economically. Using the
latest available data from 1997/1998, the
average net income of endodontists in
private practice was approximately
$230,000. This was second only to oral
surgeons. In contrast, endodontists
reported average per owner gross billings
of $491,550. Only general practitioners
and periodontists reported lower gross
billings.
The difference in the importance of
endodontic services between the two
groups is illustrated by the 24.7 endodontic
procedures completed per week by
endodontists in relation to 1.9 of the same
procedures completed by general
practitioners. Of course, this translates
directly into the business aspects of the
two practices.
The reason endodontists can realize high
net income with relatively low gross billings
is because their expenses are relatively
small. Average expenses reported by
endodontists in 1997/1998 were
$237,320—the lowest of all dentists in
private practice. Endodontists’ low
practice expenses results from the limited
equipment and supplies their practices
require and the smaller staff used by
endodontists. In 1997/1998, endodontists
employed an average of 5.6 non-dentist
staff. Only prosthodontists employed
fewer staff.
Root canal therapy is the most vital
component of endodontists’ practices, and
molar root canal therapy is by far the most
prevalent root canal procedure, both in
number and in gross billings. Molar root
canal therapy accounted for about 62% of
all endodontic procedures completed by
endodontists in 1999. Bicuspid root canals
were next in importance at 20%, followed
by anterior root canals at about 10%.
Other endodontic procedures comprised
the remaining 8% of endodontic services.
These percentages did not change
substantially when electronic claims data
from 2001 was used to estimate the
distribution of procedures. Billings for
molar root canals totaled $2.0 billion in
1999 compared to billings of $500 million
for bicuspid root canals, and $226 million
for anterior root canals.
MARKET SEGMENTATION
The market for endodontic services in the
U.S. is segmented between endodontists
and general practitioners. Endodontists
accounted for approximately $2.8 billion of
the total of $8.2 billion in expenditures for
root canal services; general practitioners
accounted for most of the remaining $5.5
billion. General practitioners provided 11.7
million root canal procedures in 1999,
compared to 4.1 million provided by
endodontists. More specifically, general
practitioners provided 4.9 million molar,
3.5 million bicuspid, and 3.3 million
anterior root canals. In comparison,
endodontists provided 2.8 million molar,
3
REFERRALS
higher general practitioner-to-endodontist
ratios.
In 2000, in the U.S. there were about 36
general practitioners per one private
practicing endodontist. Out of the 21.9
million endodontic procedures provided in
a year, general practitioners provided
about 4 procedures for every one
procedure provided by endodontists.
Given the generally accepted position as
gatekeeper to the dental care system, the
general practitioner is in a potentially
important position of directing patients to
various types of care systems including
endodontic care.
This predicted relation between referrals
and general practitioner-to-endodontist
ratios seems to be supported by data.
There is a strong correlation between the
number of general practitioners per
endodontist and the percentage of both
anterior and molar root canals performed
by endodontists.
For example, New England states
demonstrate a lower ratio of general
practitioners per endodontist, indicating
that endodontists in these states have a
large number of general practitioners from
which they can expect referrals.
Endodontists provide a relatively large
percentage of the root canals in these
states. In contrast, states like Wyoming,
Mississippi and Alaska with few
endodontists compared to general
practitioners, show a smaller percentage
of root canals provided by endodontists.
Clearly, the general practitioner-toendodontist ratio in a state is an important
indicator of the percentage of root canal
therapy that is referred to endodontists.
Referrals from general practitioners to
endodontists are crucially important to the
economic health of the endodontic
specialty. Referrals were especially
important in relation to root canal patients
because root canals represent the central
activity of endodontists. In 1999, private
practicing endodontists reported that
general practitioners were the source of
about 85.5% of patients referred to them.
Other patients as a referral source
represented about 5% of all patient
referrals. Less than 10% of all patient
referrals are from other dental specialists.
Thus, general practitioners are by far the
most important source of patients for
endodontists.
A Look At the Future
When it comes to the future everyone’s
crystal ball is cloudy. This is especially
true for the demand for endodontic
services because future demand will
depend on the growth of the U.S.
economy, socioeconomic shifts in the
population, changes in therapeutic and
preventive interventions, and the impact of
changing oral disease rates, as well as the
structure of financing arrangements.
The variation by state in the general
practitioner-to-endodontist ratios
mentioned earlier (and described in detail
in the body of the report) implies that one
or two things must be occurring. Either the
per capita number of endodontic services
is higher in states with a high density of
endodontists (e.g., California and the
Northeast), or general practitioners must
be producing a larger percentage of
endodontic services in the low-density
states (e.g., Wyoming, Mississippi, etc.).
States with the fewest number of general
practitioners per endodontist provide a
smaller referral base for endodontists.
General practitioners in these states will
refer a higher percentage of endodontic
patients per year than those states with
If the economy grows rapidly during the
coming years, the percentage of the
population that utilizes endodontic services
is likely to increase with increasing
affluence. Increasingly educated
populaces are likely to provide a stimulus
to dental demand. If major new funding
programs become available, or if major
new treatment opportunities emerge, per
capita utilization may increase even more.
4
U.S. POPULATION
term, as caries decrease and fewer teeth
are lost, implants may peak as a
procedure. It is relatively certain that other
technical and scientific advances, currently
only vaguely anticipated, will occur. Their
timing and effect on demand, however, are
unpredictable.
In the U.S., the population will continue to
grow. The U.S. Census Bureau projects
that the U.S. population will reach 332
million by 2030. The population also will
age and become more diverse. Hispanics
and Asians, in particular, will account for
greater percentages of the population.
WORKFORCE TRENDS
DISEASE TRENDS
It is against this backdrop of change and
uncertainty on the demand-side of the
market that the assessment of the future
workforce strategies for the specialty of
endodontics must be developed. These
workforce strategies are further
complicated by multiple factors on the
supply-side of the market that also will
impact the capacity to provide dental
services.
The future prevalence and extent of
endodontic disease is uncertain. A couple
of countervailing epidemiological trends
have emerged during the past two
decades of the last century. Individuals
are keeping more of their teeth, especially
their molars. These teeth are at risk for
caries attack and subsequent pulpal
disease. This has the potential to increase
the need for endodontic therapy. Against
this trend, the potential for endodontic
therapy may shift downward due to the
decrease in the extent of caries. This
could decrease future need for
complicated endodontic therapy.
The adequacy of the endodontic workforce
depends very much on the demand for
endodontic services. The size of the
endodontic market has been level since
1990. Need for endodontic therapy is
considerable, but all needed care may not
be fully realized. Utilization of endodontic
procedures is increasing at a rate of 0.5%
annually, but this does not match the rate
of increase in the U.S. population (1.2%)
and the number of endodontists (1.2%).
With the current demand conditions, there
seems to be an adequate supply of
endodontists and of endodontic services.
Furthermore, it is uncertain whether the
shift to resin material for posterior
restorations will impact endodontics.
Conventional wisdom and some research
suggest that more sequela will occur in
resin-based posterior restorations than in
amalgam restorations. However, the issue
is far from settled. Furthermore, the
properties of resin materials are steadily
improving. Thus, how the population,
epidemiological and restorative trends play
out—as the birth cohorts that experienced
fewer caries transverse the U.S. age
range—will be critically important for the
future need for endodontic therapy.
Perhaps the most perplexing aspect of
workforce planning for the endodontic
specialty is that endodontic workforce
cannot be analyzed in isolation from what
is happening to the supply of general
practitioners. The market for endodontic
services is segmented between the two
groups, and the division of the market can
change over time.
TREATMENT TRENDS
Another factor that must be assessed is
the potential for scientific advances in
providing entirely new treatment options.
The number of implants has been
increasing during the past decade. This
trend is likely to continue in the near
future. For a time, these procedures may
play a larger role in dental practice and in
endodontists’ practices. In the longer
Overall, the number of general
practitioners seems to be adequate to
accommodate current demand. After a
period of painful adjustment during the
1980s which saw the enrollment in
undergraduate dental education decline by
34%, the overall enrollment in
5
Ignoring productivity changes is likely to
lead to serious miscalculations for any
workforce policy.
undergraduate dental education expanded
by about 11% during the 1990s.
Specifically, the number of dental school
graduates declined from a high of 5,756 in
1982 to a low of 3,778 in 1993. Since
1993, graduates increased steadily to
4,041 in 1999.
PRODUCTIVITY
In a recent study, Beazoglou, Heffley,
Bailit, and Brown, showed that total dental
output (i.e., total production of dental
services) of the dental delivery system
tripled between 1960 and 1998, growing at
an annual rate of 2.95%. Change in dental
output results from an increase in the
number of dentists or from improved
productivity per dentist. Over the entire
period, the contributions to the increase in
dental output from 1) increases in the
number of dentists, and 2) increases in
dentists’ productivity (i.e., the amount of
dental output, measured as real gross
billings per hour) were almost equal: the
number of dentists increased by 1.85
times and dentists’ productivity increased
by 1.64 times.
The decline of dental school graduates
during the 1980s slowed the rate of growth
of dentists, and the number of general
practitioners, specifically. The number of
professionally active dentists and private
practitioners increased during the 1990s.
However, their growth rates were slightly
less than the growth in the U.S.
population. As a result, dentist-topopulation ratios started declining around
1995 and have continued to decrease.
Overall, there has been a 0.91% decline in
this ratio.
WORKFORCE PROJECTIONS
The ADA Dental Workforce Model projects
that the number of professionally active
dentists will increase from 166,664 in 2000
to 179,930 in 2020. About the same
proportion of these graduates will become
general practitioners in the future as the
current proportion. This increase will not
be large enough to prevent the overall
dentist-to-population ratio from declining
over this period. However, the decline will
be modest, going from around 54.5 private
practitioners per 100,00 U.S. resident
population in 2000 to about 50.7 in 2020.
It is extremely improbable that for the next
20 years the growth in the level of dentist
productivity would be zero. The national
supply of dental services is likely to
increase due to enhanced dental
productivity. Therefore, given the
projected increase, the number of general
practitioners is likely to remain adequate if
major new programs are not enacted,
declines in dental school graduates do not
occur, and productivity continues to rise.
NUMBER OF ENDODONTISTS
The dentist-to-population ratio is a crude
determinant of the dental workforce needs
of a community, especially when making
comparisons over time. The ratio implicitly
holds constant many factors that affect
both the population’s need and desire for
dental care as well as dentists’ ability to
produce those services. One of the
factors that the dentist-to-population ratio
holds constant is dentists’ productivity (i.e.,
the amount of dental output measured as
real gross billings per hour). Improved
productivity means that fewer dentists can
produce the same amount of dental
services compared to previous years.
The circumstances are somewhat different
for endodontic specialists. The relative
size of endodontics compared to the other
dental specialties is increasing and will
continue to increase as long the dental
specialties maintain their current growth
patterns. In 1982, endodontists accounted
for 1.6% of all private practice dentists. In
2000, they accounted for 2.2%.
Fueling this rapid growth is the increase in
the number of graduates from endodontic
training programs. As mentioned
previously, endodontic class size
increased from only 101 graduates in 1974
6
ENDODONTISTS RELATIVE TO THE U.S.
POPULATION AND GENERAL
PRACTITIONERS
to 188 in 2001. Those endodontists who
graduated in the 1970s will be retiring in
the next 10 to 15 years. However, it will
be considerably longer before the number
of endodontists stabilizes if the number of
graduates remains constant at the 2001
level.
The U.S. population was about 281 million
in 2000. The population per endodontist in
2000 was 82,453. The U.S. population is
projected to be around 340 million in 2035.
Using the previously calculated “steadystate level” of 6,580 professionally active
endodontists in 2035, the population-toendodontist ratio in 2035 can be estimated
at 54,270. The decline in the ratio
represents a 34% decline in number of
persons in the U.S. per endodontist
between 2000 and 2035.
The average age of a graduate from an
endodontic training program is around 2830 years old at the time of graduation, and
endodontic graduates will practice until
they are about 64-68 years old. One can
use these data to project the “steady-state”
number of endodontists that will result
from a graduation class of 188
endodontists (i.e., the endodontic class
size in 2001).
Many events could intervene and change
this projection; the population could
increase more slowly, endodontists could
graduate at an older age or retire at an
earlier age. Nevertheless, at current
levels, the number of the graduates from
endodontic training programs will generate
an increase in the number of endodontists.
As a consequence, the average
endodontist in 2035 is likely to have a
smaller population base to care for than
endodontists in 2000.
As an example, assuming that the average
graduate from an endodontic training
program is 30 years old and will retire at
the age of 65 years, he/she will have a
practice career of 35 years. In 35 years,
those endodontists who graduated in 2000
or later will comprise most of the practicing
endodontists. Further assuming that the
number of endodontist graduates remains
constant at 188 (the 2001 class size), 188
graduates per year over 35 years will
result in 6,580 endodontists in the year
2,035. This will be an increase of 72.4%
over the 3,816 professionally active
endodontists in 2000.
Since during the last decade the number
of endodontists has been increasing faster
than the number of general practitioners,
the general practitioners-to-endodontist
ratio has been declining. This, in turn,
means there are fewer general
practitioners for each endodontist to
receive referral patients from.
Thus, this would be a "steady-state"
number, i.e., the number of endodontists
would stabilize, neither growing nor
shrinking, unless the graduation size or the
retirement age changed. If endodontists
should be older than 65 years at
retirement, the steady-state number of
endodontists would increase and vice
versa for a younger retirement age.
Similar impacts would result if graduates
should be younger (an increase in the
steady-state number) or older (a decrease
in the steady-state number) when they
graduate.
If these differences in growth rates
between endodontists and general
practitioners persist, the general
practitioner-to-endodontist ratio will
continue to decline. For example, another
18 years of growth for the two groups
similar to the rates they experienced
between 1982 and 2000 will result in a
general practitioner-to-endodontist ratio of
25.7. This represents a 28.6% decline in
the ratio and this could be a cause for
concern for practicing endodontists in the
future.
7
countervailing impacts will impact on
the demand for endodontic services is
uncertain and will have to be
periodically assessed.
Fundamental Trends to
Follow
Growth of the overall economy.
Overall productivity of the dental
sector.
A robustly growing economy is vital to
the demand for endodontic services
because it will increase the per capita
disposable income of the U.S.
population. More spending money will
stimulate the demand for services.
Dental productivity has been
increasing at a little over 1% annually.
This is about the same rate of increase
as the U.S. population has been
experiencing. Therefore, productivity
enhancement has been
accommodating population growth. If
productivity trends should change, this
will need to be factored into workforce
assessments.
The future utilization patterns of
the baby-boomers as they enter
retirement.
This generation will soon swell the
ranks of the retired. However, the
elderly traditionally have not utilized
dental care as much as the working
population. Dental care is not part of
Medicare and is not likely to be
included in the near future. Therefore,
the elderly must largely rely on their
own resources for dental care. Future
generations of elderly will have more
teeth and more financial resources
than any previous elderly generation.
This may translate into a surge in
demand for endodontics services
among tomorrow’s elderly.
The overall adequacy of the
general practitioner workforce.
If the number of general practitioners
increases at about the same rate as
the demand for their services, their
appointment schedules will be full.
They will be able to keep busy without
providing complicated endodontic
therapy, which they are likely to
continue to refer to endodontists. For
a busy general practitioner, molar root
canal therapies are not an efficient use
of his/her time. However, if a general
practitioner has unfilled appointment
time, the probability and efficiency of
providing molar root canal therapy
increases.
The relative failure rates in
resins versus amalgam posterior
restorations.
The shift to resin restorative materials
has been enormous. This will
probably continue. It is uncertain how
this shift will impact the need for
endodontic therapy, but accurate and
valid data need to be developed on
this issue. Evidence-based research
is the vehicle to reduce this
uncertainty.
However, if the number of general
practitioners increases more rapidly
than the demand for their services,
their appointment schedules will not be
as full. They may decide to provide
some of the complicated endodontic
therapy they are currently referring to
endodontists.
Tooth loss trends.
During the 1990s, the number of
graduates from dental schools
increased by around 11%. Size class
is projected to increase about a similar
amount in the next 10 years. The
demand for dental services can
probably accommodate that size of
The reduction in tooth loss will
decrease the potential for implants,
other factors being equal. At the same
time, there will be more teeth retained
in the dentitions of the U.S. population.
These teeth will be at risk to need
endodontic therapy. How these
8
increase. A larger increase may
indicate that supply is outstripping
demand.
time, the ratios of general practitioners
to endodontists may remain very large
in other parts of the U.S. If regions
with fewer endodontists lobby for the
training of more endodontists to
address their perceived need, the
additional endodontists are likely to be
trained in existing programs located in
areas with sufficient numbers of
endodontists. If these graduates
practice in areas where they were
trained, this could exasperate the
imbalance between regions. Regional
assessment and cooperation is
important to avoid this dilemma.
The size of the endodontic
training program.
The size of the training program will
largely determine the future growth
rate in the number of endodontists.
Currently, the number of graduates
from these programs will ensure that
the number of practicing endodontists
increases in the future. Any
curtailment of the size of the program
could pit academic endodontists
against endodontists in private
practice.
Conclusion
The U.S. economic model for endodontic
services and delivery is a good model. It
has largely been successful at meeting the
needs and desires of the U.S. population.
It is a hi-tech, private market model.
These features are consistent with the
cultural preferences of the U.S. citizenry.
More work needs to be done to bring this
high quality care, delivered by extremely
well-trained health professionals, to those
in the U.S. that currently do not access
dental care to the same extent as the
majority of the population. This is an
achievable goal but it requires commitment
and political will on the part of all segments
of the U.S. population.
The general practitioner-toendodontist ratio.
This factor is related to the previous
one. If the number of endodontic
graduates remains at current levels,
the number of endodontists will almost
double by 2025. The population-to
endodontist ratio will decline as will the
general practitioner-to-endodontist
ratio. This means that there will be
relatively fewer patients for
endodontists, and relatively fewer
general practitioners to refer patients
to endodontists.
The geographic distribution of
endodontists.
Despite the large amount of tertiary care
that the U.S. provides, including
endodontics, the nation has not neglected
prevention. The oral health of the U.S.
population is among the highest in the
world. The system does not require
substantial modification. Careful
monitoring of supply and demand trends,
regional cooperation, and early policy
intervention should keep the endodontic
delivery system functioning well.
Currently, endodontic training
programs are primarily located in
urban areas on the east and west
coasts. In these states the ratio of
general practitioners to endodontists is
already lower than in other regions of
the country. If those graduating from
training programs practice in the
general area of the country where they
trained, the ratios in those areas could
decline even further. At the same
.
9
INTRODUCTION
Infections of the pulp and supporting mandibular and maxillary bone are found among
people all over the world. Pulpal conditions constitute one of the world’s endemic oral
conditions. The extent, severity, and course of pulpal conditions in different cultures are
influenced by diet, genetics, personal oral hygiene, social customs, group (public) and
personal dental preventive, diagnostic, and therapeutic services.
Different countries address pulpal and supporting bony conditions in various ways. The
economic affluence of countries, their technological development, as well as the
availability and preparation of dental personnel, limit and shape the scope of preventive,
diagnostic, and therapeutic management of pulpal conditions. Less affluent countries
have fewer resources to use for all human needs and wants including management of
dental diseases. Dental services in less affluent countries are typically rudimentary and
trained personnel are rare or non-existent. In these countries, pulpal conditions are
typically addressed by the extraction of the affected teeth usually without replacement. In
contrast, the dental delivery systems in more affluent countries are able to provide a
substantial amount of tertiary dental care to individuals with pulpal conditions.
In the United States, the area of dentistry that diagnoses and treats pulpal conditions is
endodontics. The specialists associated with this area, endodontists, are dentists who
have received advanced education and training in this area and who specialize in treating
pulpal conditions. Treatment for pulpal (or endodontic) conditions is also provided by
general practitioners and to a lesser extent by oral and maxillofacial surgeons and
pediatric dentists.
A substantial amount and variety of data are available for the U.S. (e.g., the amount and
type of endodontic services provided; and the number and characteristics of the dental
health professionals who provide the services) with which to describe the extent of
endodontic diseases and conditions found in the population. This report uses these data
to describe the economic factors that are important in the provision of endodontic services
in the U.S. at the turn of the new Century.
10
SOURCES OF DATA
The information used in this report came primarily from the following sources:
Distribution of Dentists in the United States by Region and State (DOD)
Survey of Dental Fees (SDF)
Survey of Dental Practice (SDP)
Survey of Dental Services Rendered (SDSR)
Electronic Dental Claims Database
U.S. Bureau of the Census
National Health and Nutrition Examination Survey (NHANES) I and III
1999 AAE Survey of Endodontists and Endodontic Practice
Distribution of Dentists by Region and State
The American Dental Association’s Distribution of Dentists in the United States by Region
and State is a census of all known dentists in the U.S., its possessions, and territories.
The census is mandated by the ADA House of Delegates and has been conducted
periodically since the 1940s. During the census, multiple attempts are made to contact
every dentist, independent of ADA membership status. The information collected allows
the ADA to maintain and update its comprehensive computer database on the number,
geographic location, practice status, and demographic information of dentists.
Formerly conducted periodically, the census is now conducted annually using a panel
methodology. That is, all dentists are assigned to one of three panels, and every year one
panel is contacted and information is updated for one-third of all dentists. This panel
method of conducting the census was implemented in 1993.
Survey of Dental Fees
The ADA’s Survey of Dental Fees collects information on dental fees from dentists in
private practice. The survey is mandated by the ADA House of Delegates and is
conducted every two years.
The questionnaire asks dentists to record the fee most often charged for different dental
procedures. As not all procedures can be included in the survey, only the most commonly
completed procedures are included. The 1999 questionnaire collected information on 167
different dental procedures.
The procedure codes for the 1999 Survey of Dental Fees were taken from Current Dental
Terminology, 2nd Edition (CDT-2).
Survey of Dental Practice
The ADA’s Survey of Dental Practice dates back to 1950. The series “was conceived as a
result of an urgent need for information about dental practice.” The Survey of Dental
Practice is a House of Delegates mandated survey and has been conducted annually
since 1982. It is the principal means by which the ADA collects the most comprehensive
and reliable statistical information on the private practice of dentistry in the U.S.
11
The Survey of Dental Practice focuses on practice characteristics such as the number and
frequency of patient visits, work schedules of dentists, and staff, auxiliary employment, as
well as wages, expenses, and income.
Survey of Dental Services Rendered
The ADA’s Survey of Dental Services Rendered provides statistical information on the
patients treated by dentists in private practice and on the dental services they receive.
This survey has been conducted approximately every ten years since 1959.
The questionnaire asked dentists to record demographic information about, and
procedures completed for every patient seen on one day. National estimates on the
number of procedures performed yearly by active private practitioners were then
calculated from the information collected by the survey. Separate estimates were
constructed for general practitioners and for six of the ADA recognized specialty
groupings.
The nomenclature and procedure codes used in the 1990 Survey of Dental Services
Rendered were CDT-1 or earlier codes and those in the 1999 Survey of Dental Services
Rendered were CDT-2 codes.
Because of the large number of dental codes, not all procedures were included in the
survey. Only the most commonly completed procedures were listed on the questionnaire.
The ADA’s Health Policy and Resources Center (HPRC) maintains a large multi-year
electronic dental claims database. The database currently contains electronic claims
submitted from 76,000 dental offices for 84.5 million patients. The database spans the
time period from 1997 to the present and contains claims from all fifty states and the
District of Columbia. Patient and procedure data fields that are found in the electronic
claims database include: patient age, gender, dates of service, CDT procedure codes, as
well as corresponding fee data. The electronic claims data used in this study spans the
time period from July 2001 to December 2001.
The electronic claims database allows a highly detailed examination of endodontic
procedure provided. The database, though, has one limitation. The specialty of the
dentist or dental office submitting a claim is not identified.
A logistic regression model was created to identify dentists/dental offices in the database
as either endodontists or non-endodontists based on the number and types of claims they
filed. The procedures used as identifiers of an endodontist were developed using the
1999 Survey of Dental Services Rendered as the data from this survey included both
specialty and procedure codes. The procedures found to be the most accurate predictors
of endodontists in combination with procedures which were accurate predictors of nonendodontists were used in the logistic regression. Those identified as non-endodontists
were later relabeled as general practitioners as the vast majority of this group was
composed of general practitioners.
12
U.S. Bureau of the Census
The population statistics used in this report came from the U.S. Bureau of the Census.
National Health and Nutrition Examination Survey I and III
Dental epidemiological data from the First and the Third National Health and Nutrition
Examination Surveys were used to assess the burden of disease and its possible impact
on the need for endodontic services.
The 1999 AAE Survey of Endodontists and Endodontic Practice was a three-part project
developed by the American Association of Endodontists (AAE). The purpose of the survey
was to obtain the information and the data needed to develop a workforce assessment
model that could be used to examine the characteristics of endodontic care in U.S.
The project consisted of three separate surveys. The Survey of Endodontic Practice
obtained information about endodontists’ private practices. The Survey of Endodontists
was used to collect data about the characteristics of endodontists in private practice and
the Patient Encounter Form was used to collect information about the dental services
rendered to patients and the amount of time spent in treatment by endodontists and the
dental team members.
13
POTENTIAL MARKET FOR ENDODONTIC SERVICES
The potential market for endodontic services for the adult population in the United States
is determined by five fundamental factors:
1) The size of the population;
2) The age distribution of the population;
3) The number of teeth present in the dentitions;
4) The extent and severity of caries, and its sequela; and
5) The type of restorative materials used to restore carious teeth.
U.S. Population Trends
Population estimates for the United States by age for 1980 and 2000, along with
projections for 2010 and 2020 are presented in Table 1. The total U.S. population has
increased by about 50 million since 1980 and is expected to grow by another 50 million by
2020.
Table 1: U.S. Population (millions) in 1980 and 2000,
and Projections for 2010 and 2020
Age
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Total
1980
16.0
17.0
18.0
21.0
21.0
20.0
18.0
14.0
12.0
11.0
12.0
12.0
10.0
9.0
7.0
11.0
229.0
2000
19.2
20.5
20.5
20.2
19.0
19.4
20.5
22.7
22.4
20.1
17.6
13.5
10.8
9.5
8.9
16.6
281.4
14
2010
20.0
19.0
20.0
22.0
21.0
20.0
19.0
19.0
20.0
22.0
22.0
19.0
16.0
12.0
9.0
19.7
299.7
2020
22.0
21.0
21.0
21.0
21.0
21.0
21.0
21.0
20.0
19.0
20.0
21.0
21.0
18.0
14.0
23.0
325.0
Along with an increase in the size, the population will also experience significant changes
in its distribution by age. Over the next twenty years, the population will get older as the
numerically largest generation, the baby-boomers, ages. Born between 1945 to 1964, the
leading edge of the baby-boomers were in their mid-thirties in 1980, mid-fifties in 2000,
and will be in their mid-seventies in 2020. (See Figures 1 and 2.)
The change in the age distribution is important in assessing the potential need for
endodontic services because the majority of endodontic services are performed on
individuals between the ages of 35 to 74 years. As of 2000, the youngest of the babyboomers were in their late thirties.
In the past, the two most important decades of life for endodontic services was 45-64
years of age. The 45-54 age group has already experienced substantial growth since
1980, especially during the past 10 years. This age cohort will continue to grow through
2010 when it will begin to decline as the youngest baby boomers age out of this age group
and are replaced by the numerically smaller generation that follows them.
In contrast, the 55-64 age group grew only slightly since 1980 but will experience marked
growth during the next twenty years with the arrival of the bulk of the baby-boomers.
An age group with a somewhat lower utilization, but high disease level, is the 65 years and
older age group. This cohort will grow by more than 50% between 2000 and 2020 with the
arrival of the leading edge of the baby-boomers. Utilization of endodontic services by this
age group will increase, if, as predicted, this age group in 2020 retains more of their teeth
than did previous generations and/or continues working longer.
15
Figure 1: Change in the U.S. Population from 1980 to 2000, by Age Group
12
11
10
9
8
8
3
-4
1
75+
70-74
55-59
50-54
45-49
40-44
0
35-39
-2
30-34
-2
-2
25-29
5-9
-1
20-24
1
0-4
0
2
2
65-69
2
2
60-64
3
15-19
4
6
5
10-14
Millions
6
Age Group
Figure 2: Projected Change in the U.S. Population from 2000 to 2020
12
10
10
9
8
8
7
1
1
-4
40-44
-6
Age Group
16
75+
70-74
65-69
60-64
-1
55-59
-3
35-39
30-34
25-29
20-24
15-19
-1
50-54
1
45-49
1
10-14
-2
3
2
2
0
3
3
5-9
4
5
0-4
Millions
6
Need for Endodontic Services
One approach to developing an estimate of the potential market for endodontic services is
to combine demographic and epidemiological information to develop an assessment of
need for endodontic services. The presence of clinical signs of tissue damage resulting
from past or current endodontic disease only suggests a possible need for care. In
addition, need assessment requires a normative judgment as to the amount and kind of
services required by an individual in order to attain or maintain some level of health.
Need for care generally arises because of the existence of untreated disease. In addition,
the scientific basis for efficacious therapy must also exist. In affluent societies, untreated
disease in some population subgroups usually coexists with the majority of the population
receiving the highest quality of care. In less affluent societies, a preponderance of disease
may go without therapeutic intervention.
It should be noted that estimates of the potential size of the market for endodontic services
are based on assumptions and data that may change over time. Estimates also are
dependent on the methods used and provide only general guides to the extent of need in a
population. In fact, several factors that could impact need for endodontic services have
changed over the last 20 years. For example, the size of the population at highest risk for
endodontic disease has increased and will continue to do so. While scientific advances
have resulted in changes in treatment protocols.
From the population and epidemiological data, it is apparent that millions of people in the
U.S. have clinical signs of previous or current oral diseases (specifically caries) or
conditions (fractured teeth or unserviceable restorations) which could develop into needs
for endodontic therapy. See Table 2.
The number of teeth present among dentate persons increased for all age groups between
NHANES I (conducted from 1971 to 1974) and NHANES III (conducted from 1988
to1994). The increase was not large, ranging from 2.44 teeth among persons 35-44 years
old to only 0.53 among those 55-64 years old. However, during the next 20 years, 25-34year-olds will become middle aged, and thus, experience higher risk for endodontic
services. They will enter middle age with more teeth than previous generations.
17
Table 2: Number of Teeth Present and Number of Sound, Filled,
Decayed Teeth and Surfaces
Age
NHANES I
NHANES III
Difference
Teeth Present
25-34
35-44
45-54
55-64
65-74
24.46
21.98
20.92
19.12
16.75
26.07
24.42
21.94
19.65
18.94
1.61
2.44
1.02
0.53
2.19
Sound Teeth
25-34
35-44
45-54
55-64
65-74
13.93
12.13
11.78
10.61
9.56
18.36
14.64
11.56
9.94
9.14
4.43
2.51
-0.22
-0.67
-0.42
Filled Teeth
25-34
35-44
45-54
55-64
65-74
8.65
8.54
7.99
7.33
6.14
6.77
9.03
9.72
9.06
9.18
-1.88
0.49
1.73
1.73
3.04
Filled Surfaces
25-34
35-44
45-54
55-64
65-74
19.28
20.21
19.82
18.78
15.93
13.77
22.14
27.40
28.08
28.99
-5.51
1.93
7.58
9.3
13.06
Decayed Teeth
25-34
35-44
45-54
55-64
65-74
1.88
1.31
1.15
1.18
1.05
0.94
0.75
0.66
0.65
0.62
-0.94
-0.56
-0.49
-0.53
-0.43
Decayed Surfaces
25-34
35-44
45-54
55-64
65-74
3.98
3.01
2.72
3.06
3.19
1.96
1.84
1.56
1.49
1.69
18
-2.02
-1.17
-1.16
-1.57
-1.5
Aside from the increase in the number of teeth at risk for endodontic services, there is a
declining rate of total edentulism. The percentage of the population without any teeth
declined during the past 20 years and will continue to decline in the 21st Century. This
trend will produce millions of Americans that will retain some teeth, and therefore, be at
risk to need endodontic services.
However, the total number of teeth does not tell the entire story. In fact, the caries attack
rate is a fundamental precursor of subsequent need for endodontic services. As shown in
Table 2, sound teeth increased markedly for the younger age cohorts but declined slightly
for those aged 45 years and older. In contrast, the average number of filled teeth
increased between the early 1970s and the early 1990s for all adult age groups over 35
years. This increase is significant because filled teeth are at much greater risk than sound
teeth to require endodontic therapy. This increase, when combined with the increase in
the population of adults, has resulted in a dramatic expansion of the total number of teeth
with fillings, and the expansion occurred largely in the age cohorts, which are at higher risk
to need endodontic therapy.
Nevertheless, when assessing the impact of this increase on the potential need for
endodontic therapy in the future, caution is warranted. The total caries attack rate among
the U.S. child population has been declining for over two decades. Future generations of
Americans are likely to reach middle age with a smaller burden of caries experience. The
data indicate that this shift is already occurring among young adults. In fact, cumulative
caries experience declined between the early 1970s and the early 1990s for all adults up
to age 45 years. This trend is likely to extend into the older adult age groups during the
next twenty years.
Another aspect of caries epidemiology is important to consider when assessing future
need for endodontic therapy. Teeth with untreated caries are likely to be at even higher
risk to develop clinical sequela that will require endodontic intervention. As shown in
Table 2, untreated caries (the ‘D’ component of the DMF index) decreased in all adult age
groups over the period under discussion. If this trend continues, fewer clinical sequela
from caries and more traumatic events occurring with previous restorations can be
expected. Thus, fractures of existing amalgam will probably play an even larger role as
future causative events which will require endodontic intervention.
Finally, the type of restorative material being place in dentitions is a potentially important
indicator of future complications requiring endodontic services. Many believe that resin
restorations, especially when placed as multi-surface restorations in posterior teeth, are
more likely to develop clinical conditions requiring endodontic intervention, than similarly
aged and sized amalgams.
The type of restorative materials used in intracoronal restorations underwent a huge
change during the 1990s, as demonstrated by the data in Table 3. The total number of
restorations placed by dentists in 1999 increased moderately (about 9.6 million
restorations) over the number placed in 1990. However, the per capita number of
restorations declined slightly and the number of restorations per patient declined by 15%
from 1.07 per patient in 1990 to 0.91 per patient in 1999. The number of amalgams
placed declined from almost 100 million in 1990 to about 80 million in 1999, a 20%
19
reduction. In contrast, the number of resin restorations increased from 47.7 million in 1990
to 85.8 million in 1999, an increase of nearly 80%. The number of amalgams per patient
declined from 0.72 in 1990 to 0.41 in 1999, while the number of resins per patient
increased from 0.35 to 0.50 during the same period.
Table 3: Trends in the Placement of Restorations,
by Type of Restorative Material, 1990 and 1999
Total restorations
Total population
Per capita restorations
Total Patients (2 yrs+)
Per patient restorations
Total amalgams
Per patient amalgams
Total resins
Per patient resins
1990
147,212,900
248,791,000
0.59
137,818,110
1.07
99,504,100
0.72
47,708,800
0.35
1999
156,783,100
276,453,000
0.57
172,016,000
0.91
70,994,700
0.41
85,788,400
0.50
Sources: American Dental Association, Survey Center, 1990 and 1999 Surveys of
Dental Services Rendered; and the U.S. Bureau of the Census.
As shown in Table 3, the total number of restorations, rather than the per capita number, is
important in assessing the need and demand for endodontic interventions. The total
number of restorations has increased overall, and particularly for resin restorations.
Moreover, most of the increase in resin placement occurred in posterior teeth as illustrated
in Figure 3.
The U.S. population has been undergoing mixed trends regarding the various
demographic and epidemiological factors that fundamentally impact the potential need for
endodontic services. The population has been increasing and aging. This has produced
more people in the age groups that, in the past, have been the highest utilizers of
endodontic services. In the future, however, the number of people in these high utilizing
age groups will grow smaller as the baby-boomers exit the population.
On average, individuals are retaining more teeth, and thus, are at risk to need endodontic
intervention. However, the number of sound teeth has been increasing and is likely to
continue to increase. The number of filled teeth has increased but may not continue to do
so as those cohorts who experienced fewer caries attacks when they were children
become middle-aged.
Finally, there has been an enormous shift in the restorative materials placed, especially in
posterior teeth. These conflicting tendencies cloud the assessment of future need for
endodontic services. Perhaps the picture will become clearer if these trends endure or
grow stronger.
20
Figure 3: Number of Amalgams and Resins, 1990 and 1999
50,000,000
45,000,000
40,000,000
35,000,000
30,000,000
25,000,000
20,000,000
15,000,000
10,000,000
5,000,000
0
Amalgam,
one surface
Amalgam,
two surfaces
Amalgam,
three
surfaces
Amalgam,
four plus
surfaces
Resin
restoration,
anterior
Resin
restoration,
posterior
Source: American Dental Association, Survey Center, 1990 and 1999 Surveys of
Dental Services Rendered.
OVERALL MARKET FOR ENDODONTIC SERVICES
Fundamentally, need assessment focuses on which, and how many, services should be
utilized. In almost all circumstances, this will differ from the services actually utilized.
Even if methods to estimate the need for endodontic services were very precise, they
would provide only part of the information required to describe the economics of
endodontic services. To understand the actual market of these services, the effective
demand for the services, as well as the availability of human and non-human resources,
are important. These supply and demand factors play an important role in translating
unmet need into effective demand. An understanding of the economic and social
conditions of the population, reluctance to seek professional dental care, and the role that
price plays in determining care received help explain differences between services needed
and services actually provided.
Demand for Endodontic Services
In the U.S., professionally trained dentists provide endodontic services through private
markets shaped by supply and demand. Public funding for endodontic services is meager.
This makes an assessment of demand for endodontic dental services very important for
understanding the actual delivery of care.
21
In assessing demand, the consumer is the primary source that drives the use of dental
services. The demand for dental care reflects the amount of care desired by patients at
alternative prices. The demand for dental services is significantly responsive to changes
in dental fees. If other factors that influence demand remain constant, higher fees result in
lower demand and vice versa. Among these other factors that influence the level of
demand are: income, family size, population size, education levels, prepayment coverage,
health history, ethnicity and age.
Most factors that positively influence demand for dental care have been expanding. The
U.S. economy has grown robustly for most of the past two decades, resulting in an
increase in discretionary income among the U.S. population. People are becoming more
knowledgeable about dental health and what is required to maintain it. As the population
has become more affluent and educated, the value placed on oral health has increased.
In addition, the desire for esthetic dentistry has grown and will probably continue to do so.
All of these factors have enhanced the demand for dental services, in general, and
endodontic services, in particular.
Trends in Utilization and Expenditures for Endodontic Services
OVERVIEW
This section of the paper provides a comprehensive description of patterns in utilization
and expenditures seen in the endodontic services marketplace. The endodontic services
marketplace consists of the dental services performed to treat endodontic diseases by all
dentists. This section is divided into two substantive areas. The first is a discussion seen
in endodontic service patterns that are due to provider specialization and patient age. The
second discussion focuses on the dominant role played by the delivery of root canals in
the endodontic services marketplace.
The data used in this section are drawn from two sources. The first is the SDSR for the
years 1990 and 1999. The second source is the HPRC Electronic Claims Database for
the months of July through December 2001. The two sources are used in concert for the
following reasons: 1) the random sample-based SDSR data are more representative of
the entire U.S. marketplace, but they are limited by the surveys’ sample size and scope of
data collection and 2) the size and detail of the electronic claims database permits
information to be obtained for procedures that are infrequently provided and for
geographic areas below the national level.
While the claims data cannot be considered to be representative of all dental services
performed in the U.S., they, nevertheless, can provide a good general indication of the
relative percentage of procedure utilization and patient demographics among general
practitioners and endodontists across the U.S. SDSR and the electronic claims data show
pervasive agreement in identifying the universal patterns found in utilization and
expenditures seen in endodontic services both in the direction of the patterns observed
and often in the percents seen. Taken together, the two sources of data provide a
comprehensive, accurate, and complementary picture of the utilization and expenditures
for endodontic services in the U.S. Taken together, the two sources of data provide a
22
comprehensive, accurate, and complementary picture of the utilization and expenditures
for endodontic services in the U.S.
NATIONAL EXPENDITURES FOR ENDODONTIC SERVICES
The best single measure of the size of the endodontic services market is total national
expenditures for those services. In 1999, expenditures for endodontic services were
estimated to total $8.6 billion. On a per capita basis, expenditures for endodontic services
amounted to $32.19. Focusing on those individuals who visited a dentist, endodontic
services averaged $50.05 per patient.
Root canal therapy comprised $8.2 billion, or 95.4% of the total national expenditures for
endodontic services. Other endodontic services, such as pulp caps, pulpotomies and
apicoectomies accounted for the remainder. Molar teeth accounted for the largest root
canal expenditures. Molar root canal totaled $4.7 billion--almost 57% of expenditures for
root canals. Bicuspid root canals accounted for $2.1 billion- about 26%. Anterior teeth
were the source of the remaining $1.4 billion in root canal expenditures.
Previously, development of accurate estimates for endodontic expenditures has been
limited by the lack of detailed and representative information on the quantity all the various
endodontic procedures provided and their associated fees. The data available for this
study redress many of these limiting factors; nevertheless, several assumptions are
embedded in these national estimates. Detailed and representative fee data are available.
The SDSR collected information on major, but not all, endodontic procedures. Those
procedures that are covered by the SDSR represent over 90% of the charges for
endodontic services that are found in electronic claims. The estimate based on the SDSR
data was increased by the appropriate percent to adjust of the incomplete coverage of
endodontic procedures by SDSR. Root canals, the most important procedures for
expenditure estimates, are fully covered with the SDSR data. Some of the less frequent
procedures are bundled together. The electronic claims data were used to estimate the
relative proportions of these bundled procedures. These proportions were used to
unbundle these procedures in the SDSR data. Then, representative fees were applied to
the estimates of the number of unbundled procedures.
TRENDS IN TOTAL, PER CAPITA, AND PER PATIENT UTILIZATION OF ENDODNTIC SERVICES
Estimates of the number of endodontic services provided were developed from the data
collected by the 1990 and 1999 Survey of Dental Services Rendered. These estimates
provided the basis for calculations of per capita and per patient utilization of endodontic
services.
As shown in Table 4, endodontic procedures account for only a small percentage of all
dental procedures. In 1990, endodontic procedures (20,754,000) accounted for 2.1% of
total dental procedures (1,012,748,300). By 1999, while total endodontic procedures
increased to 21,932,800, they accounted for an even smaller percentage (1.7%) of total
dental procedures, which increased to 1,273,874,500.
23
Table 4: Endodontic Procedures and All Dental Procedures, 1990 and 1999
Endodontic procedures
Percent of all dental procedures
All dental procedures
1990
20,754,000
2.1%
1999
21,932,800
1.7%
1,012,748,300
1,273,874,500
As shown in Table 5, endodontic procedures were not common among the U.S. population
as a whole or among dental patients. The number of endodontic procedures per capita
was about the same in 1990 (0.057 per capita) and 1999 (0.059 per capita). About 6% of
the population received an endodontic procedure in both years. In contrast, the number of
endodontic procedure per patient declined from 0.102 per patient in 1990 to 0.092 per
patient in 1999. About 1% less of dental patients received endodontic care in 1999. This
means that the increase in per capita utilization of endodontic services occurred because
a larger percentage of the population visited a dentist in 1999, compared to 1990. If the
percentage of the population that visits a dentist does not continue to increase in the
future, the number of endodontic procedures per capita could decline. If this happens, it
may mean the endodontist-to-population ratio will not need to be as large in the future.
Table 5: Endodontic Procedures per Capita and per Patient, 1990 and 1999
Age
2-4
5-11
12-17
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
Overall
1990
Per Capita Per Patient
.003
.010
.008
.011
.018
.026
.042
.075
.070
.121
.082
.131
.087
.147
.088
.164
.062
.129
.024
.067
.058
.102
1999
Per Capita Per Patient
.001
.003
.007
.009
.016
.021
.038
.063
.067
.113
.081
.122
.082
.121
.075
.123
.076
.137
.052
.102
.059
.092
Source: American Dental Association, Survey Center, 1999 Survey of Dental Services Rendered.
AGE DISTRIBUTION OF ENDODONTIC PATIENTS
Differences are seen in the ages at which endodontic services are provided. Among all
dentists, endodontic services are rare for children 2-4 years old. Only 1.1% of endodontic
patients were in that age group. Beginning at age 5, the use of endodontic services
begins to increase. Those in the 5-11 age group comprise 8.5% of endodontic patients, as
did those in the 12-17 age group. After age 25, the number of endodontic services begins
to increase. People aged 25-54 years comprise almost half of endodontic patients. After
24
the age of 54, endodontic services decrease as a function of an increasing endentulous
population. Thus, the primary users of endodontic services were the 25-64 age group.
(See Table 6.)
The age distribution of endodontic patients among general practitioners mirrors the
distribution among all dentists. This is because general practitioners deliver the largest
proportion of endodontic services.
The age distribution of endodontic patients was substantially different from that of general
practitioners. General practitioners’ patients were systematically younger than
endodontists’ patients. General practitioners’ patients less than 18 years old accounted
for slightly over 18% of their endodontic patients. In contrast, middle aged patients 35-64
years old constituted a larger percentage of endodontists’ patients, 61%, compared 48%
for general practitioners. (See Table 6.)
Table 6: SDSR Data, Age Distribution of Patients Who Received at Least One
Endodontic Procedure, by Age of Patient, 1999
Age
2-4
5-11
12-17
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
Overall
General
Practitioners
Number Percent
211
1.1%
1,678
8.7%
1,660
8.6%
1,348
7.0%
2,431
12.7%
3,485
18.1%
3,352
17.4%
2,371
12.3%
1,709
8.9%
965
5.0%
19,210
Endodontists
Number Percent
0
0.0%
8
1.3%
11
1.8%
31
5.1%
101
16.7%
135
22.4%
132
21.9%
100
16.6%
59
9.8%
26
4.3%
100.0%
603
100.0%
All Dentists
Number
Percent
211
1.1%
1,686
8.5%
1,671
8.4%
1,379
7.0%
2,532
12.7%
3,620
18.3%
3,484
17.6%
2,471
12.5%
1,768
8.9%
991
5.0%
19,813
100.0%
In the electronic claims database, the same relationships are found with some notable
differences between the two sources of data. The number of younger endodontic patients
is greater and this is directly due to differences between the data sources. In the claims
database, patients were younger overall because they belonged to a commercially insured
population. In the SDSR. patients were more representative of the general population.
Moreover in Table 6 (which displays SDSR data), data from pediatric dentists were
excluded, while data from pediatric dentists were included in Table 7 (which displays
electronic claims data).
25
Table7: Electronic Claims Database, Age Distribution of Patients Who Received at
Least One Endodontic Procedure, 2001
Age
2-4
5-11
12-17
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
General
Practitioners
Number Percent
11,420
2.9%
64,340
16.5%
25,660
6.6%
31,300
8.0%
58,040
14.9%
78,200
20.1%
68,260
17.5%
35,980
9.2%
11,780
3.0%
4,880
1.3%
Overall
389,860
100.0%
Endodontists
Number Percent
11
0.0%
860
1.0%
2,310
2.8%
3,775
4.6%
10,803
13.1%
20,179
24.4%
23,518
28.5%
14,250
17.3%
4,658
5.6%
2,194
2.7%
82,558
100.0%
All Dentists
Number
Percent
11,431
2.4%
65,200
13.8%
27,970
5.9%
35,075
7.4%
68,843
14.6%
98,379
20.8%
91,778
19.4%
50,230
10.6%
16,438
3.5%
7,074
1.5%
472,418
100.0%
Source: American Dental Association, Health Policy Resources Center, Electronic Claims Database.
AGE OF PATIENTS RECEIVING ROOT CANALS
As illustrated in Figure 4, in 1999, the distribution patterns of anterior, bicuspid, and molar
root canals differed by age group. Anterior root canals were the least common of the three
root canals. But among the very young (11 years old or younger) and the very old (65
years old or older), they were the most common endodontic procedure performed.
Bicuspid root canals were mainly provided to patients who were in the 25-44 age group.
Among other age groups, the number of bicuspid canals were less than or similar to the
number of anterior canals. Molar root canals were the most common root canal procedure
performed on 12-64 years old. Only among the very young and very old are molar root
canals rare. The largest number of molars was provided to individuals in the 35-44 age
group.
26
Figure 4: Root Canal Treatment by Age, 1999
2,500,000
Number of Procedures Completed
Anterior
Bicuspid
2,000,000
Molar
1,500,000
1,000,000
500,000
0
2-4
5-11
12-17 18-24 25-34 35-44 45-54 55-64 65-74
75+
Patient Age Group
SEGMENTATION OF THE ENDODONTIC SERVICES MARKET
Providers of Endodontic Services
TOTAL PRODUCTION OF ENDODONTIC SERVICES BY GENERAL PRACTITIONERS AND
ENDODONTISTS
All dentists except orthodontists performed endodontic procedures. However, general
practitioners and endodontists provided the huge majority of endodontic procedures.
General practitioners provided 75.2% of all the endodontic procedures completed in 1999;
endodontists provided 20.3%. See Table 8. Pediatric dentists, at 3.3%, were the only
other specialty, completing a significant number of endodontic procedures, which
consisted almost entirely of pulpotomies and pulp caps.
While the number of procedures completed by general practitioners increased from 15.8
million in 1990 to 16.5 million in 1999, as a percentage of all endodontic procedures
completed, the share done by general practitioners dropped from 76.1% to 75.2%. From
1990 to 1999, the number of procedures completed by endodontists increased from 3.9
million to 4.5 million. As percentage of all endodontic procedures completed, endodontists
share increased from 18.6% to 20.3%.
27
Table 8: Distribution of Endodontic Procedures by Specialty,
1990 and 1999
Type of Dentist
General Practitioners
Endodontists
Pediatric Dentists
Oral and Maxillofacial Surgeons
Orthodontic and Dentofacial
Orthopedists
Periodontists
Prosthodontists
1990
15,785,100
3,860,700
942,200
108,800
0
31,800
25,400
0.2%
0.1%
50,700
18,800
0.2%
0.1%
Total
20,754,000
100.0%
21,932,800
100.0%
76.1%
18.6%
4.5%
0.5%
0.0%
1999
16,493,200
4,459,900
721,300
188,900
0
75.2%
20.3%
3.3%
0.9%
0.0%
Pulpotomies were primarily performed by general practitioners and consisted of two
types–pulp caps and therapeutic pulpotomies. Endodontists performed fewer than 9% of
the nation’s pulpotomies. In the 1999 SDSR data, the performance of pulpotomies was
largely outside of the endodontic specialty with the greatest number of these procedures
being provided by general practitioners.
General practitioners provided the majority of anterior, bicuspid, and molar root canals.
General practitioners provided 88% of anterior root canals, as compared to only 12% for
endodontists. For bicuspid root canals, general practitioners provided 79% of the therapy
versus 21% for endodontists. Lastly, general practitioners provided 64% of molar root
canals, while endodontists provided only 36%. As seen in the 1999 SDSR data presented
in Table 9, overall, general practitioners performed six out of ten root canals.
28
Table 9: Proportion of Common Endodontic Procedures Provided by
General Practitioners and Endodontists, 1999
General
Practitioners
Molar root canals
Bicuspid root canals
Anterior root canals
Pulpotomy
Pulp cap
Bleaching
Apicoectomy
4,887,500
3,501,600
3,317,600
1,802,800
1,609,200
1,237,600
136,900
63.9%
79.4%
88.3%
91.9%
99.0%
98.1%
47.3%
Endodontists
2,761,900
908,500
438,000
158,700
16,400
23,900
152,500
36.1%
20.6%
11.7%
8.1%
1.0%
1.9%
52.7%
All Dentists
7,649,400
4,410,100
3,755,600
1,961,500
1,625,600
1,261,500
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
289,400
100.0%
Source: American Dental Association, Survey Center, 1999 Surveys of Dental Services Rendered.
RELATIVE IMPORTANCE OF ENDODONTIC SERVICES AMONG GENERAL PRACTITIONERS AND
ENDODONTISTS
Among general practitioners, the vast majority of endodontic services were pulp caps,
pulpotomies, anterior, bicuspid, and molar root canals. Approximately 92% of endodontics
performed by general practitioners fell within these five procedures. For endodontists, the
most frequently performed procedures were anterior, bicuspid, and molar root canals.
Together, these three procedures accounted for 92% of the endodontic services delivered
by endodontists. (See Table 10.)
29
Table 10: Endodontic Procedures Completed by
Endodontic Procedures
Molar root canals
Pulpotomy
Pulp cap
Bleaching
Apicoectomy
Root amputation
Total
General
Practitioners
4,887,500
29.6%
3,501,600
21.2%
3,317,600
20.1%
1,802,800
10.9%
1,609,200
9.8%
1,237,600
7.6%
136,900
0.8%
0
0.0%
16,493,200
100.0%
Endodontists
2,761,900
61.9%
908,500
20.4%
438,000
9.8%
158,700
3.6%
16,400
0.4%
23,900
0.5%
152,500
3.4%
0
0.0%
4,459,000
100.0%
According to both the 1999 SDSR and the July to December 2001 electronic claims
database, all of the endodontic services provided by general practitioners amounted to
slightly more than 1% of the total volume of dental care provided by general practitioners.
For endodontists, endodontic procedures comprised 34% of the services reported in the
1999 SDSR (see Table 11) and 47% in the electronic claims database (see Table 12).
The other procedures performed by endodontist were ancillary services such as exams
and radiographs required as part of root canal therapy.
Table 11: SDSR Data, Endodontic Procedures and All Procedures Completed
Among General Practitioners and Endodontists, 1999
Number of endodontic procedures
Percent of total dental procedures
Number of other procedures
General
Practitioners
11,706,700
1.1%
1,038,989,400
98.9%
Endodontists
4,108,400
34.1%
7,939,600
65.9%
1,050,696,100
12,048,000
30
Table 12: Electronic Claims Database, Endodontic Procedures and All Procedures
Completed Among General Practitioners and Endodontists, 2001
Number of endodontic procedures
Number of other procedures
General
Practitioners
490,980
1.1%
47,399,100
98.9%
Endodontists
47,890,080
193,521
91,972
47.5%
101,549
52.5%
Endodontists for the most part only performed six procedures. As listed in the table below,
these procedures included root canals along with the prep and post work associated with
them. All together, these six procedures accounted for 90.3% of all procedures done by
endodontists. In comparison, these six procedures accounted for only a small percentage
of the procedures completed by general practitioners. Endodontics is only a small part of
what general practitioners do. Molar root canals, the most common endodontic therapy
done by endodontists, were only 0.5% of the procedures done by general practitioners.
Table 13: Procedures Most Commonly Performed
by Endodontists, 1999
Procedure
Periapical radiographs
Molar root canals
Limited oral evaluation
Consultation
65,562,500
6.2%
4,887,500
0.5%
22,571,600
2.1%
3,501,600
0.3%
3,944,600
3.8%
3,317,600
3.2%
Endodontists
4,566,500
37.9%
2,761,900
22.9%
1,725,700
14.3%
908,500
7.5%
474,500
3.9%
438,000
3.6%
16.1%
90.3%
Totals
31
Among endodontists, twenty-one procedures accounted for 95% of the procedures done in
the electronic claims database (see Table 14). Similar patterns can be seen in the
distribution of endodontic procedures between the SDSR and the electronic claims
database.
In the electronic claims database, root canals were the most common procedures
performed by endodontists with molars, bicuspid and anterior endodontics therapy
occurring 27.80%, 8.03%, and 4.61%, respectively (see Table 14). For general
practitioners, the corresponding rates were one-half percent for molars and one-third
percent for bicuspid and anterior root canals (See Appendix 2, Table A2-1).
As shown in Table 14, pulpotomies and pulp-caps do not appear in the top 21 codes
performed by endodontists in the claims data. These procedures accounted for only 1% of
endodontic services in the claims data. In contrast, in the 1999 SDSR data, pulpotomies
and pulp caps were 9% of the endodontic procedures provided by endodontists. This is
understandable given the underlying methods of the two data sources. Pulpotomies and
pulp caps are either palliative or temporary procedures provided in lieu of root canal
therapy. When general practitioners provide these services, they view the majority of
them as separate from root canals and bill separately on the claim. Alternatively, the few
of these procedures that endodontists provide are viewed as part of the overall root canal
therapy and are not billed separately.
32
Table 14: Electronic Claims Database, CDT Procedures Which Accounted
for 95% of All Endodontists Procedures, 2001
Summary Statistics
CDT Procedure Codes
and Descriptions
D3330 Molar (excl. final
restoration)
D0140 Limited oral eval.
D0220 Intraoral - periapical
1st film
D3320 Bicuspid (excl. final
restoration)
D9310 Consultation (dx.
serv. by dentist/physician
not provider)
D3310 Anterior (excl. final
restoration)
D0230 Intraoral - periapical
each addl. film
D0460 Pulp vitality tests
D3348 Retreatment of
previous root canal therapy
– molar
D2954 Prefab. post and
core in addition to crown
D3430 Retrograde filling per root
D0120 Periodic oral eval.
D9110 Palliative
(emergency) treatment of
dental pain - minor proc.
D0150 Comprehensive oral
eval.
D9230 Analgesia,
anxiolysis, inhalation of
nitrous oxide
D2140 Amalgam - 1
surface, permanent
D3410 Apicoectomy/
periradicular surgery anterior
- anterior
D2950 Core buildup,
includes pins
- bicuspid
D3425 Apicoectomy/
periradicular surgery molar (1st root)
Percentage Measures
Percent of
Total Endo
Procedures
Cumulative
Percent of
Total Endo
Procedures
Percent of
All
Procedures
1.04
27.80%
27.80%
27.56%
32,281
25,341
1.03
1.05
17.30%
13.83%
45.10%
58.92%
17.15%
13.71%
15,410
14,795
1.04
8.03%
66.96%
7.96%
11,200
10,905
1.03
5.84%
72.79%
5.79%
8,845
7,946
1.11
4.61%
77.41%
4.57%
6,620
5,517
1.20
3.45%
80.86%
3.42%
3,959
3,632
3,658
3,512
1.08
1.03
2.06%
1.89%
82.92%
84.81%
2.05%
1.88%
3,261
3,012
1.08
1.70%
86.51%
1.69%
2,415
1,859
1.30
1.26%
87.77%
1.25%
2,045
1,761
1,994
1,674
1.03
1.05
1.07%
0.92%
88.84%
89.76%
1.06%
0.91%
1,616
1,589
1.02
0.84%
90.60%
0.84%
1,493
1,432
1.04
0.78%
91.38%
0.77%
1,485
1,427
1.04
0.77%
92.15%
0.77%
1,226
1,090
1.12
0.64%
92.79%
0.63%
1,172
1,067
1.10
0.61%
93.40%
0.61%
1,170
1,115
1.05
0.61%
94.01%
0.60%
1,085
1,057
1.03
0.57%
94.58%
0.56%
1,051
1,016
1.03
0.55%
95.13%
0.54%
Number
of
Procedures
Number
of
Patients
53,325
51,473
33,180
26,523
33
Procedures
per Patient
Provision of Root Canals
THE PREDOMINANCE OF ROOT CANALS
In both the 1999 SDSR and the electronic claims database, the three root canal
procedures were the predominant endodontic procedures performed by endodontists. In
the 1999 SDSR, root canals were 90% and 96% of the shared endodontic procedures for
general practitioners and endodontists (see Table 15). In the electronic claims database,
root canals comprised 91% and 85% of the endodontic procedures that were shared
between general practitioners and endodontists (see Table 16). After considering the
limitations of the 1999 SDSR, the two sources of data are in close agreement (see
Appendix 3).
Table 15: SDSR Data, Root Canals and Other Endodontic Procedures
Number of root canals
Percent of total endodontic procedures
Number of other endodontic procedures
All endodontic procedures
General
Practitioners
11,706,700
89.5%
3,412,000
10.5%
Endodontists
4,108,400
95.9%
175,100
4.1%
15,118,700
4,283,500
Table 16: Electronic Claims Data, Root Canals and Other Endodontic Procedures
Number of root canals
Number of other endodontic procedures
All endodontic procedures
General
Practitioners
260,440
90.7%
26,760
9.3%
Endodontists
77,580
84.7%
14,043
15.3%
287,200
91,623
From the size of the percentages involved, it can be seen that the root canals played a
dominant role in driving endodontic services during the study period. Root canals on
anterior teeth, bicuspids, and particularly molars comprised the majority of endodontic
services for both general practitioners and endodontists. However, root canals are the
economic foundation of the specialty of endodontics.
34
DISTRIBUTION OF ROOT CANALS BY TYPE OF TOOTH AND TYPE OF DENTIST
As shown in Table 17, the distribution found for anterior, bicuspid, and molar endodontic
therapies were not similar among general practitioners and endodontists. General
practitioners provided all three procedures and provided almost as many molar root canals
(41.8%) as they provided anterior and bicuspid root canals combined (58.2%). In contrast,
two-thirds of the endodontic therapies done by endodontists were on molars (67.2%) with
only a third done on anteriors and bicuspids (32.8%).
Table 17: Root Canal Treatments Completed by
Root
Canals
Anterior
Bicuspid
Molar
Total
General
Practitioners
3,317,600
28.3%
3,501,600
29.9%
4,887,500
41.8%
11,706,700
Endodontists
438,000
10.7%
908,500
22.1%
2,761,900
67.2%
100.0%
4,108,400
100.0%
Total
3,755,600
4,410,100
7,649,400
15,815,100
23.7%
27.9%
48.4%
100.0%
General practitioners completed 88.3% of the root canals done on anterior teeth and
79.4% of the bicuspids, but only 63.9% of the molars. In total, general practitioners
completed 74.0% of all root canals or almost three times as many as endodontists—11.7
million compared to 4.1 million, respectively. (See Figure 5.)
35
Figure 5: Root Canal Treatments Performed by
3,317,600
Anterior
Endodontists
438,000
3,501,600
Bicuspid
908,500
4,887,500
Molar
2,761,900
11,706,700
Total
4,108,400
0
2,000,000
4,000,000
6,000,000
8,000,000 10,000,000 12,000,000 14,000,000
In the electronic claims database, a similar overall distribution of root canals occurred
between general practitioners and endodontists. General practitioners provided all three
procedures and only provided slightly more molar root canals than anteriors and bicuspids.
In contrast, two-thirds of the endodontic therapies done by endodontists were on molars
with only a third done on anteriors and bicuspids (See Table 18).
36
Table 18: Anterior, Bicuspid, and Molar Root Canals
Among General Practitioners, Endodontists, and All Dentists, 2001
Percent of
Total
Number of
Procedures
Percent of
Total
All
Dentists
Number of
Procedures
Endodontists
Anterior (excl. final restoration)
Bicuspid (excl. final restoration)
Molar (excl. final restoration)
63,180
70,800
126,440
24.3%
27.2%
48.6%
8,845
15,410
53,321
11.4%
19.9%
68.7%
72,025
86,210
179,761
21.3%
25.5%
53.2%
Total
260,420
100.0%
77,576
100.0%
337,996
100.0%
Percent of
Total
Number of
Procedures
General
Practitioners
In the electronic claims database, general practitioners completed 87.7% of the root
canals done on anterior teeth and 82.1% of the bicuspids, but only 70.3% of the molars.
Overall, general practitioners completed 77% of the root canals or more than three times
as many as the endodontists: 260,420 compared to 77,576 (see Table 18).
The differences seen in the distribution of root canals treated between endodontists and
general practitioners are driven by clinical complexity and its corresponding effect on
referral decisions. Molar root canals present the greatest clinical complexity and are more
likely to be referred to endodontists. In the electronic claims database, slightly more than
one anterior root canal in ten (11%) and one in five bicuspids (20%) were referred to
endodontists. The corresponding number for molar patients was one in three (69%).
From the 1999 SDSR data, the numbers were nearly the same, 11%, 22%, and 67%,
respectively. Referral decisions by general practitioners steered patients to the
endodontist for all root canals. Molar canals accounted for the largest type of care
referred due to the greater clinical complexity of the procedure.
AGES OF ROOT CANAL PATIENTS AMONG GENERAL PRACTITIONERS AND ENDODONTISTS
The electronic claims database allowed for detailed analysis of the distribution of root
canals by patient age. As shown in Table 19, the provision of root canals between general
practitioners and endodontists differed by patient age. General practitioners saw
proportionately more patients aged 45 years and younger in their practice than
endodontists. In contrast, endodontists saw a greater percentage of patients over the age
of 45 years. The endodontists’ practice consisted of older patients. Conversely, the
general practitioners’ practice consisted of younger patients.
37
Table 19: Number of Patients Who Received at Least One
Endodontic Procedure, by Age of Patient, 2001
Age
2-4
5-11
12-17
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
General
Practitioners
Number Percent
160
0.1%
2,800
1.2%
14,320
6.2%
19,980
8.7%
39,860
17.3%
58,040
25.2%
52,720
22.9%
28,640
12.4%
9,720
4.2%
4,000
1.7%
Overall
230,240
100.0%
Endodontists
Number Percent
9
0.0%
657
0.9%
2,117
2.9%
3,500
4.8%
9,644
13.2%
17,783
24.3%
20,726
28.3%
12,639
17.3%
4,110
5.6%
1,971
2.7%
73,156
100.0%
All Dentists
Number
Percent
169
0.1%
3,457
1.1%
16,437
5.4%
23,480
7.7%
49,504
16.3%
75,823
25.0%
73,446
24.2%
41,279
13.6%
13,830
4.6%
5,971
2.0%
303,396
100.0%
As shown in Tables 20-22, the patient age differences seen in the electronic claims
database between general practitioners and endodontists were not distributed uniformly
among the three types of root canals. For anterior root canals, patients 55 years and older
were a larger percentage of endodontists’ patients (25.6%) compared to general
practitioners’ patients (18.3%)—a 7.3% difference. Also, for both bicuspid and molar root
canals, patients 45 years and older accounted for a larger percentage of endodontist
patients than general practitioners—a difference of 16.4% for each.
38
Table 20: Number of Patients Who Received at Least One Anterior
Root Canal Procedure, by Age of Patient, 2001
Age
2-4
5-11
12-17
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
Overall
General
Practitioners
Number Percent
120
0.2%
840
1.6%
3,320
6.3%
4,640
8.7%
6,760
12.8%
12,100
22.8%
11,480
21.7%
8,740
16.5%
3,220
6.1%
1,760
3.3%
52,980
100.0%
Endodontists
Number Percent
0
0.0%
257
3.2%
582
7.3%
520
6.5%
812
10.2%
1,385
17.4%
1,696
21.3%
1,472
18.5%
729
9.2%
493
6.2%
7,946
100.0%
All Dentists
Number
Percent
120
0.2%
1,097
1.8%
3,902
6.4%
5,160
8.5%
7,572
12.4%
13,485
22.1%
13,176
21.6%
10,212
16.7%
3,949
6.5%
2,253
3.7%
60,926
100.0%
Table 21: Number of Patients Who Received at Least One Bicuspid
Age
2-4
5-11
12-17
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
Overall
General
Practitioners
Number Percent
20
0.0%
220
0.3%
1,780
2.7%
4,080
6.2%
10,740
16.3%
17,000
25.7%
18,420
27.8%
9,180
13.9%
3,560
5.4%
1,100
1.7%
66,100
100.0%
Endodontists
Number Percent
1
0.0%
4
0.0%
128
0.8%
446
3.0%
1,487
10.1%
3,075
20.8%
4,587
31.0%
3,338
22.6%
1,174
7.9%
555
3.8%
14,795
39
100.0%
All Dentists
Number
Percent
21
0.0%
224
0.3%
1,908
2.4%
4,526
5.6%
12,227
15.1%
20,075
24.8%
23,007
28.4%
12,518
15.5%
4,734
5.9%
1,655
2.1%
80,895
100.0%
Table 22: Number of Patients Who Received at Least One Molar
Age
2-4
5-11
12-17
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
General
Practitioners
Number Percent
40
0.0%
1,760
1.5%
9,400
8.0%
11,800
10.0%
23,480
20.0%
31,020
26.4%
24,620
20.9%
11,260
9.6%
3,140
2.7%
1,180
1.0%
Overall
117,700
100.0%
Endodontists
Number Percent
8
0.0%
396
0.8%
1,420
2.7%
2,587
5.0%
7,468
14.5%
13,557
26.3%
14,736
28.6%
8,046
15.6%
2,285
4.4%
966
1.9%
51,469
100.0%
All Dentists
Number
Percent
48
0.0%
2,156
1.3%
10,820
6.4%
14,387
8.5%
30,948
18.3%
44,577
26.4%
39,356
23.3%
19,306
11.4%
5,425
3.2%
2,146
1.3%
169,169
100.0%
If endodontists continue to treat a larger proportion of older patients, these findings
suggest that the demand for root canals provided by endodontists may grow at a higher
rate as the baby-boom cohort enter the 45 an older age groups. Whether this pattern will
persist depends fundamentally on the underlying reasons for its existence. If referral
decisions are based on the complexity of treatment, then these patient age patterns will
persist. On the other hand, if general practitioners are referring as a matter of
convenience they may rethink their referral decisions as their patient base ages.
PROVISION OF ROOT CANALS PER PRACTITIONER
As a group, general practitioners completed more root canals than endodontists. To a
certain extent, this is a factor of the large number of general practitioners compared to the
relatively small number of endodontists. The ratio of general practitioners to endodontists
is approximately 36 to 1. Thus, for endodontists to complete an equivalent number of root
canals, each individual endodontist would have to complete 36 procedures for every one
procedure completed by a general practitioner.
On a per dentist level, endodontists performed more root canals than general practitioners.
The average general practitioner completed 94.6 root canals per year in 1999. Each
endodontist, in comparison, completed an average of 1,236.3 root canals. On average,
each endodontist completed 4.9 times as many anterior root canals, 9.7 times as many
bicuspid root canals, and 26.3 times as many molar root canals as a general practitioner.
40
Figure 6: Root Canals per Dentist, 1999
26.8
Anterior
Endodontists
131.8
28.3
Bicuspid
273.4
39.5
Molar
831.1
94.6
Total
1,236.3
0
200
400
600
800
1,000
1,200
1,400
41
Assuming a fifty-week work year, a general practitioner completed an average of 1.9 root
canals per week compared to 24.7 completed by an endodontist.
Figure 7: Total Root Canals per Week per Dentist, 1999
1.9
Endodontists
24.7
0
5
10
15
20
25
30
42
FINANCIAL SEGMENTATION OF THE MARKET
Fees for All Endodontist Procedures
Both the Survey of Dental Fees (SDF) and the electronic claims database have
information about the fees charged by general practitioners and endodontists. However,
the electronic claims database contains considerable more detail and will be used
extensively in this section.
In both the SDF and the electronic claims database, endodontists’ average fees were
substantially higher than those of general practitioners. A comparison of fees showed
general practitioners’ average fees ranged from 66% to 77% of endodontists’. Also, the
average fee charged by endodontists for an anterior root canal was close to the average
fee charged by general practitioners for a molar.
Table 23: SDF Data, Average Fees for Endodontic Procedures, 1999
General
Practitioner-toEndodontist
General
Root
Fee Ratio
Endodontists
Practitioners
Canals
0.71
$516.43
Anterior
$368.03
0.73
Bicuspid
$441.98
$603.71
0.77
Molar
$549.26
$716.99
Total
$465.81
$670.56
0.69
Source: American Dental Association, Survey Center, 1999 Survey of Dental Fees.
Table 24: Electronic Claims Database, Average Fees for Root Canals, 2001
General
Practitioner-toEndodontist
General
Root
Fee Ratio
Endodontists
Practitioners
Canals
0.66
$593.99
$394.83
Anterior
0.71
$484.24
$681.95
Bicuspid
0.74
Molar
$607.21
$812.17
Total
$522.26
$761.43
0.69
43
Endodontists also charged, on average, higher fees for the other procedures they
commonly performed. For one procedure, periapical radiographs (first film), the average
fee was almost the same. For the other procedures, endodontists’ average fee was
substantially higher most noticeable for direct pulp caps. General practitioners’ average
fee of $41.74 was only 38% of endodontists’ average fee of $108.60.
Table 25: Average Fees for Other Procedures, 1999
Procedure
Periapical radiographsfirst film
Direct pulp cap
Indirect pulp cap
Pulpotomy
Apicoectomy
General
Practitioners
Endodontists
General
Practitionerto-Endodontist
Fee Ratio
$ 14.36
$ 33.22
$ 41.74
$ 40.99
$ 92.42
$324.87
$ 14.81
$ 55.03
$108.60
$ 90.61
$153.23
$571.84
0.97
0.60
0.38
0.45
0.60
0.57
Source: American Dental Association, Survey Center, 1999 Survey of Dental Fees.
In the electronic claims database, the average fee for an endodontic procedure when all
endodontic procedures were grouped together was $638.84. (See Table 26.) The
average fee among endodontists was considerably higher than among general
practitioners, $724.55 compared to only $317.71.
Table 26: Selected Fee Statistics for All Endodontic Procedures, 2001
General practitioners
Summary Statistics
Number of
Procedures
Total
Performed
Charges
490,980 $155,987,903
Measures of Central Tendency
Average
Fee per
Standard
procedure
Deviation
Median
$317.71
$253.10 $334.00
Endodontists
91,972
$66,638,257
$724.55
$207.67
$750.00
All dentists
699,473
$297,063,812
$638.83
$273.97
$700.00
While the average fee for an endodontic procedure is very different between endodontists
and general practitioners, it is easy to misunderstand the magnitude of the difference. On
the surface, it appears that the average fee for an endodontic procedure by an endodontist
is 2.3 times greater than the corresponding fee for a general practitioner. However, the
difference between these two groups can be simply explained by the presence of
pulpotomies and pulp caps.
Together pulpotomies and pulp caps account for nearly one-fourth of the endodontic
procedures completed; they are among the least expensive endodontic procedures
performed; and they are rarely performed by endodontists. General practitioners perform
almost all pulpotomies and pulp caps. This procedure accounts for a substantial
44
percentage of the endodontic procedures completed by general practitioners, but because
of it’s low average fee contributes only a minimal account to the total charges of general
practitioners. The large number of low fee pulpotomies and pulp caps has the effect,
statistically, of reducing general practitioners’ average fee for endodontic services.
In comparison, endodontists do not have any low cost, high volume procedures to reduce
their average fee. Accordingly, a comparison based on the average fee for endodontic
services by the two types of dentists is misleading in that it overstates the extent of the
differences between them.
Table 27 compares the average fee for an endodontist procedure by general practitioners
and endodontists not including pulp caps and pulpotomies. The net effect of removing
these low cost, high volume procedures was to greatly increase the average fee among
general practitioners, while holding the endodontist average fee constant. Endodontists
still have a higher average fee, but it is not as great as in Table 27. The difference
between the two types of dentists can be attributed to the large number of high-fee molar
root canals performed by endodontists.
Table 27: Selected Fee Statistics for All Endodontic Procedures Excluding
Pulpotomy and Pulp Capping, 2001
Median
Standard
Deviation
Measures of Central Tendency
Average
Fee per
Procedure
Total
Charges
Number of
Procedures
Performed
Summary Statistics
General
practitioners
287,200
$142,501,633
$496.18
$177.99
$500.00
Endodontists
91,623
$66,580,163
$726.68
$205.13
$750.00
All dentists
484,806
$282,787,043
$695.44
$216.55
$725.00
The preceding discussion demonstrates that a simple comparison of average fees of
endodontist and general practitioners for all endodontic services as defined by the Current
Dental Terminology (CDT) codes is misleading. This type of simple comparison will make
it more difficult for endodontists to justify their fee schedules or other fee negotiations with
payers because the difference is too large to be justified as due to the clinical complexity
posed by the patients.
A more meaningful approach to the comparison of fees between endodontists and general
practitioners is to consider fees for only the set of procedures that the two both perform.
Table 28 presents average fees for the 16 procedures that comprised 95% of the total fees
charged by endodontists and the corresponding average fees for general practitioners
from the electronic claims database.
45
In the electronic claims database, the average fee (weighted by the number of procedures)
for all 16 of the procedures performed by endodontists was ten times that of general
practitioners ($381.03 and $38.83, respectively). This difference reflected the fact that
endodontists performed a much greater volume of more expensive procedures compared
to general practitioners.
Root canals were the three most frequently performed procedures among both providers.
All three types of canals were more expensive when performed by endodontists. The
difference varied with the type of root canal provided. The average fee for anterior root
canals was 50% higher when provided by endodontists. Similarly, the average bicuspid
fee was 41% higher, while the average molar fee was 34% higher.
For the remaining 13 procedures, endodontists’ fees were higher for 12 procedures and
were less for one procedure. The exception was found in pulp vitality tests where
endodontists’ average fee was $26.80 as compared to $30.07 for general practitioners.
Endodontists’ average fee for all 13 procedures combined was 2.7 times that of general
practitioners’ fee ($83.49 versus $30.71 for general practitioners).
While on average endodontists charge more than general practitioners, the difference in
individual fees was not large. The difference in the simple average fee for all 16
procedures was only $63.94. Differences for individual fees ranged from 11% less for pulp
vitality tests (D0460) to 34% more than the amount charged by general practitioners for
molar root canals (D3330). In general, endodontists’ fees were one-third more (36%) per
procedure than were general practitioners’.
46
Table 28: Selected Summary Fees Among Endodontists and General Practitioners,
by CDT Procedures Which Accounted for 95% of Endodontist Fees, 2001
Fees for
Endodontists
Average
Fee
Per
Procedure
Average
Difference
Fee Per
Procedure
Between
Providers
Fees for
General
Practitioners
Average
Fee
Per
Procedure
CDT Procedure Codes
and Descriptions
Total
Charges
D3330 Molar (excl. final restoration)
$43,309,122
$812.17
$76,788,346
$607.21
$204.96
D3320 Bicuspid (excl. final restoration)
$10,508,834
$681.95
$34,284,290
$484.24
$197.71
D3310 Anterior (excl. final restoration)
$5,253,800
$593.99
$24,945,553
$394.83
$199.15
D3348 Retreatment of previous root canal
therapy - molar
$3,182,321
$876.19
$1,375,840
$681.11
$195.08
D0140 Limited oral eval.
$1,916,268
$57.75
$27,213,680
$40.20
$17.56
D9310 Consultation (dx. serv. by
dentist/physician not p
$823,424
$73.52
$2,417,840
$64.20
$9.32
D2954 Prefab. post and core in addition to crown
$691,236
$211.97
$18,984,462
$197.96
$14.01
D0220 Intraoral - periapical 1st film
$494,222
$18.63
$30,908,292
$15.94
$2.70
D3430 Retrograde filling - per root
$319,942
$132.48
$301,380
$106.87
$25.61
D9110 Palliative (emergency) treatment of dental
pain
$255,465
$145.07
$9,533,837
$61.52
$83.54
D0120 Periodic oral eval.
$122,677
$59.99
$248,116,387
$28.75
$31.24
D2140 Amalgam - 1 surface, permanent
$114,058
$76.81
$47,946,391
$68.78
$8.02
D0460 Pulp vitality tests
$106,120
$26.80
$399,910
$30.07
$-3.26
D0150 Comprehensive oral eval.
$98,282
$60.82
$65,369,856
$42.31
$18.50
D0230 Intraoral - periapical each addl. film
$90,408
$13.66
$16,665,889
$11.33
$2.32
D9230 Analgesia, anxiolysis, inhalation of nitrous
oxide
$67,753
$45.38
$6,495,632
$28.76
$16.62
47
Total
Charges
Difference
National Expenditures for Root Canals
As general practitioners perform more root canals than do endodontists, they also receive
a greater share of the annual expenditures than do endodontists, $5.5 billion compared to
$2.8 billion. But their share of the national expenditure is not in proportion to the number
of root canals they completed. General practitioners do 74.0% of the procedures, but
receive only 66.4% of the national expenditure. Endodontists earned a greater share of
the national expenditures because of their higher fees for all three root canal procedures
and the large number of molar root canals they completed.
Table 29: Estimated National Expenditures on Root Canal Therapy 1999
Root
Canals
Anterior
Bicuspid
Molar
General
Practitioners
$1,220,976,328
$1,547,637,168
$2,684,508,250
Endodontists
$ 226,196,340
$ 548,470,535
$1,980,254,681
Total
Expenditures
$1,447,172,668
$2,096,107,701
$4,664,762,931
Total
$5,453,121,746
$2,754,921,556
$8,208,043,302
Source: American Dental Association, Survey Center, 1999 Survey of
Dental Services Rendered and 1999 Survey of Dental Fees.
48
BUSINESS ASPECTS OF ENDODONTIC PRACTICE
Net Income
Twice thus far, the ADA’s Survey of Dental Practice (SDP) was extended and geared to
gather information on all specialties rather than specialists as a group—once in 1992 and
again in 1997/1998. Using data from these two special editions of SDP, it is clear that
endodontists’ finances are quite unique. As shown in Figure 8, they had the second
highest average net income in both 1992 and 1997/1998 surpassed only by oral and
maxillofacial surgeons.
Figure 8: Average Net Income of Specialists, 1990 and 1997/1998
$800,000
1997/1998
1992
$600,000
$400,000
$238,150
$230,050
$223,730
$219,910
$165,640
$200,000
$171,840
$171,570
$153,240
$145,020
$138,580
$165,790
$119,570
$133,430
$98,140
$0
Oral and
Maxillofacial
Surgeons
Endodontists
Orthodontic
and
Dentofacial
Orthopedists
Pediatric
Dentists
Periodontists Prostodontists
Source: American Dental Association, Survey Center, 1993 Survey of Dental Practice:
Specialists in Private Practice and 1998/1999 Survey of Dental Practice.
49
General
Practitioners
Gross Billings per Owner
Endodontists had the second lowest average gross billings per owner among specialists.
As shown in Figure 9, in 1992, only prosthodontists had lower average gross billings per
owner. In 1997/1998, only periodontists had lower average gross billings per owner.
Figure 9: Average Gross Billings per Owner, 1992 and 1997/1998
$800,000
1997/1998
1992
$618,590
$614,410
$572,100
$600,000
$512,800
$491,550
$400,000
$461,850
$454,070
$425,070
$432,820
$374,330
$395,310
$386,740
$367,730
$270,760
$200,000
$0
Oral and
Maxillofacial
Surgeons
Endodontists
Orthodontic
and
Dentofacial
Orthopedists
Pediatric
Dentists
General
Practitioners
50
Practice Expenses per Owner
Endodontists had a high average net income despite having low gross billings per owner
because they had very low average practice expenses per owner. Actually, endodontists
have the lowest practice expenses per owner of all dentists—including general
practitioners. Among specialists, periodontists, who had the second lowest average
practice expenses per owner in 1997/1998, had an average practice expenses per owner
that was $30,010 higher than that of endodontists. See Figure 10.
Figure 10: Average Practice Expenses per Owner, 1992 and 1997/1998
$800,000
1997/1998
1992
$600,000
$368,040
$400,000
$305,940
$309,210
$299,960
$267,330
$237,320
$200,000
$230,760
$222,870
$222,580
$179,230
$217,470
$255,070
$213,290
$182,030
$0
Oral and
Maxillofacial
Surgeons
Endodontists
Orthodontic
and
Dentofacial
Orthopedists
Pediatric
Dentists
General
Practitioners
Endodontists’ low practice expenses came from the limited amount of equipment and
supplies their practices required along with low staffing costs. On average, an endodontist
in 1997 employed 5.6 non-dentist staff members of whom 3.2 were chairside assistants,
1.8 were secretaries/receptionists, 0.5 were bookkeepers/business personnel, and 0.2
were sterilization assistants. Only prosthodontists employed fewer non-dentist staff.
51
Endodontists were able to control their practice expenses during the 1990s. Their
expenses represented only 48.3% of their gross billings in 1992. By 1997, that percentage
was nearly identical, 47.9%. In contrast, expenditures as a percent of gross billings
increased for general practitioners and orthodontists over that period while pediatric
dentists were able to substantially reduce their expense ratio. See Figure 11.
Figure 11: Practice Expenses as a Percent of Gross Billings, 1992 and 1997/1998
100%
1997/98
60.0%
58.0%
60.3%
56.2%
57.9%
51.4%
59.5%
58.4%
52.4%
47.9%
48.3%
49.1%
60%
49.8%
80%
67.2%
1992
40%
20%
0%
Oral and
Maxillofacial
Surgeons
Endodontists
Orthodontic and
Dentofacial
Orthopedists
Pediatric Dentists
Periodontists
Prostodontists
General
Practitioners
Practice Characteristics of Endodontists
Time in Practice
Endodontists in private practice reported spending an average (and median) of 36 hours
per week in their practices. About 16% reported spending less than 30 hours per week in
the practice while 17% reported spending more than 45 hours week in the practice. Figure
12 shows the percentage distribution of private practicing endodontists by number of hours
per week spent in the practice.
52
Figure 12: Percentage Distribution of Endodontists,
by Hours per Week Spent in the Practice and Gender, 1999
30%
28.3%
Female
25.4%
25%
Male
23.0%
20%
15%
24.4%
18.7%
18.6%
17.7%
17.2%
14.4%
12.4%
10%
5%
0%
< 30
30-34
35-39
40-44
45+
Hours per Week
Source: American Association of Endodontists, 2001 Workforce Assessment Committee, 1999 Survey of
Endodontists and Endodontic Practices: A Statistical Report of Results.
As illustrated in Figure 12, the time spent in the practice tends to vary according to gender.
The percentage of endodontists spending less than 30 hours per week was 14.4% for
males compared to 28.3% for females. The largest percent of male endodontists (50%)
spend 35 to 44 hours in the practice compared to about 31% of females. Overall, female
endodontists spent an average of 33.5 hours in the practice compared to 36.3 hours for
male endodontists. While the average hours per week differ by only 2.8 hours by gender,
the distribution of time spent in the practice is quite different by gender.
Age is also a factor in the amount of time spent in practice. The average age of an
endodontist is 47.3 years. The average age for females is 43.1 years and for males, 48.1
years. Most female endodontists (82%) are under the age of 50 compared to 54% of male
endodontists.
53
Figure 13: Average Hours Endodontists Spent in the Practice,
by Age Group and Gender, 1999
45
Female
40
35
39.3
38.0
34.7
36.0
32.4
33.9
38.0
36.0
35.6
30
Hours
Male
28.1
25
20
15
10
5
0
<35
35-39
40-44
45-49
50+
Age Group
For endodontists under the age of 35, the average number of hours spent in the practice is
similar by gender (35 hours for females and 36 hours for males). For the older age
groups, the differences are greater with the average number of hours for males being
higher than that of females (see Figure 13). There are few female endodontists over the
age of 50 years, which partially accounts for the relatively large difference in average
hours among the oldest age group. The average number of hours reaches a maximum in
the 40-44 age group for males and in the 45-49 age group for females.
The patient volume that can be treated by an endodontist depends on the complexity of
the procedure and the amount of time available for treating patients. While total hours in
the practice involve activities other than treatment time, Figure 14 shows the average
amount of time spent by volume of patient visits and gender. The overall average number
of patient visits was 45.9 per week. This average was 46.1 visits per week among male
endodontists and 40.9 visits per week among female endodontists.
54
Figure 14: Average Hours Endodontists Spent in the Practice,
by Number of Patient Visits per Week and Gender, 1999
50
Female
45
43.1
Male
40
34.3
35
Hours
40.2
38.0
38.2 38.7
60-69
70+
32.2
29.7
30
23.5
25
20
36.3
39.7
39.1 38.3
20.1
15
10
5
0
<20
20-29
30-39
40-49
50-59
Number of Patient Visits
As shown in Figure 14, hours in the practice tend to increase with the volume of patient
visits. The average hours of female endodontists peaked at 43.1 hours with 50-59 patient
visits, while the average hours of males reached a high of 40.2 hours with 60-69 patient
visits.
Time Treating Patients
The largest percentage of practice hours was spent treating patients. Treatment time is
the pertinent measure of the production of endodontic services. In 1999, endodontists
spent an average of about 32 hours per week treating patients. Female endodontists
averaged about 29.6 hours of treatment time per week while males averaged 32.7 hours
per week. Figure 15 shows the distribution of endodontists by treatment time and by
gender. Overall, about 24% of endodontists spent less than 30 hours per week treating
patients. Broken down by gender, this percentage is 22.1% for male endodontists and
38.9% for females.
55
Figure 15: Percentage Distribution of Endodontists,
by Treatment Hours per Week and Gender, 1999
45%
Female
40%
38.9%
Male
35%
31.9% 32.3%
30%
25%
26.8%
22.1%
20%
15.0%
15%
12.7%
10%
8.0%
6.2% 6.1%
5%
0%
< 30
30-34
35-39
40-44
45+
Treatment Hours per Week
The average number of treatment hours per week by age and by gender is depicted in
Figure 16. Overall, average treatment hours per week were greater for males compared
to females in each age group. For females, the average treatment hours per week was
approximately 30 hours up to age 50 and then declined to 26.4 hours. For males, the
average treatment hours was 34.5 hours per week up to age 50 and then declined to 30.7
hours per week. See Figure 16.
56
Figure 16: Average Treatment Hours Among Endodontists,
by Age Group and Gender, 1999
40
Female
30
30.1
35.2
34.6
34.2
35
Male
33.4
31.5
29.6
30.7
29.6
26.4
Hours
25
20
15
10
5
0
<35
35-39
40-44
45-49
50+
Age Group
Average treatment hours per week are shown in Figure 17 for various levels of patient
visits. Over the range of patient visits, the average treatment hours tend to generally
increase for both male and female endodontists and the average treatment times are
generally similar. The largest differences in average treatment times between male and
female practitioners occurred for patient visits of “less than 20 visits” (male hours greater
by 2.6 hours), “30-39 visits” (male hours greater by 2.5 hours), and “60-69 visits” (male
greater by 3.5 hours). In general, increases in patient visits per week are associated with
increases in treatment hours per week.
57
Figure 17: Average Treatment Hours Among Endodontists,
by Number of Patient visits per Week and Gender, 1999
40
Female
35
Male
32.7
35.0 34.5
36.5 36.2
36.4
35.7 35.9
32.9
30.3
30
27.3
28.5
Hours
25
20
20.1
17.6
15
10
5
0
<20
20-29
30-39
40-49
50-59
60-69
70+
Number of Patient Visits
Time by Patient Visits and Endodontic Procedures
Provider time per unit of output is one measure of the endodontists’ input into the
production of endodontic services. Other inputs include assistant time, capital inputs such
as operatories and chairs, and supplies. One measure of the endodontist input into
production is treatment time per patient visit. This measure of provider input is relatively
easy to measure as endodontist time and visits are readily available measures. The
amount of provider time spent per patient visit does not, however, take account of the
variation in time used to provide various endodontic services that constitute a patient visit.
Figure 18 shows the percentage distribution of endodontists by the number of minutes per
patient visit. Most of the endodontists reported times that did not exceed 70 minutes per
visit. About 61% of females reported less than one hour per visit compared to 68% of
males. Alternatively, about 21% of females reported more than one hour per visit
compared to 15.6% of males.
58
Figure 18: Percent of Endodontists, by Amount of
Time
e (in Minutes) Spent per Patient Visit and Gender, 1999
26.6%
30%
Female
Male
10.1%
5.6%
6.4%
2.8%
5%
7.5%
15.8%
18.4%
4.6%
10.1%
10%
11.0%
15%
14.6%
16.5%
17.1%
16.5%
20%
16.5%
25%
0%
<30
30-39
40-49
50-59
60-69
70-79
80-89
90+
Minutes per Patient Visit
The overall average amount of time per visit was 61 minutes among endodontists—this
translates to 60.3 minutes for female endodontists and 61.4 minutes for male
endodontists. As shown in Figure 19, the largest number of minutes per visit occurs for
both female and male endodontists in the youngest age group of less than 35 years old
(93.7 minutes per visit for females and 112.5 minutes per visit for males). For all age
groups older than 35 years, the average number of minutes per visit was less than one
hour.
59
Figure 19: Average Amount of Time (in Minutes) Spent per
Patient Visit, by Age Group and Gender, 1999
120
100
112.5
Female
Male
93.7
Minutes
80
60
51.9
55.8
60.0
57.6
51.3
52.3 51.3
49.8
40
20
0
<35
35-39
40-44
45-49
50+
Age Group
While the number of minutes per visit is easily measured, it has a major limitation. It does
not provide information regarding the mix of procedures that can occur within a visit nor
the variation in the amount of time to provide different procedures. A more accurate
assessment of productive efficiency can be obtained by with time per procedure.
Table 30 contains estimates of the average number of minutes per procedure by
endodontists in private practice. These are based on data collected from a sample of
private practicing endodontists in the U.S. The sample of endodontists was asked to
complete an endodontic patient encounter form in which the endodontist recorded
information about the patient, the procedures rendered, and the amount of time spent by
the endodontist, hygienist, and assistant for each procedure rendered.
60
The data in Table 30 are estimates of the average number of minutes spent by the
endodontist for each procedure. The average times are ranked and displayed from the
highest to the lowest. The procedures which averaged the highest time spent by the
endodontist consisted primarily of the core endodontic procedures, while those procedures
with the lowest times were predominantly adjunctive procedures. The results shown in
Table 30 for the 66 procedures indicate the following:
Two procedures (molar root canal retreatment and bicuspid root-end
resection) averaged more than 50 minutes of endodontist time.
Eight procedures averaged more than 40 minutes of endodontist time.
Twenty procedures including 16 core endodontic procedures, required
more than an average of 20 minutes of endodontist time.
Forty-six procedures including 7 core endodontic procedures required less
than 20 minutes of endodontist time.
The five procedures for which average endodontist times ranged from 47.8
minutes to 52.7 minutes were (in order from lowest to highest time): molar
root canal, anterior root-end resection, cast post-core added to crown,
bicuspid root-end resection, and molar root canal retreatment.
Sixteen procedures (only one was a core endodontic procedure—surgical
isolation for tooth with rubber dam) required less than 5 minutes of
endodontist time (3 of the procedures required zero time).
61
Table 30: Average Time Spent by Endodontists per Procedure (in Minutes), 1999
Code Procedure
Min
Code Procedure
Min
3348
3421
2952
3410
3330
3346
3347
3425
3320
3310
3920
3450
3426
3352
3220
3399
9430
9110
2955
3430
2161
7270
3351
7110
4263
2940
3999
2950
3353
9310
3110
7510
9230
52.7
51.1
50.0
48.5
47.8
43.2
43.2
41.8
37.6
34.6
32.5
31.5
29.2
27.9
27.3
26.9
26.5
25.7
25.4
22.8
20.0
20.0
19.3
16.8
16.8
16.3
15.1
14.3
14.0
12.2
11.0
10.8
10.8
9952
3950
130
3960
110
4249
140
2330
2385
9210
2140
9951
119
7285
2110
7286
9610
9215
3910
415
470
460
250
471
999
230
240
399
220
270
330
2970
9630
10.8
10.4
9.8
9.8
9.1
8.7
8.6
7.5
7.0
7.0
6.9
6.4
6.4
5.7
5.0
5.0
5.0
4.7
4.7
4.2
4.1
3.6
2.1
1.9
1.8
1.6
1.4
0.7
0.7
0.3
0.0
0.0
0.0
Root canal treatment, molar ret
Bicuspid root-end resection/peri
Cast post-core added to crown
Anterior root-end resection/peri
Root canal treatment, molar
Root canal treatment, anterior ret
Root canal treatment, bicuspid ret
Molar root-end resection/peri
Root canal treatment, bicuspid
Root canal treatment, anterior
Hemisection
Root resection-per root
Root-end resection/periradicular
Apexification/recalcification interim
Pulpotomy
Perforation repair,surgical-nonsurg
Office visit for observation
Palliative (emergency) treatment
Post removal (noendo therapy)
Root-end filling-per root
Amalgam-four or more surfaces
Tooth replantation (avulsed tooth)
Apexification/recalcification initial
Extraction
Bone replacement graft
Sedative filling
Unspecified endodontic procedure
Core buildup, including any pins
Apexification/recalcification final
Consultation
Pulp cap
Incision-drainage of abscess
Analgesia
Occlusal adjustment-complete
Canal prep,fitting of dowel or post
Emergency oral exam
Bleaching of discolored teeth
Initial oral exam
Crown lengthening
Limited oral evalution
Resin-one surface, anterior
Resin-one surface, posterior
Local anesthesia no operative
Amalgam-one surface, perm
Occlusal adjustment-limited
Recall examination
Biopsy of oral tissue, hard
Amalgam-one surface, primary
Biopsy of oral tissue, soft
Therapeutic drug
Local anesthesia
Surgical isolation for tooth
Bacteriological studies
Diagnostic tests
Pulp vitality tests
Extraoral-1st film/image
Diagnostic photographs
Other tests and lab
Intraoral periapical
Intraoral occlusal film or image
Other radiographic procedure
Intraoral periapical-1st
Bitewings-single film/image
Panoramic film/image
Temporary crown, fractured tooth
Other drugs and/or medicaments
Source: American Association of Endodontists, 2001 Workforce Assessment Committee, 1999
Survey of Endodontists and Endodontic Practices: A Statistical Report of Results.
62
Table 31 contains the average minutes per procedure by the chairside assistant that was
supporting the endodontist at the time the procedure was being provided. The results in
Table 31 indicate that chairside assistants work in support of endodontists as most of the
procedures on which chairside assistants spent the largest amount of time were the core
endodontic services.
Table 31: Average Time Spent by Chairside Assistants
per Procedure (in Minutes), 1999
Code Procedure
Min
Code Procedure
2952
3410
3421
3348
3330
3425
3346
3920
3450
3320
3347
3310
3220
9110
9430
3426
2940
3430
2161
7270
3353
3351
7110
4263
2955
3999
3352
2950
7510
2385
3110
3950
3399
50.0
48.9
46.5
45.3
41.6
40.4
36.6
35.0
34.9
32.8
32.3
30.5
29.2
28.7
28.3
25.9
21.3
20.9
20.0
20.0
18.8
17.7
17.3
16.8
15.4
14.6
13.7
12.6
11.9
11.8
11.0
10.7
10.2
2110
3960
2140
4249
130
9210
9310
110
7286
240
119
330
9630
140
999
230
9230
220
399
2970
9951
460
470
9952
2330
471
270
250
3910
7285
415
9610
9215
Hemisection
Pulpotomy
Sedative filling
Extraction
Pulp cap
10.0
8.9
8.2
Crown lengthening
7.9
Emergency oral exam
7.1
7.0
Consultation
6.9
Initial oral exam
6.6
6.6
6.5
Recall examination
5.5
5.3
Other drugs and/or medicaments 5.0
4.7
Other tests and lab
4.3
4.1
Analgesia
3.2
3.1
3.0
Temporary crown, fractured tooth 3.0
2.7
Pulp vitality tests
2.6
Diagnostic tests
2.5
2.5
2.5
2.5
2.4
2.2
1.5
0.7
0.5
Therapeutic drug
0.0
Local anesthesia
0.0
63
Min
Together the endodontist time and the time of the chairside assistant make up the total
direct time input into the production of endodontic services. In order to examine those
procedures that require relatively more or less endodontist time, the data presented in
Table 32 contains the ratio of endodontist time to chairside assistant time. The
procedures at the beginning of the table are those in which endodontists provided most of
the input with minimal help from chairside assistants. Those at the end of Table 32 reflect
procedures in which most of the input came from chairside assistants.
The upper left side of Table 32 indicates those procedures for which the endodontist
provides services alone and the lower right side of Table 32 indicates those procedures in
which the endodontist spends little time. For example, the lower right side of Table 32
reflects procedures such as radiographs in which most time input comes from the
chairside assistant while the upper left side of Table 32 reflects procedures where the time
input comes primarily from the endodontist (e.g., bacteriological studies, biopsy).
Most of procedures (68%) reflect a relative endodontist input time that ranges between 0.5
and 1.5. An input ratio of 1.5 means that the endodontist time is 1.5 times greater than the
chairside assistant time while an input ratio of 0.5 means the endodontist time is half the
chairside assistant time. About one-third of the procedures reflect endodontist and
chairside assistant input times that are primarily equal ranging between 0.9 and 1.1. While
endodontist and chairside assistant input times vary across procedures, it is apparent that
for most procedures, the chairside assistant works in support of the endodontist and has
similar procedure input times.
64
Table 32: Ratio of Average Endodontist Time to Chairside Assistant
Time (in Minutes), per Procedure, 1999
Code Procedure
7285
415
9952
9230
3910
2330
3399
9951
3352
140
9310
2955
470
460
130
110
3347
3346
119
3348
3330
3320
2950
3310
3426
4249
3421
3960
3351
3430
3999
3425
Analgesia
Consultation
Diagnostic tests
Pulp vitality tests
Emergency oral exam
Initial oral exam
Recall examination
Crown lengthening
Ratio
Code
Procedure
8.5
8.3
4.3
3.4
3.1
3.0
2.6
2.4
2.0
1.8
1.8
1.6
1.6
1.4
1.4
1.4
1.3
1.2
1.2
1.2
1.2
1.1
1.1
1.1
1.1
1.1
1.1
1.1
1.1
1.1
1.0
1.0
2161
2952
3110
4263
7270
9210
3410
7110
3950
250
9430
3220
3920
7510
3450
9110
2140
2940
471
7286
3353
2385
2110
999
230
399
220
240
270
330
2970
9630
Pulp cap
Extraction
Pulpotomy
Hemisection
Sedative filling
Other tests and lab
Temporary crown, fractured tooth
Other drugs and/or medicaments
65
Ratio
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
0.9
0.9
0.9
0.9
0.9
0.9
0.8
0.8
0.8
0.8
0.7
0.6
0.5
0.4
0.4
0.2
0.2
0.2
0.1
0.0
0.0
0.0
ENDODONTIC WORKFORCE
While demand-side forces drive the market for endodontic services, to be complete, one
should factor in the supply-side of the equation. This requires an evaluation of the
adequacy of the number and types of dental workforce personnel, as well as their
productivity and work patterns. Since both general practitioners and endodontists provide
endodontic services, the number, busyness, and referral patterns of general practitioners
to endodontists are critically important to the economic milieu that endodontists will
experience.
Number of Endodontists
In 2000, the number of professionally active endodontists was 3,816 (see Figure 20). Of
these, 3,408 were active private practitioners. Professionally active dentists are those
whose primary and/or secondary occupation is one of the following: private practice (full- or
part-time), dental school faculty/staff member, armed forces, other federal service, state or
local government employee, hospital staff dentist, graduate student/intern/resident, or other
health/dental organization staff member. Active private practitioners are those whose
primary and/or secondary occupation is private practice, full- or part-time.
66
Figure 20: Number of Professionally Active and Private Practice
Endodontists in the Unites States, 1982-2000
4,500
Professionally Active Dentists
4,000
1991
3,816
3,408
3,725
3,323
3,605
3,210
1994
3,401
2,994
1993
3,303
2,902
1987
3,204
2,810
1,500
2,566
2,000
2,214
1,853
2,500
2,551
2,188
2,992
3,000
3,102
2,730
3,500
3,496
3,082
Active Private Practitioners
1,000
500
0
1982
1995
1996
1997
1998
1999
2000
Source: American Dental Association, Survey Center, 1982-2000 Distribution of Dentists
in the United States by Region and State.
As shown in Figure 20, both the numbers of endodontists who were professionally active
and active private practitioners have been growing over time. Between 1982 and 2000,
the number of professionally active endodontists increased from 2,214 to 3,816, and the
number of endodontists in private practice increased from 1,853 to 3,408. Thus, the
proportion of active private practicing endodontists has increased from 83.7% in 1982 to
89.3% in 2000. See Figure 21.
67
Figure 21: Percent of Endodontists in Private Practice, 1982-2000
90%
89.3%
89.0% 89.2%
88%
88.0% 88.2%
87.7% 87.9%
1993
1994
85.8% 85.8%
86%
84%
88.0%
83.7%
82%
80%
1982
1987
1991
1995
1996
1997
1998
1999
2000
The age and gender distribution of professionally active endodontists has been changing
in a pattern similar to the changes experienced by the overall dental workforce. In recent
years, females have been entering the field of endodontics, whereas before the 1980s
females seldom became dentists or endodontists. As a consequence, few females are
found in the older age groups of this specialty. In contrast, females are becoming more
prevalent among endodontists less than 50 years of age. See
Figure 22.
The number of male endodontists 50 years old or older increased between 1993 and
2000, but the number of male endodontists under 50 years old decreased during the same
time period. As baby-boomer endodontists leave practice over the next 10 to 15 years,
the number of endodontists leaving practice could be larger than the number entering for
some of those years. However, even if the number leaving should be larger than the
number entering, the shortfall will not be large. Therefore, the endodontic workforce is
likely to grow slowly while the baby-boomers exit, but will grow more rapidly after that
transition is complete. However, attempts to keep new entrants to the specialty at the
same level as retirees during the period would necessitate an increase in the size of the
endodontic training programs. More will be said about the long-run steady-state number
of endodontists implied by an increase in class size later in the paper.
68
Figure 22: Number of Professionally Active Endodontists by
Age and Gender, 1993 and 2000
1,400
1,150
1,146
1,200
994
1,000
1993
2000
642
636
709
800
600
389
400
30-39
40-49
50-59
60-69
Age Group: Male
1
0
< 30
3
2
40-49
0
42
10
30-39
77
23
27
< 30
192
89
50
77
91
70+
196
155
191
200
50-59
60-69
70+
Age Group: Female
Endodontics is emerging from a primarily academic discipline, which it was in its early
days, to a true community-based specialty similar to oral surgery and orthodontics. This
trend is likely to continue. The current level of graduates from endodontic programs will
ensure a continued growth in the number of endodontists in private practice because
dental schools will not be able to accommodate more endodontists as faculty members
due to the budgetary crises confronting most schools.
Historically endodontics has been one of the smaller community-based specialties. As of
2000, endodontists were the fifth largest of the nine specialty groupings. See Figure 23.
However, as shown in Figure 24, the growth rate for endodontists was a much faster
growth rate than any of the other specialties. The number of endodontists increased by
84% between 1982 and 2000.
69
Figure 23: Number of Dentists in Specialty Areas, 2000
12,000
38
10
390
175
Oral and
Maxillofacial
Pathology
Prosthodontics
Endodontics
Pediatric
Dentistry
Periodontics
Oral and
Maxillofacial
Surgery
Orthodontics
and Dentofacial
Orthopedics
0
Oral and
Maxillofacial
Radiology
1,120
314
2,000
Public Health
Dentistry
3,224
2,501
4,258
3,816
3,408
4,000
3,697
6,000
4,937
6,440
8,000
4,317
Active Private Practitioners
5,542
10,000
9,294
8,659
Professionally Active Dentists
Source: American Dental Association, Survey Center, 2000 Distribution of Dentists
Figure 24: Growth in the Number of Private Practitioners by Specialty, 1982-2000
2.0
General Practice
Oral Surgery
1.84
Endodontics
1.8
Orthodontics
Pediatric Dentistry
Periodontics
1.6
1.60
Prosthodontics
1.47
1.4
1.33
1.27
1.25
1.2
1.16
1.0
0.8
1982
1987
1991
1993
1994
1995
1996
1997
1998
1999
2000
70
Thus, the relative size of endodontics compared to the other dental specialties is
increasing and will continue to increase as long the dental specialties maintain their
current growth patterns. In 1982, endodontists accounted for 1.6% of all private practice
dentists. In 2000, they accounted for 2.2%. See Table 33.
Table 33: Endodontists as a Percentage of Active Private Practitioners
Type of Dentist
1982
2000
Percent Change
80.3%
81.3%
+ 1.0%
Oral and Maxillofacial Surgeons
3.7%
3.6%
- 0.1%
Endodontists
1.6%
2.2%
+ 0.6%
Orthodontic and Dentofacial
6.4%
5.7%
- 0.7%
Orthopedists
Pediatric Dentists
2.2%
2.4%
+ 0.2%
Periodontists
2.3%
2.8%
+ 0.5%
Prosthodontists
1.7%
1.6%
- 0.1%
Source: American Dental Association, Survey Center, 1982 and 2000 Distribution of Dentists
Fueling this rapid growth is the increase in the number of graduates from endodontic
training programs. As displayed in Figure 25, endodontic class size has increased from
101 graduates in 1974 to 188 in 2001. Those endodontists who graduated in the 1970s
will be retiring in the 10 to 15 years. However, it will be considerably longer before the
number of endodontists stabilizes if the number of graduates remains constant at the 2001
level.
71
179
179
2000
1996
1999
162
1994
1995
164
159
158
157
1993
162
140
135
135
119
135
123
132
1986
127
1985
139
1982
145
142
1980
1981
130
1977
100
109
120
121
146
144
1976
140
101
Number of Graduates
160
160
180
1992
176
200
188
Figure
gure 25: Graduates from Endodontic Training Programs, 1974-2001
80
60
40
2001
1998
1997
1991
1990
1989
1988
1987
1984
1983
1979
1978
1975
0
1974
20
Source: American Dental Association, Survey Center, Surveys of Predoctoral
Dental Education (Various Years).
As an example, assuming that the average graduate from an endodontic training program
is 30 years old and will retire at the age of 65 years, he/she will have a practice career of
35 years. In 35 years, those endodontists who graduated in 2000 or later will comprise
most of the practicing endodontists. Further assuming that the number of endodontist
graduates remains constant at 188 (the 2001 class size), 188 graduates per year over 35
years will result in 6,580 endodontists in the year 2,035. This will be an increase of 72.4%
over the 3,816 professionally active endodontists in 2000. This would be a “steady-state”
number—i.e., the number of endodontists would stabilize, neither growing nor shrinking,
unless the graduation size or the retirement age changed. If endodontists should be older
than 65 at retirement, the steady-state number of endodontists would increase and vice
versa for a younger retirement age. Similar impacts would result if graduates should be
younger (an increase in the steady-state number) or older (a decrease in the steady-state
number) when they graduate.
The U.S. population was approximately 281 million in 2000. The population per
endodontist in 2000 was 82,453. The U.S. population is projected to be around 340
million in 2035. At the previously calculated, steady-state level of 6,580 professionally
active endodontists, the population-to-endodontist ratio in 2035 is estimated to decline by
72
34% to 54,270. Thus, the average endodontist in 2035 will have a smaller population
base to care for than endodontists in 2000.
Number of Endodontists Relative to the Number of General
Practitioners
In 1982, the ratio of general practitioners to endodontists was 50.3 to 1. During the 1990s,
the number of endodontists increased faster than the number of general practitioners. As
a result, the ratio declined to only 36.4 to 1 in 2000. Since endodontists receive most of
their patients from general practitioners, a lower ratio means a fewer sources for referrals.
See Figure 26.
If these differences in growth rates between endodontists and general practitioners persist,
the general practitioner-to-endodontist ratio will continue to decline. For example, another
18 years of growth for the two groups similar to the rates they experienced between 1982
and 2000 will result in a ratio of 25.7 to 1.
Figure 26: Ratio of General Practitioners to Endodontists, 1982-2000
60.0
50.0
50.3
47.2
43.9
42.6
42.0
41.0
40.0
39.9
39.0
38.4
37.2
36.4
1999
2000
30.0
20.0
10.0
0.0
1982
1987
1991
1993
1994
1995
1996
1997
1998
Source: American Dental Association, Survey Center, 1982- 2000 Distribution of Dentists
73
Location of Endodontists
Like most specialists, endodontists are most often located in areas with large populations.
States with large urban areas tend have a larger number of endodontists. Rural areas,
especially in the Midwest and Mountain regions, have fewer endodontists. Approximately
one-third of endodontists are located in just three states: California (523 endodontists),
New York (314), and Florida (227). At the other extreme, Alaska and North Dakota each
have 5 endodontists and Wyoming has just one. See Figure 28
Figure 27: Number of Private Practice Endodontists, by State, 2000
523
600
500
314
400
200
100
0
California
New York
227
Florida
173
Massachusets
167
Pennsylvania
154
Texas
147
Illinois
145
New Jersey
114
Michigan
108
Ohio
106
Washington
78
Maryland
77
Virgina
76
Connecticut
75
Georgia
75
North Carolina
61
Arizona
55
Colorado
54
Minnesota
51
Tennessee
50
Indiana
49
Alabama
48
Wisconsin
44
Oregon
38
Missouri
35
South Carolina
33
Louisiana
27
Kentucky
27
Oklahoma
27
Utah
21
Iowa
20
Nevada
Hawaii 17
17
Kansas
17
Nebraska
Washington DC 16
Rhode Island 16
Arkansas 15
New Hampshire 14
Idaho 12
Mississippi 12
West Virginia 12
New Mexico 10
Vermont 10
Maine 8
Montana 8
Delaware 7
South Dakota 6
Alaska 5
North Dakota 5
Wyoming 1
300
Since states with large populations would be expected to have more health professionals,
the population-to-endodontist ratio will provide a better assessment of a state’s endodontic
workforce. Figure 28 displays the ratio of a state’s population35 years and older (the
relevant population) to the number of endodontists in the state. Figure 28 shows very
large variations in the population-to-endodontist ratio among states. California and New
York, the states with the most endodontists, are among the states with the lowest
population per endodontist ratios. Both states are relatively affluent and that partly
explains why these states can maintain a high population-to-endodontist ratio. In contrast,
Wyoming, Mississippi, and Arkansas have the highest population-per-endodontist ratios.
The populations of these states are not large and may not have the per capita income
levels of perhaps some of the more industrial states.
74
300,000
250,000
255,130
Figure 28: U.S. Population Aged 35 Years and Older per Endodontist,
by State, 2000
150,000
100,000
50,000
114,720
91,900
89,880
89,020
83,700
79,470
76,930
76,130
72,930
66,270
65,890
64,800
63,920
62,360
61,200
60,390
58,110
57,890
57,840
57,370
54,520
54,200
51,740
51,390
50,780
50,430
50,010
47,340
47,060
46,550
46,090
44,280
41,850
41,100
40,370
40,140
39,300
38,300
37,040
35,140
34,600
33,020
32,220
31,090
30,770
30,640
28,110
24,220
19,320
17,670
200,000
Wyoming
Mississippi
Arkansas
New Mexico
Maine
West Virginia
Kansas
Kentucky
Missouri
Iowa
North Dakota
Louisiana
Oklahoma
South Dakota
Texas
Indiana
Montana
South Carolina
Alaska
Delaware
Tennessee
Ohio
North Carolina
Georgia
Idaho
Nebraska
Wisconsin
Nevada
New Hampshire
Virgina
Alabama
Minnesota
Michigan
Illinois
Arizona
Oregon
Pennsylvania
Florida
Colorado
Hawaii
Maryland
Rhode Island
Vermont
Utah
New York
New Jersey
California
Washington
Connecticut
Massachusets
Washington DC
0
Similar interstate variation is apparent with the number of graduates from endodontic
training programs. As shown in Table 34, five states produce over 50% of endodontic
graduates. It is more than coincidence that these states also exhibit very high densities of
endodontists per their populations.
Almost half of the states (24) along with District of Columbia have no endodontic training
programs. Included among these states are the three states with the fewest endodontists
(Alaska, North Dakota, and Wyoming) and the three states with the largest population (35
years and older)-to-endodontist ratios (Wyoming again, Mississippi, and Arkansas).
75
Table 34: Number, Percent, and Cumulative Percent of
Endodontic Students, by State, 2000
State
Massachusetts
New York
Pennsylvania
California
Texas
Ohio
Florida
Michigan
Connecticut
North Carolina
Alabama
Maryland
Illinois
Louisiana
Minnesota
Iowa
New Jersey
Washington
Kentucky
Oregon
Virginia
Indiana
Nebraska
Georgia
West Virginia
Wisconsin
Percent Cum Pct.
Endodontic
of
of
Students Students Students
52
14.3%
14.3%
41
11.3%
25.5%
37
10.2%
35.7%
32
8.8%
44.5%
25
6.9%
51.4%
20
5.5%
56.9%
18
4.9%
61.8%
16
4.4%
66.2%
10
2.7%
69.0%
10
2.7%
71.7%
9
2.5%
74.2%
9
2.5%
76.6%
8
2.2%
78.8%
8
2.2%
81.0%
8
2.2%
83.2%
7
1.9%
85.2%
7
1.9%
87.1%
7
1.9%
89.0%
6
1.6%
90.7%
6
1.6%
92.3%
6
1.6%
94.0%
5
1.4%
95.3%
5
1.4%
96.7%
4
1.1%
97.8%
4
1.1%
98.9%
4
1.1%
100.0%
76
State
Alaska
Arizona
Arkansas
Colorado
Delaware
Hawaii
Idaho
Kansas
Maine
Mississippi
Missouri
Montana
Nevada
New Hampshire
New Mexico
North Dakota
Oklahoma
Rhode Island
South Carolina
South Dakota
Tennessee
Utah
Vermont
Washington DC
Wyoming
Total Students
Percent Cum Pct.
Endodontic
of
of
Students Students Students
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
0
0.0%
100.0%
364
100.0%
REFERRAL PATTERNS
Impact of the General Practitioner-to-Endodontist Ratio on Referral
Patterns
Given the generally accepted position as gatekeeper to the dental care system, the
general practitioner is in a potentially important position of directing patients to various
types of care systems including endodontic care. The variation in endodontist densities
described in the previous section implies that one or two things must be occurring. Either
the per capita number of endodontic services is higher in states with a high density of
endodontists (e.g., California and the Northeast) or general practitioners must be
producing a larger percentage of endodontic services in the low-density states (e.g.,
Wyoming, Mississippi, etc.).
Figure 29 shows the general practitioner-to-endodontist ratio for all states. The states with
the fewest number of general practitioners per endodontist provide a smaller referral base
for endodontists. Therefore, general practitioners in these states will refer a higher
percentage of endodontic patients per year than those states with higher general
practitioner to endodontist ratios.
77
Figure 29: Number of General Practitioners per Endodontist, by State, 2000
221
250
200
150
50
70
62
61
60
59
57
56
55
54
53
51
47
47
47
47
47
47
46
45
44
44
44
44
43
43
41
41
39
38
38
38
37
37
36
36
36
34
34
33
32
32
29
28
28
27
27
26
26
25
20
100
Wyoming
Mississippi
Kentucky
Kansas
Alaska
Arkansas
Maine
New Mexico
Iowa
Missouri
West Virginia
Wisconsin
North Dakota
South Dakota
Montana
Louisiana
Oklahoma
Nebraska
Texas
Idaho
Illinois
Hawaii
Ohio
Indiana
Tennessee
Minnesota
Michigan
Utah
Oregon
Delaware
New Hampshire
Colorado
Virginia
South Carolina
Pennsylvania
New York
Maryland
Georgia
New Jersey
California
Wash DC
North Carolina
Nevada
Alabama
Arizona
Vermont
Rhode Island
Washington
Florida
Connecticut
Massachusetts
0
This pattern seems to be supported by data from electronic claims database. Figure 30
displays the percentage of anterior root canals performed by endodontists across all
states. Figure 31 displays the percentage of molar root canals performed by endodontists
by state. Endodontists perform a markedly smaller percentage of anterior root canals than
molar root canals. More importantly, there is a strong correlation between the number of
general practitioners per endodontist and the percentage of both anterior and molar root
canals performed by endodontists.
For example, New England states demonstrate a lower ratio of general practitioner per
endodontist, indicating that endodontists in these states have a smaller number of general
practitioners from which they can expect referrals. In contrast, states like Wyoming,
Mississippi and Alaska with few endodontists compared to general practitioners show a
smaller percentage of root canals provided by endodontists. Clearly, the general
practitioner-to-endodontist ratio in a state is an important indicator of the percentage of
root canal therapy that is referred to endodontists.
The existence of a relationship between the ratio of general practitioner per endodontist
and the percent of root canals performed by endodontists can be demonstrated
78
statistically. State data show the number of molar root canals performed by endodontists
decreases as the ratio of general practitioner per endodontist increases.
In addition, the existence of a good degree of correlation between the ratio of general
practitioner per endodontist and the percent of root canals performed by endodontists was
seen in a simple regression analysis and this finding further underscores the significance
of the role played by the general practitioner-to-endodontist ratio in the percent of root
canal therapy that is referred to endodontists.
100%
10
0%
Figure 30: Percent of Anterior Root Canals Performed by Endodontists,
by State, 2001
90%
80%
70%
50%
40%
30%
20%
10%
0%
Vermont
42%
Colorado
37%
South Carolina
36%
Kansas
32%
Massachusetts
30%
Delaware
29%
California
27%
Arizona
17%
Michigan
17%
New Mexico
16%
Florida
15%
South Dakota
15%
North Carolina
15%
Wisconsin
14%
Maryland
14%
Minnesota
14%
Ohio
13%
Tennessee
13%
Washington
13%
Missouri
13%
Pennsylvania
13%
Alabama
13%
Arkansas
13%
Washington DC
12%
New Hampshire
12%
Connecticut
11%
Virginia
11%
North Dakota
10%
Utah
9%
New Jersey
8%
Oregon
8%
Indiana
8%
Louisiana
7%
Texas
7%
Nebraska
6%
Nevada
6%
Kentucky
6%
New York
5%
Maine
3%
Iowa
Illinois 2%
Georgia 2%
Alaska 2%
Oklahoma 2%
Mississippi 1%
Idaho 1%
Montana 0%
West Virginia 0%
Wyoming 0%
60%
79
100%
10
0%
Figure 31: Percent of Molar Root Canals Performed by Endodontists,
by State, 2001
80%
70%
60%
50%
40%
30%
20%
10%
0%
Vermont
76%
Delaware
74%
Massachusetts
64%
South Carolina
63%
Maryland
57%
Arizona
56%
South Dakota
54%
Colorado
51%
North Carolina
50%
Kansas
46%
Tennessee
45%
California
44%
New Hampshire
41%
Minnesota
39%
Wisconsin
35%
Ohio
35%
Washington
34%
Florida
34%
Missouri
34%
Virginia
32%
Michigan
30%
Connecticut
30%
Nevada
30%
Pennsylvania
28%
Alabama
27%
New Jersey
25%
New Mexico
24%
North Dakota
23%
Arkansas
21%
Oregon
20%
Kentucky
19%
Indiana
17%
Texas
17%
Utah
16%
Maine
15%
Louisiana
14%
Iowa
13%
Washington DC
13%
Nebraska
12%
New York
10%
Illinois
9%
Mississippi
8%
Georgia
4%
Alaska
4%
Oklahoma
Idaho 2%
Montana 0%
West Virginia 0%
Wyoming 0%
90%
Patient Referrals
In 1999, general practitioners reported only 9% of their new patients were referrals from
other general practitioners or specialists. Their largest single source of new patients was
their existing patient pool (63.6%). In contrast, in 1999, endodontists reported that general
practitioners were the source from which they received 85.5% of their new patients. Their
second source for patients was other specialists, but at 9.3%, this was a much smaller
source than general practitioners. Thus, the single most important source of patients for
endodontists in private practice is general practitioners. See Figure 32.
80
Figure 32: Percent of Patient Referrals to Endodontists,
by Source of Referral, 1999
90%
85.5%
80%
70%
60%
50%
40%
30%
20%
9.3%
10%
5.2%
0%
Specialists
All Others
Source of Referral
The percentage of patients referred to endodontists by general practitioners is shown in
Figure 33 by the age group of practicing endodontists. The percentage of referrals from
general practitioners does not vary greatly across age groups. The largest percentage of
referrals by general practitioners (86.8%) is made to endodontists in the 45-49 age
group—generally the most productive years of an endodontist. The average percentage
referral to endodontists who were less than 35 years of age was about 85.4% (i.e., about
the same as the overall average). The percentage of general practitioner referrals drops
to 84.6% among endodontists in the 50-54 age group, and is the lowest (82.5%) among
endodontists in the 60-64 age group.
81
Figure 33: Percent of Patients Referred to Endodontists
by General Practitioners, 1999
88%
87%
86%
86.5%
86.8%
86.3%
85.4%
85.1%
85%
84.6%
84%
83.2%
83%
82.5%
82%
81%
80%
< 35
35-39
40-44
45-49
50-54
55-59
60-64
65+
Endodontist Age Group
The percentage of referrals by general practitioners to endodontists by gender of the
endodontist is shown in Figure 34. The percentage of patients referred does not vary
significantly between male and female endodontists. Female endodontists reported that
general practitioners referred 83.5% of their patients to them, and males reported 85.8%.
82
Figure 34: Percent of Referrals by General Practitioners to
Male and Female Endodontists, 1999
100%
85.8%
83.5%
80%
60%
40%
20%
0%
Female Endodontists
Male Endodontists
As shown in Figure 35, there is greater variation in the percentage of patients referred by
general practitioners to endodontists by U.S. Census regions. The lowest percentage of
general practitioner referrals occurred in the New England region (77.0%), while the
highest percentage occurred in the Pacific region (89.4%). In general, the Western region
(Pacific and Mountain) showed the highest percentage of referrals from general
practitioners (88.4%) and the North East region (New England and Middle Atlantic) had
the lowest percentage (80.1%).
83
Figure 35: Percent of Patients Referred to Endodontists by General Practitioners,
by U.S. Census Region of the Practicing Endodontist, 1999
100%
80%
77.0%
81.2%
85.2%
89.3%
86.2%
84.7%
South
Atlantic
East
South
Central
88.8%
85.0%
89.4%
60%
40%
20%
0%
New
England
Middle
Atlantic
East
North
Central
West
North
Central
West
South
Central
Mountain
Pacific
U.S. Census Region
Figure 36 shows the average number of new treatment cases and retreatment cases
referred to an endodontist by general practitioners for the U.S. Census regions.
Endodontists in the East North Central region had the largest average number of new
cases referred to them by general practitioners (39.2 cases). Endodontists in the East
South Central region had the lowest number (26.4 cases). The average number of
general practitioner retreatment referrals to practicing endodontists was highest in the
West South Central region (11.1 cases) and lowest in the East South Central region (5.8
cases).
84
Figure
e 36: Average Number of New Cases and Retreatment (per Week) Referred to
an Endodontist by General Practitioners, by U.S. Census Region, 1999
27.6
26.4
30
29.1
31.6
31.8
35
New Treatment Cases
Retreatment Cases
35.5
31.9
38.9
40
39.2
45
25
9.0
11.1
West
North
Central
5.8
9.3
East
North
Central
7.1
9.2
8.3
10
7.6
15
10.4
20
5
0
New
England
Middle
Atlantic
South
Atlantic
East
South
Central
U.S. Census Region
85
West
South
Central
Mountain
Pacific
APPENDIX I: SUPPLEMENTARY ANALYSIS
Comparison of Non-Endodontic Services Among General
practitioners and Endodontist
Procedures provided by the endodontist included those that were preparatory or ancillary
to endodontic procedures, as well as other endodontic procedures in addition to root canal
therapy. These procedures contributed much less to gross billings and total endodontists’
time than the root canals; numerically, however, the represent a significant portion of all
procedures performed by endodontists. An examination of these preparatory and ancillary
procedures and low frequency endodontic procedures provides a more complete
description of endodontists workload.
The section below contains detailed discussions of the following areas of endodontic
services: 1) Clinical and oral evaluations, 2) Radiographs and diagnostic procedures,
3) Apicoectomy and periradicular surgical services, 4) Restorative procedures, and 5) Lab
test and examinations.
CLINICAL AND ORAL EVALUATIONS
Among endodontists, 86% of the clinical and oral evaluation procedures performed were
limited and problem focused. The limited examination allows endodontists to focus of
specific endodontic problems of presenting patients without unneeded time and effort of a
comprehensive examination. Emergency oral exams, periodic evaluations, and other
types of exams comprised the remaining 14 % of clinical and oral evaluations used among
endodontists; emergency oral exams comprised 3% while periodic evaluations comprised
5% of these procedures. Other types of exams (e.g. comprehensive oral evaluations, reevaluations) occurred almost 6% of the time. Periodic oral evaluations were usually
follow-up exams done for an existing endodontic condition or exams conducted post
endodontic therapy.
Endodontists charged considerably more for clinical evaluations than did their general
practitioner counterparts. For problem-focused evaluations, the endodontist charged 44%
more than the general practitioner. For emergency oral exams and periodic exams, their
fees were 46% more and twice as much, respectively.
86
Table A1-1: Clinical and Oral Evaluation Procedures
Endodontist
1,994
8,631,340
2,045
78.7%
5.3%
93,280
1,037
97,420
1,050
0.9%
2.7%
642,960
32,281
676,980
33,180
6.2%
86.4%
1,502,340
1,589
1,544,880
1,616
14.1%
4.2%
Detailed and extensive oral
evaluation
9,100
454
9,540
461
0.1%
1.2%
Re-evaluation-limited and
problem focused
3,520
55
3,800
57
0.0%
0.1%
10,679,100
37,410
10,963,960
38,409
100.0%
100.0%
Periodic oral evaluation
Emergency oral
examination
Comprehensive oral
evaluation
Totals
General
Practitioner
8,427,900
General
Practitioner
General
Practitioner
Percent of
Procedures
Endodontist
Total
Procedures
Endodontist
Patient
Count
87
Figure A1-1: Percentage Distribution of Clinical and Oral Evaluation Procedures
Emergency oral
examination
0.9%
Endodontists
2.7%
6.2%
Limited oral
evaluation
86.4%
14.2%
Other evaluation
5.6%
78.7%
Periodic oral
evaluation
5.3%
0%
20%
40%
60%
80%
100%
88
Table A1-2: Average Fees for Clinical and Oral Evaluation Procedures
Endodontist
$59.99
8,631,340
2,045
71.7%
5.5%
Emergency oral
examination
43.15
63.28
97,420
1,050
1.2%
3.0%
40.20
57.75
676,980
33,180
7.9%
85.7%
Comprehensive oral
evaluation
42.31
60.82
1,544,880
1,616
18.9%
4.4%
evaluation
86.04
61.38
9,540
461
0.2%
1.3%
Re-evaluation-limited and
problem focused
43.24
60.95
3,800
57
0.0%
0.2%
NA
NA
10,963,960
38,409
100.0%
100.0%
Periodic oral evaluation
Totals
General
Practitioner
$28.75
General
Practitioner
General
Practitioner
Percent of
Total Charges
Endodontist
Total
Procedures
Endodontist
Average
Fees
89
Figure A1-2: Average Fees for Clinical Exam and Evaluation Procedures
$43.13
Emergency oral
examination
Endodontists
$63.28
$40.20
Limited oral
evaluation
$57.75
$42.58
Other evaluation
$60.94
$28.75
Periodic oral
evaluation
$59.99
$0
$25
$50
$75
$100
RADIOGRAPHS AND DIAGNOSTIC PROCEDURES
Endodontists and general practitioners provided different amounts of radiographs and
diagnostic procedures. The vast majority of endodontists’ radiographic procedures were
periapical radiographs - first films and additional films. These two categories accounted
for 99 percent of the radiograph and diagnostic procedures with the remaining one percent
being distributed among the nine other procedures found in this clinical area. Among
general practitioners the two periapical film categories amounted to only 34% of
radiograph procedures. Among endodontists, the average fee for periapical films about
20% higher than fees charged by the general practitioners for similar procedures.
90
Table A1-3: Radiographs and Diagnostic Procedures
Intraoral - complete series
Endodontist
General
Practitioner
General
Practitioner
Percent of
Procedures
Endodontist
Total
Procedures
Endodontist
General
Practitioner
Patient
Count
739,220
26
759,460
27
7.5%
0.1%
1,782,200
25,341
1,939,500
26,523
19.3%
79.0%
800,380
5,517
1,470,700
6,620
14.6%
19.7%
34,000
6
52,220
6
0.5%
0.0%
Extraoral - 1st film
1,640
1
1,760
1
0.0%
0.0%
Extraoral - each addl. film
1,660
1
2,540
2
0.0%
0.0%
56,920
146
68,640
150
0.7%
0.4%
Bitewings - 2 films
2,085,540
200
2,124,600
212
21.1%
0.6%
Bitewings - 3 films
2,693,420
7
2,752,340
7
27.3%
0.0%
820,560
10
842,900
10
8.4%
0.0%
16,560
4
19,140
4
0.2%
0.0%
9,032,100
31,259
10,033,800
33,562
99.60%
100.0%
Intraoral - periapical 1st film
Intraoral - periapical each
addl. film
Intraoral - occlusal film
Bitewing - 1 film
Panoramic film
Oral/facial images
Totals
91
Figure A1-3: Percentage Distribution of Radiographs and Diagnostic Procedures
Among General Practitioner and Endodontists, 2001
Endodontists
19.3%
1st film
79.0%
14.6%
19.7%
66.1%
Other radiographs
1.3%
0%
20%
40%
60%
80%
100%
92
Table A1-4: Average Fees for Radiographs and Diagnostic Procedures
Endodontist
$81.58
$78.48
759,460
27
18.8%
0.4%
$15.94
$18.63
1,939,500
26,523
9.3%
82.9%
Intraoral - periapical each
addl. film
$11.33
$13.66
1,470,700
6,620
5.1%
15.2%
Intraoral - occlusal film
$20.70
$11.33
52,220
6
0.3%
0.0%
Extraoral - 1st film
$35.91
$15.00
1,760
1
0.0%
0.0%
Extraoral - each addl. film
$35.87
$20.00
2,540
2
0.0%
0.0%
Bitewing - 1 film
$13.19
$17.06
68,640
150
0.3%
0.4%
Bitewings - 2 films
$25.17
$23.55
2,124,600
212
16.2%
0.8%
Bitewings - 3 films
$38.50
$43.71
2,752,340
7
32.2%
0.0%
Panoramic film
$65.84
$71.80
842,900
10
16.9%
0.1%
Oral/facial images
$26.95
$108.00
19,140
4
0.2%
0.0%
NA
NA
10,033,800
33,562
99.4%
100.0%
Totals
General
Practitioner
Intraoral - complete series
General
Practitioner
General
Practitioner
Percent of
Total Charges
Endodontist
Total
Procedures
Endodontist
Average
Fees
93
Figure A1-4: Average Fees for Radiographs and Diagnostic Procedures
Endodontists
$15.94
1st film
$18.63
$11.33
$13.66
$42.27
Other radiographs
$26.85
$0
$5
$10
$15
$20
$25
$30
$35
$40
$45
RESTORATIVE PROCEDURES
Endodontists provided very wide variety of restorative procedures in conjunction with
delivering endodontic services. Numerically, however, restorative procedures constituted
only a small part of endodontists’ practice.
One exception to this rule was in the core build-up and placement of prefabricated posts
and cores procedures. Endodontists performed the core build-up procedure about four
times as often as general practitioners. They placed of prefabricated posts and cores
thirty-eight times more often than general practitioners. Core build-up and prefabricated
post procedures combined accounted for less than 1% of general practitioner’s procedures
and almost two percent of all endodontist procedures.
The primary type of restorative technique used among endodontists was an amalgam or
composite resin restoration. When the endodontist performed a restorative procedure it
was most often a one surface amalgam or a one surface composite resin restoration.
Typically, these procedures were done to restore endodontically treated teeth after root
canal placement.
94
The average fees for the restorative procedures most often performed by endodontists
were near and sometimes less than those charged by general practitioners. For one
surface amalgams, the endodontist charged about 12% more than the general practitioner
($76.81 versus $68.78). The same relationship held for two surfaces amalgams, where
the difference was 6% ($93.41 versus $88.39). However, general practitioners charged
more for composite resin restorations than endodontists—$90.47 versus $81.77 for one
surface anterior resins and $100.76 versus $86.90 for one surface posterior resins.
Table A1-5: Restorative Procedures Among General Practitioners
and Endodontists, 2001
General
Practitioner
Endodontist
General
Practitioner
Endodontist
Percent of
Procedures
Endodontist
Amalgam – 1 surface,
permanent
Amalgam – 2 surfaces,
permanent
Resin-composite – 1
surface, anterior
surface, posterior
Other restorative
procedures
Totals
Total
Procedures
General
Practitioner
Patient
Count
453,300
1,427
697,080
1,485
86.1%
17.4%
542,560
80
759,980
81
9.4%
0.9%
404,480
492
647,920
534
8.0%
6.3%
830,920
950
1,436,940
990
17.8%
11.6%
3,036,300
5,074
4,095,200
5,452
50.5%
63.8%
5,267,560
8,023
7,637,120
8,542
94.3%
100.0%
95
Figure A1-5: Percentage Distribution of Restorative Procedures
Amalgam 2 surface
permanent
8.6%
Amalgam 1 surface
permanent
Endodontists
17.4%
9.4%
1.0%
56.2%
Other restoration
63.8%
8.0%
Resin 1 surface
anterior
6.3%
17.8%
Resin 1 surface
posterior
11.6%
0%
20%
40%
60%
80%
100%
96
Table A1-6: Average Fees for Restorative Procedures
General
Practitioner
Endodontist
General
Practitioner
Endodontist
Percent of
Total Charges
68.78
76.81
697,080
1,485
40.0%
89.8%
88.39
93.41
759,980
81
56.0%
0.6%
90.47
81.77
647,920
534
48.9%
3.4%
100.76
86.90
1,436,940
990
12.1%
6.8%
176.68
186.91
4,095,200
5,452
73.4%
80.2%
NA
NA
7,637,120
8,542
100.0%
100.0%
General
Practitioner
Amalgam – 1 surface,
permanent
Amalgam – 2 surfaces,
permanent
surface, anterior
surface, posterior
Other restorative
procedures
Totals
Total
Procedures
Endodontist
Average
Fees
97
Figure A1-6: Average Fees for Restorative Procedures
$68.78
Amalgam 1 surface
permanent
Endodontists
$76.81
$88.39
Amalgam 2 surface
permanent
$93.41
$176.68
Other restoration
$186.91
$90.47
Resin 1 surface
anterior
$81.77
$100.76
Resin 1 surface
posterior
$86.90
$0
$25
$50
$75
$100
$125
$150
$175
$200
LAB TESTS AND EXAMS PROCEDURES
Lab procedures comprised 2% of endodontists’ total procedures. Ninety-six percent of the
lab test procedures among endodontists were pulp vitality tests. For general practitioners,
pulp vitality tests comprised 24% of endodontic procedures. On average, endodontists
charged 11% less than general practitioners for pulp vitality tests—$26.80 versus $30.07.
98
Table A1-7: Lab Test Procedures Among General Practitioners
and Endodontists, 2001
Endodontist
General
Practitioner
General
Practitioner
General
Practitioner
Percent of
Procedures
Endodontist
Total
Procedures
Endodontist
Patient
Count
Bacteriologic studies for
pathologic
Pulp vitality tests
4,580
144
4,940
149
8.8%
3.6%
11,600
3,658
13,300
3,959
23.6%
95.7%
Diagnostic casts
34,560
1
35,520
1
63.1%
0.0%
60
19
80
19
0.1%
0.4%
1,680
11
1,980
11
3.5%
0.3%
52,480
3,833
55,820
4,139
99.1%
100.0%
Histopathologic
examinations
Unspecified diagnostic
procedure
Totals
99
Figure A1-7: Percentage Distribution of Lab Test Procedures
8.8%
Endodontists
Bacteriologic studies
3.6%
67.6%
Other lab tests
0.7%
23.6%
Pulp vitality test
95.6%
0%
20%
40%
60%
80%
100%
100
Table A1-8: Average Fees for Lab Test Procedures
Endodontist
$14.81
$35.00
4,940
149
25.9%
4.6%
$30.07
$26.80
13,300
3,959
14.1%
93.1%
Diagnostic casts
$63.08
$17.00
35,520
1
79.2%
0.0%
Histopathologic
examinations
Unspecified diagnostic
procedure
Totals
$75.00
$86.58
80
19
0.2%
1.4%
$32.74
$91.36
1,980
11
2.3%
0.9%
NA
NA
55,820
4,139
98.4%
100.0%
General
Practitioner
pathologic
Pulp vitality tests
General
Practitioner
General
Practitioner
Percent of
Total Charges
Endodontist
Total
Procedures
Endodontist
Average
Fees
101
Figure A1-8: Average Fees for Lab Test Procedures
Endodontists
$14.81
$35.00
$61.88
Other lab tests
$86.03
$30.07
Pulp vitality test
$26.80
$0
$10
$20
$30
$40
$50
$60
$70
$80
$90 $100
APICOECTOMY AND PERIRADICULAR PROCEDURES
Apicoectomy and periradicular surgical services were a small part of both endodontists’
and general practitioners’ practices. These procedures comprised 3% of endodontists’
practice; they comprised a negligible component of general practitioners’ workload
(< 0.1%). Apicoectomy and periradicular services were almost 2% of endodontists’ gross
billings but only an insignificant amount of general practitioners’ billings.
The most frequently provided apicoectomy and periradicular surgical procedure among
endodontists was apicoectomy of tooth roots on anterior, bicuspids, or molar teeth (57%).
Apicoectomies on anterior roots were provided most frequently (21%), followed by molar
(18%) and bicuspid roots (13%). Placement of retrograde fillings was quite common at
41%.
102
Table A1-9: Apicoectomies and Periradicular Procedures
General
Practitioners
Endodontists
General
Practitioners
Endodontists
Percent of
Procedures
Endodontists
Total
Procedures
General
Practitioners
Patient
Count
A/P surgery – anterior
A/P surgery – bicuspid
A/P surgery – molar
A/P surgery – additional root
Retrograde filling - per root
Root amputation - per root
Intentional reimplantation
1,500
820
1,140
580
2,160
600
40
1,090
712
1,016
323
1,859
110
7
1,620
840
1,180
620
2,820
600
40
1,226
749
1,051
352
2,415
112
7
21.0%
10.9%
15.3%
8.0%
36.5%
7.8%
0.5%
20.7%
12.7%
17.8%
6.0%
40.8%
1.9%
0.1%
Totals
6,840
5,117
7,720
5,912
100.0%
100.0%
103
Figure A1-9: Percentage Distribution of Apicoectomies and Periradicular
Procedures Among General Practitioners and Endodontists, 2001
A/P surgery additional root
8.0%
6.0%
Endodontists
21.0%
20.7%
A/P surgery - anterior
10.9%
12.7%
A/P surgery bicuspid
15.3%
17.8%
A/P surgery - molar
Intentional
reimplantation
0.5%
0.1%
36.5%
40.8%
Retrograde filling
7.8%
Root amputation
1.9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
104
The average fee for apicoectomies and periradicular procedures among endodontists was
significantly higher than for general practitioners. (See Table A1-10 and Figure A1-10).
Table A1-10: Average Fees for Apicoectomies and Periradicular
General
Practitioners
Endodontists
General
Practitioners
Endodontists
Totals
Percent of
Total Charges
Endodontists
A/P surgery – anterior
A/P surgery – bicuspid
A/P surgery – molar
A/P surgery – additional
Intentional reimplantation
Total
Procedures
General
Practitioners
Average
Fees
$430.83
$460.62
$505.71
$153.74
$106.87
$302.92
$450.00
$612.92
$649.29
$689.94
$168.27
$132.48
$439.50
$578.00
1,620
840
1,180
620
2,820
600
40
1,226
749
1,051
352
2,415
112
7
30.6%
17.0%
26.2%
4.2%
13.2%
8.0%
0.8%
31.4%
20.3%
30.3%
2.5%
13.4%
2.1%
0.2%
NA
NA
7,720
5,912
100.0%
100.0%
105
Figure A1-10: Average Fees for Apicoectomies and Periradicular
A/P surgery additional root
$153.74
$168.27
Endodontists
$430.83
A/P surgery - anterior
$612.92
$460.62
A/P surgery bicuspid
$649.29
$505.71
A/P surgery - molar
$689.94
Intentional
reimplantation
$450.00
$578.00
$106.87
$132.48
Retrograde filling
$302.92
Root amputation
$439.50
$0
$200
$400
$600
$800
$1,000
State Analysis Using the Electronic Claims Data
DISTRIBUTION OF ENDODONTISTS BY STATE
In the electronic claims database, the state of California has the greatest number of
endodontists who submitted electronic claims. These data indicate that 177 separate
endodontists submitted electronic claims from July through December of 2001. Using the
number of endodontists practicing in California as estimated by the ADA Distribution of
dentists, 26.6% of endodontists submitted electronic claims. For Florida analogous
analysis showed that 38 or 5.7% of endodontists submitted these claims. For Texas, the
numbers were 31 or 4.6%. The top ten states listed in Table A1-11 accounted for 62.4%
of endodontists in the electronic claims database while the remaining 40 states and the
District of Columbia accounted for the remaining 37.6%.
The estimate of the distribution of endodontists among states using the electronic claims
database is consistent with the distribution estimated using the 1999 SDSR. However, the
estimated of total number of endodontists is lower using the claims database. This is
because a substantial number of endodontists do not submit claims electronically.
106
19
16
15
15
13
12
12
11
10
9
7
7
6
6
6
2.40%
2.25%
2.25%
1.95%
1.80%
1.80%
1.65%
1.50%
1.35%
1.05%
1.05%
0.90%
0.90%
0.90%
71.17%
73.42%
75.68%
77.63%
79.43%
81.23%
82.88%
84.38%
85.74%
86.79%
87.84%
88.74%
89.64%
90.54%
107
Cumulative
Percent
South Carolina
Colorado
Illinois
Virginia
New Jersey
Arizona
Missouri
Tennessee
Minnesota
Wisconsin
Connecticut
Maryland
Indiana
Louisiana
Utah
3.30% 65.92%
2.85% 68.77%
Georgia
Kansas
Kentucky
New Mexico
Oklahoma
Alabama
Delaware
Nevada
Vermont
Arkansas
District of
Columbia
New
Hampshire
Alaska
Iowa
Mississippi
Nebraska
South Dakota
Idaho
Maine
North Dakota
Montana
West Virginia
Wyoming
Rhode Island
Hawaii
Totals
Percent of
Total
22
26.58%
32.28%
36.94%
41.29%
45.35%
49.25%
52.70%
56.01%
59.31%
62.61%
Number of
Endodontists
Pennsylvania
26.58%
5.71%
4.65%
4.35%
4.05%
3.90%
3.45%
3.30%
3.30%
3.30%
State
177
38
31
29
27
26
23
22
22
22
Cumulative
Percent
Number of
Endodontists
California
Florida
Texas
Ohio
Washington
North Carolina
New York
Massachusetts
Michigan
Oregon
Percent of
Total
State
Table A1-11: Distribution of Endodontists in the
Electronic Claims Database, by State, 2001
5
5
5
5
5
4
4
4
4
3
0.75%
0.75%
0.75%
0.75%
0.75%
0.60%
0.60%
0.60%
0.60%
0.45%
91.29%
92.04%
92.79%
93.54%
94.29%
94.89%
95.50%
96.10%
96.70%
97.15%
3
0.45%
97.60%
3
2
2
2
2
2
1
1
1
0
0
0
0
0
666
0.45%
0.30%
0.30%
0.30%
0.30%
0.30%
0.15%
0.15%
0.15%
0.00%
0.00%
0.00%
0.00%
0.00%
100.0%
98.05%
98.35%
98.65%
98.95%
99.25%
99.55%
99.70%
99.85%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
ENDODONTIST FEES FOR ROOT CANANLS BY STATE
As shown in Table A1-12, North Dakota had the lowest average fee for root canals
charged by endodontists ($532.71). The ten states with the lowest fees for root canals all
had average fees below $650. Alaska and the District of Columbia had the highest
average fees for root canals among endodontists ($1079.66 and $1095.65, respectively).
The top ten states with the highest average fees for root canals all had fees greater than
$840 dollars—with the highest fee approaching $1,100.
Table A1-12: Electronic Claims Data, Average Fees for Root Canals
Among Endodontists, by State, 2001
State
North Dakota
Iowa
Nebraska
Kentucky
Alabama
Idaho
Mississippi
Oklahoma
Utah
South Dakota
South Carolina
Indiana
Michigan
Arkansas
Illinois
Pennsylvania
Louisiana
Florida
North Carolina
Tennessee
Delaware
Virginia
Ohio
Arizona
Wisconsin
Oregon
Kansas
Texas
Vermont
Missouri
New Mexico
Minnesota
Colorado
New York
California
Number of
Procedures
Performed
140
293
253
619
899
119
47
279
303
222
1,764
881
4,424
335
2,143
4,266
794
2,863
2,823
962
829
1,770
2,272
1,798
1,894
1,299
1,606
3,326
262
1,251
427
2,800
3,086
1,225
15,814
Total
Charges
$74,579.00
$158,495.00
$144,950.00
$355,122.00
$531,028.00
$70,645.00
$29,255.00
$173,960.00
$189,920.00
$140,853.00
$1,145,207.00
$577,049.25
$2,934,347.50
$226,066.00
$1,462,557.00
$2,950,271.00
$550,076.00
$1,990,251.00
$1,990,024.00
$678,344.00
$592,632.00
$1,265,829.25
$1,631,404.75
$1,291,513.50
$1,361,766.75
$936,331.50
$1,158,860.00
$2,446,738.00
$192,927.50
$934,699.00
$326,500.39
$2,148,988.00
$2,372,907.50
$996,305.00
$13,062,988.75
108
Average
Fees per
Procedure
$532.71
$540.94
$572.92
$573.70
$590.69
$593.66
$622.45
$623.51
$626.80
$634.47
$649.21
$654.99
$663.28
$674.82
$682.48
$691.58
$692.79
$695.16
$704.93
$705.14
$714.88
$715.16
$718.05
$718.31
$718.99
$720.81
$721.58
$735.64
$736.36
$747.16
$764.64
$767.50
$768.93
$813.31
$826.04
Standard
Deviation
$71.77
$71.71
$90.92
$77.95
$61.49
$85.63
$66.85
$93.09
$78.51
$70.85
$93.81
$92.95
$89.79
$76.31
$111.62
$110.95
$80.87
$120.08
$94.21
$117.10
$110.95
$135.56
$132.62
$100.59
$110.36
$109.36
$82.17
$108.55
$103.03
$96.07
$95.65
$73.64
$104.05
$182.09
$125.42
Among Endodontists, by State, 2001 (Cont.)
State
New Jersey
Maryland
Nevada
Georgia
Washington
Connecticut
New Hampshire
Maine
Massachusetts
Alaska
District of Columbia
Number of
Procedures
Performed
2,840
483
199
405
3,717
744
504
99
4,421
41
39
Total
Charges
$2,373,883.00
$406,432.00
$171,722.00
$351,635.00
$3,288,467.75
$658,607.00
$446,715.00
$91,220.00
$4,102,686.72
$44,266.00
$42,730.00
Average
Fee per
Procedure
$835.87
$841.47
$862.92
$868.23
$884.71
$885.22
$886.34
$921.41
$928.00
$1079.66
$1095.64
Standard
Deviation
$87.17
$119.55
$89.00
$101.26
$168.15
$117.07
$175.02
$122.56
$128.43
$1312.91
$98.22
GENERAL PRACTITIONER FEES FOR ROOT CANANLS BY STATE
As shown in Table A1-13, West Virginia had the lowest average fee for root canals
charged by general practitioners ($354.80). The ten states with the lowest fees for root
canals all had average fees below $475. Alaska and the District of Columbia had the
highest average fees for root canals among general practitioners ($702.09 and $700.00,
respectively). The top ten states with the highest average fees for root canals all had fees
greater than $595 dollars—with the highest fee slightly over $700.
109
Among General Practitioners, by State, 2001
State
Number of
Procedures
Performed
West Virginia
Kentucky
Iowa
North Dakota
South Dakota
Wyoming
Mississippi
Nebraska
Illinois
Missouri
Idaho
Kansas
Tennessee
Ohio
Alabama
Utah
Pennsylvania
Michigan
Vermont
New Mexico
Indiana
North Carolina
Texas
Louisiana
Oregon
Wisconsin
Oklahoma
Virginia
Arkansas
Nevada
Arizona
Maryland
South Carolina
Minnesota
Washington
Georgia
Florida
New Jersey
Colorado
New Hampshire
Maine
New York
California
200
4,160
2,960
580
500
280
840
2,420
29,860
3,300
7,360
1,900
1,860
6,140
3,540
1,880
13,240
12,640
20
1,560
5,320
5,240
20,840
5,820
7,200
4,860
9,760
5,460
1,480
860
2,160
940
1,520
6,440
10,460
7,100
7,640
12,240
3,360
1,380
820
11,620
24,800
Total
Charges
Average Fee
per
Procedure
Standard
Deviation
$70,960.00
$1,554,560.00
$1,108,800.00
$218,900.00
$198,300.00
$113,660.00
$342,540.00
$1,073,540.00
$13,762,493.00
$1,533,080.00
$3,424,780.00
$900,060.00
$883,800.00
$2,925,980.20
$1,690,020.00
$902,310.40
$6,392,390.00
$6,177,360.00
$9,900.00
$778,368.80
$2,674,340.00
$2,638,066.80
$10,498,916.60
$2,996,080.00
$3,727,720.00
$2,525,240.00
$5,144,350.00
$2,882,460.00
$795,620.00
$462,640.00
$1,164,640.00
$510,840.00
$828,880.00
$3,515,661.20
$5,751,876.00
$3,908,895.20
$4,353,660.00
$7,133,120.00
$1,968,520.00
$822,800.00
$492,320.00
$6,995,724.80
$15,090,996.00
$354.80
$373.69
$374.59
$377.41
$396.60
$405.93
$407.79
$443.61
$460.90
$464.57
$465.32
$473.72
$475.16
$476.54
$477.41
$479.95
$482.81
$488.72
$495.00
$498.95
$502.70
$503.45
$503.79
$514.79
$517.74
$519.60
$527.09
$527.92
$537.58
$537.95
$539.19
$543.45
$545.32
$545.91
$549.89
$550.55
$569.85
$582.77
$585.87
$596.23
$600.39
$602.04
$608.51
$51.45
$99.63
$116.82
$45.29
$102.85
$89.59
$81.98
$89.89
$117.84
$138.06
$121.71
$81.04
$100.18
$121.71
$91.59
$121.79
$124.66
$88.98
*
$103.20
$108.30
$125.59
$143.68
$121.16
$142.22
$121.88
$116.24
$118.12
$130.20
$137.27
$130.89
$155.69
$113.79
$117.05
$168.13
$148.19
$176.78
$164.38
$112.34
$136.86
$130.56
$207.13
$174.41
* Large due to small sample.
110
Among General Practitioners, by State, 2001 (Cont.)
State
Delaware
Montana
Massachusetts
Connecticut
District of Columbia
Alaska
Number of
Procedures
Performed
480
280
3,180
2,580
260
1,100
Total
Charges
Average
Fee per
Procedure
Standard
Deviation
$293,900.00
$173,780.00
$1,994,280.00
$1,656,760.00
$182,000.00
$772,300.00
$612.29
$620.64
$627.13
$642.16
$700.00
$702.09
$92.49
$134.95
$175.53
$147.79
$125.83
$129.44
DIFFERENCES IN FEES FOR ROOT CANANLS BY STATE
Overall, the average fee for root canals among endodontists and general practitioners
were positively related and highly correlated (R-square = 0.72). In other words, in states
where the general practitioner average fee was high, the endodontist average fee was
also high. The differences in average fees between endodontists and general
practitioners varied substantially. The state with the smallest difference in average fees
charged by general practitioners and endodontists for root canals was Oklahoma, with a
difference of only $96.43. In contrast, the greatest difference in average fees occurred in
the District of Columbia ($395.64). The five states with the least difference in fees for root
canals between these two types of providers all had differences of less than $125, and the
five states with the greatest differences, all had differences above $280 (see Table A1-14).
111
Table A1-14: Average Differences in Fees for Root Canals Between
General Practitioners and Endodontists, by State, 2001
State
District of
Columbia
Number of
Procedures
Performed
GPs
Total
Charges
GPs
Number of
Procs
Performed
ENDOs
Total
Charges
ENDOs
Average
Fee Per
Procedure
GPs
Average
Fee Per
Procedure
ENDOs
Average
Difference
Fees per
Procedure
Between
Providers
260
$182,000.00
39
$42,730.00
$700.00
$1095.64
$395.64
Alaska
1,100
$772,300.00
41
$44,266.00
$702.09
$1079.66
$377.57
Washington
10,460
$5,751,876.00
$3,288,467.75
$549.89
$884.71
$334.82
3,717
Nevada
860
$462,640.00
199
$171,722.00
$537.95
$862.92
$324.97
Maine
820
$492,320.00
99
$91,220.00
$600.39
$921.41
$321.02
$351,635.00
$550.55
$868.23
$317.69
$4,102,686.72
$627.13
$928.00
$300.87
Georgia
7,100
$3,908,895.20
405
Massachusetts
3,180
$1,994,280.00
4,421
Maryland
940
$510,840.00
483
$406,432.00
$543.45
$841.47
$298.03
New
Hampshire
1,380
$822,800.00
504
$446,715.00
$596.23
$886.34
$290.11
Missouri
3,300
$1,533,080.00
1,251
$934,699.00
$464.57
$747.16
$282.59
New Mexico
1,560
$778,368.80
427
$326,500.39
$498.95
$764.64
$265.68
New Jersey
12,240
$7,133,120.00
2,840
$2,373,883.00
$582.77
$835.87
$253.10
Kansas
1,900
$900,060.00
1,606
$1,158,860.00
$473.72
$721.58
$247.87
Connecticut
2,580
$1,656,760.00
744
$658,607.00
$642.16
$885.22
$243.07
Ohio
6,140
$2,925,980.20
2,272
$1,631,404.75
$476.54
$718.05
$241.50
Vermont
20
$9,900.00
262
$192,927.50
$495.00
$736.36
$241.36
South Dakota
500
$198,300.00
222
$140,853.00
$396.60
$634.47
$237.87
$2,446,738.00
$503.79
$735.64
$231.85
$678,344.00
$475.16
$705.14
$229.98
Texas
20,840
$10,498,916.60
Tennessee
1,860
$883,800.00
Minnesota
6,440
$3,515,661.20
2,800
$2,148,988.00
$545.91
$767.50
$221.59
Illinois
29,860
$13,762,493.00
2,143
$1,462,557.00
$460.90
$682.48
$221.58
California
24,800
$15,090,996.00
15,814
$13,062,988.75
$608.51
$826.04
$217.53
47
$29,255.00
$407.79
$622.45
$214.66
$342,540.00
3,326
962
Mississippi
840
New York
11,620
$6,995,724.80
1,225
$996,305.00
$602.04
$813.31
$211.27
Pennsylvania
13,240
$6,392,390.00
4,266
$2,950,271.00
$482.81
$691.58
$208.77
Oregon
7,200
$3,727,720.00
1,299
$936,331.50
$517.74
$720.81
$203.07
112
Table A1-14: Average Differences in Fees for Root Canals Between
General Practitioners and Endodontists, by State, 2001 (Cont.)
State
Number of
Procedures
Performed
GPs
Total
Charges
GPs
Number of
Procedures
Performed
ENDOs
Total
Charges
ENDOs
Average
Fee Per
Procedure
GPs
Average
Fee Per
Procedure
ENDOs
Average
Difference
Fees per
Procedure
Between
Providers
$1,990,024.00
$503.45
$704.93
$201.48
$355,122.00
$373.69
$573.70
$200.01
North Carolina
5,240
$2,638,066.80
2,823
Kentucky
4,160
$1,554,560.00
619
Wisconsin
4,860
$2,525,240.00
1,894
$1,361,766.75
$519.60
$718.99
$199.39
Virginia
5,460
$2,882,460.00
1,770
$1,265,829.25
$527.92
$715.16
$187.23
Colorado
3,360
$1,968,520.00
3,086
$2,372,907.50
$585.87
$768.93
$183.06
Arizona
2,160
$1,164,640.00
1,798
$1,291,513.50
$539.19
$718.31
$179.12
Louisiana
5,820
$2,996,080.00
794
$550,076.00
$514.79
$692.79
$178.00
Michigan
12,640
$6,177,360.00
4,424
$2,934,347.50
$488.72
$663.28
$174.56
Iowa
2,960
$1,108,800.00
293
$158,495.00
$374.59
$540.94
$166.34
$218,900.00
140
$74,579.00
$377.41
$532.71
$155.29
North Dakota
580
Indiana
5,320
$2,674,340.00
881
$577,049.25
$502.70
$654.99
$152.30
Utah
1,880
$902,310.40
303
$189,920.00
$479.95
$626.80
$146.85
Arkansas
1,480
$795,620.00
335
$226,066.00
$537.58
$674.82
$137.24
Nebraska
2,420
$1,073,540.00
253
$144,950.00
$443.61
$572.92
$129.31
Idaho
7,360
$3,424,780.00
119
$70,645.00
$465.32
$593.66
$128.33
Florida
7,640
$4,353,660.00
2,863
$1,990,251.00
$569.85
$695.16
$125.31
Alabama
3,540
$1,690,020.00
899
$531,028.00
$477.41
$590.69
$113.28
South Carolina
1,520
$828,880.00
1,764
$1,145,207.00
$545.32
$649.21
$103.89
Delaware
480
$293,900.00
829
$592,632.00
$612.29
$714.88
$102.58
Oklahoma
9,760
$5,144,350.00
279
$173,960.00
$527.09
$623.51
$96.43
Montana
280
$173,780.00
0
0
$620.64
0
NA
West Virginia
200
$70,960.00
0
0
$354.80
0
NA
Wyoming
280
$113,660.00
0
0
$405.93
0
NA
113
APPENDIX II: SUPPLEMENTARY ANALYSIS—DETAILED
DESCRIPTION OF PROCEDURES PROVIDED BY
ENDODONTISTS
Table A2-1: Distribution of Dental Procedures Among Endodontists by
CDT Procedure for the Top 50 CDT Codes Among Endodontists, 2001
Summary
Statistics for
Endodontists
CDT Procedure Codes
and Descriptions
Percentage
Measures
Number of
Procedures
Performed
Number of
Patients
Receiving
Procedure
Average
Number
of Procedures
Per Patient
Percent
of
Total
Endontic
Procedures
Cumulative
Percent
of Total
Endontic
Procedures
Percent of
All Procedures
Performed
CDT3
Codes
Procedure
Description
D3330
53,325
51,473
1.04
27.80%
27.80%
27.56%
D0140
Limited oral eval.
33,180
32,281
1.03
17.30%
45.10%
17.15%
D0220
26,523
25,341
1.05
13.83%
58.92%
13.71%
D3320
15,410
14,795
1.04
8.03%
66.96%
7.96%
D9310
Consultation (dx. serv. by dentist
11,200
10,905
1.03
5.84%
72.79%
5.79%
D3310
8,845
7,946
1.11
4.61%
77.41%
4.57%
D0230
Intraoral - periapical each addl. film
6,620
5,517
1.20
3.45%
80.86%
3.42%
D0460
Pulp vitality tests
3,959
3,658
1.08
2.06%
82.92%
2.05%
D3348
Retreatment of previous root canal
3,632
3,512
1.03
1.89%
84.81%
1.88%
D2954
Prefab. post and core
3,261
3,012
1.08
1.70%
86.51%
1.69%
D3430
2,415
1,859
1.30
1.26%
87.77%
1.25%
D0120
Periodic oral eval.
2,045
1,994
1.03
1.07%
88.84%
1.06%
D9110
1,761
1,674
1.05
0.92%
89.76%
0.91%
D0150
Comprehensive oral eval.
1,616
1,589
1.02
0.84%
90.60%
0.84%
D9230
Analgesia, anxiolysis, inhalation
1,493
1,432
1.04
0.78%
91.38%
0.77%
D2140
Amalgam - 1 surface, permanent
1,485
1,427
1.04
0.77%
92.15%
0.77%
D3410
Apicoectomy/periradicular surgery
1,226
1,090
1.12
0.64%
92.79%
0.63%
D3346
1,172
1,067
1.10
0.61%
93.40%
0.61%
D2950
Core buildup, includes pins
1,170
1,115
1.05
0.61%
94.01%
0.60%
D3347
1,085
1,057
1.03
0.57%
94.58%
0.56%
D3425
1,051
1,016
1.03
0.55%
95.13%
0.54%
114
Table A2-1: Distribution of Dental Procedures Among Endodontists by CDT
Procedure for the Top 50 CDT Codes Among Endodontists, 2001 (Cont.)
Summary
Statistics for
Endodontists
CDT Procedure Codes
and Descriptions
Percentage
Measures
Number of
Procedures
Performed
Number of
Patients
Receiving
Procedure
Average
Number
of Procedures
Per Patient
Percent
of
Total
Endontic
Procedures
Cumulative
Percent
of Total
Endontic
Procedures
Percent of
All Procedures
Performed
CDT3
Codes
Procedure
Description
D0130
Emergency oral examination - NOS
1,050
1,037
1.01
0.55%
95.67%
0.54%
D2385
Resin-composite - 1 surface, poster
990
950
1.04
0.52%
96.19%
0.51%
D3421
749
712
1.05
0.39%
96.58%
0.39%
D3332
Incomplete endodontic therapy
585
567
1.03
0.30%
96.88%
0.30%
D2330
Resin-composite - 1 surface, anterior
534
492
1.09
0.28%
97.16%
0.28%
D3950
Canal preparation and fitting of
preformed dowel or post
505
480
1.05
0.26%
97.43%
0.26%
D0160
Detailed and extensive oral eval.
461
454
1.02
0.24%
97.67%
0.24%
D4910
Periodontal maintenance procedures
456
429
1.06
0.24%
97.90%
0.24%
D3999
355
331
1.07
0.19%
98.09%
0.18%
D3426
352
323
1.09
0.18%
98.27%
0.18%
D7510
Incision and drainage of abscess
342
328
1.04
0.18%
98.45%
0.18%
D2955
Post removal (not w endodontic tx)
307
289
1.06
0.16%
98.61%
0.16%
D2940
Sedative filling
282
268
1.05
0.15%
98.76%
0.15%
D3220
Therapeutic pulpotomy removal, meds
230
215
1.07
0.12%
98.88%
0.12%
D3351
Apexification/recalcification
230
194
1.19
0.12%
99.00%
0.12%
D0272
Bitewings - 2 films
212
200
1.06
0.11%
99.11%
0.11%
D4341
Periodontal scaling and root planing
191
98
1.95
0.10%
99.21%
0.10%
D7110
Extraction - single tooth
185
164
1.13
0.10%
99.30%
0.10%
D3960
Bleaching of discolored tooth (2)
180
168
1.07
0.09%
99.40%
0.09%
D0270
Bitewing - 1 film
150
146
1.03
0.08%
99.48%
0.08%
D0415
149
144
1.03
0.08%
99.55%
0.08%
D3331
Treatment of root canal obstruction
142
134
1.06
0.07%
99.63%
0.07%
D7286
Biopsy of oral tissue
121
121
1.00
0.06%
99.69%
0.06%
D9430
116
114
1.02
0.06%
99.75%
0.06%
D3450
112
110
1.02
0.06%
99.81%
0.06%
115
Table A2-1: Distribution of Dental Procedures Among Endodontists by CDT
Procedure for the Top 50 CDT Codes Among Endodontists, 2001 (Cont.)
Summary
Statistics for
Endodontists
CDT Procedure Codes
and Descriptions
Percentage
Measures
Number of
Procedures
Performed
Number of
Patients
Receiving
Procedure
Average
Number
of Procedures
Per Patient
Percent
of
Total
Endontic
Procedures
Cumulative
Percent
of Total
Endontic
Procedures
111
91
1.22
0.06%
99.87%
0.06%
Percent of
All Procedures
Performed
CDT3
Codes
Procedure
Description
D3352
D9999
Unspecified adjunctive procedure
88
86
1.02
0.05%
99.91%
0.05%
D4263
Bone replacement graft - 1st site
85
81
1.05
0.04%
99.96%
0.04%
D2150
Amalgam - 2 surfaces, permanent
81
80
1.01
0.04%
100.0%
0.04%
Totals
191,825 182,566
116
100.0%
99.12%
Table A2-2: Distribution of Dental Procedures Among General
Practitioners by CDT Procedure Ranked by Frequency of the Top 50 CDT
Procedures Performed by Endodontists, 2001
CDT Procedure Codes
and Descriptions
CDT3
Codes
Procedure
Description
Summary
Statistics for
Number of
Procedures
Performed
Number of
Patients
Receiving
Procedure
Percentage
Measures
Average
Number
of Procedures
Per Patient
Percent
of
Total
Endontic
Procedures
Cumulative
Percent
of Total
Endontic
Procedures
Percent of
All Procedures
Performed
D3330
126,460
117,720
1.07
0.55%
0.55%
0.26%
D0140
Limited oral eval.
676,980
642,960
1.05
2.94%
3.49%
1.41%
D0220
1,939,500
1,782,200
1.09
8.43%
11.92%
4.05%
D3320
70,800
66,100
1.07
0.31%
12.22%
0.15%
D9310
Consultation (dx. serv. by dentist)
37,660
36,440
1.03
0.16%
12.39%
0.08%
D3310
63,180
52,980
1.19
0.27%
12.66%
0.13%
D0230
1,470,700
800,380
1.84
6.39%
19.05%
3.07%
D0460
Pulp vitality tests
13,300
11,600
1.15
0.06%
19.11%
0.03%
D3348
2,020
1,880
1.07
0.01%
19.12%
0.00%
D2954
Prefab. post and core in addition
95,900
83,940
1.14
0.42%
19.54%
0.20%
D3430
2,820
2,160
1.31
0.01%
19.55%
0.01%
D0120
Periodic oral eval.
8,631,340
8,427,900
1.02
37.50%
57.05%
18.02%
D9110
154,960
145,500
1.07
0.67%
57.72%
0.32%
D0150
1,544,880
1,502,340
1.03
6.71%
64.43%
3.23%
D9230
Analgesia, anxiolysis, inhalation
225,840
201,900
1.12
0.98%
65.41%
0.47%
D2140
697,080
453,300
1.54
3.03%
68.44%
1.46%
D3410
1,620
1,500
1.08
0.01%
68.45%
0.00%
D3346
660
540
1.22
0.00%
68.45%
0.00%
D2950
222,600
185,320
1.20
0.97%
69.42%
0.46%
D3347
640
640
1.00
0.00%
69.42%
0.00%
D3425
1,180
1,140
1.04
0.01%
69.43%
0.00%
D0130
97,420
93,280
1.04
0.42%
69.85%
0.20%
117
Procedures Performed by Endodontists, 2001 (Cont.)
CDT Procedure Codes
and Descriptions
CDT3
Codes
Procedure
Description
D2385
Resin-composite - 1 surface,
poster
D3421
Summary
Statistics for
Number of
Procedures
Performed
Number of
Patients
Receiving
Procedure
Percentage
Measures
Average
Number
of Procedures
Per Patient
Percent
of
Total
Endontic
Procedures
Cumulative
Percent
of Total
Endontic
Procedures
Percent of
All Procedures
Performed
1,436,940
830,920
1.73
6.24%
76.09%
3.00%
840
820
1.02
0.00%
76.10%
0.00%
D3332
100
100
1.00
0.00%
76.10%
0.00%
D2330
anterior
647,920
404,480
1.60
2.81%
78.91%
1.35%
D3950
1,020
860
1.19
0.00%
78.92%
0.00%
D0160
9,540
9,100
1.05
0.04%
78.96%
0.02%
D4910
Periodontal maintenance
procedures
524,820
469,680
1.12
2.28%
81.24%
1.10%
D3999
1,120
1,020
1.10
0.00%
81.24%
0.00%
D3426
620
580
1.07
0.00%
81.25%
0.00%
D7510
Incision and drainage of abscess-
7,820
7,120
1.10
0.03%
81.28%
0.02%
D2955
Post removal (not w endodontic
tx)
140
140
1.00
0.00%
81.28%
0.00%
D2940
Sedative filling
76,040
65,620
1.16
0.33%
81.61%
0.16%
D3220
Therapeutic pulpotomy removal
106,480
76,020
1.40
0.46%
82.07%
0.22%
D3351
240
240
1.00
0.00%
82.07%
0.00%
D0272
Bitewings - 2 films
2,124,600
2,085,540
1.02
9.23%
91.30%
4.44%
D4341
Periodontal scaling and root
planing
411,280
175,120
2.35
1.79%
93.09%
0.86%
D7110
635,440
484,680
1.31
2.76%
95.85%
1.33%
D3960
7,560
6,600
1.15
0.03%
95.88%
0.02%
D0270
Bitewing - 1 film
68,640
56,920
1.21
0.30%
96.18%
0.14%
D0415
4,940
4,580
1.08
0.02%
96.20%
0.01%
D3331
Treatment of root canal
obstruction
20
20
1.00
0.00%
96.20%
0.00%
118
Procedures Performed by Endodontists, 2001 (Cont.)
CDT Procedure Codes
and Descriptions
CDT3
Codes
Procedure
Description
D7286
Biopsy of oral tissue
D9430
Summary
Statistics for
Number of
Procedures
Performed
Number of
Patients
Receiving
Procedure
Percentage
Measures
Average
Number
of Procedures
Per Patient
Percent
of
Total
Endontic
Procedures
Cumulative
Percent
of Total
Endontic
Procedures
Percent of
All Procedures
Performed
5,080
4,360
1.17
0.02%
96.23%
0.01%
39,680
37,940
1.05
0.17%
96.40%
0.08%
D3450
600
600
1.00
0.00%
96.40%
0.00%
D3352
160
160
1.00
0.00%
96.40%
0.00%
D9999
61,540
51,360
1.20
0.27%
96.67%
0.13%
D4263
Bone replacement graft - 1st site
6,520
4,620
1.41
0.03%
96.70%
0.01%
D2150
759,980
542,560
1.40
3.30%
100.0%
1.59%
23,017,220
19,933,480
Totals
119
100.0%
48.06%
Table A2-3: Selected Summary Fee Statistics by CDT Procedure for the
Top 50 CDT Codes Among Endodontists, 2001
CDT Procedure Codes
and Descriptions
Summary
Statistics
Num of
Patients
Receiving
Procs
Number of
Procs
Performed
Measures of
Central Tendency
CDT3
Codes
Procedure
Description
Total
Charges
D3330
51,473
53,325 $43,309,122.03
D0140
Limited oral eval.
32,281
33,180
D0220
25,341
26,523
D3320
D9310
Average
Fee
Per
Procedure
Standard
Deviation
Median
$812.17
$128.15
$799.00
$1,916,268.40
$57.75
$14.79
$55.00
$494,221.70
$18.63
$9.57
$17.00
14,795
15,410 $10,508,833.75
$681.95
$112.11
$665.00
Consultation (dx. serv. by
dentist/physician not provider)
10,905
11,200
$823,423.60
$73.52
$24.08
$75.00
D3310
7,946
8,845
$5,253,800.33
$593.99
$111.57
$580.00
D0230
5,517
6,620
$90,408.00
$13.66
$4.87
$12.75
D0460
Pulp vitality tests
3,658
3,959
$106,120.00
$26.80
$13.70
$25.00
D3348
therapy - molar
3,512
3,632
$3,182,320.87
$876.19
$162.99
$875.00
D2954
Prefab. post and core in addition to
crown
3,012
3,261
$691,235.50
$211.97
$56.97
$195.00
D3430
1,859
2,415
$319,942.11
$132.48
$48.25
$125.00
D0120
Periodic oral eval.
1,994
2,045
$122,677.00
$59.99
$23.07
$56.00
D9110
Palliative (emergency) treatment of
dental pain - minor proc.
1,674
1,761
$255,464.50
$145.07
$63.67
$150.00
D0150
1,589
1,616
$98,282.00
$60.82
$17.91
$65.00
D9230
Analgesia, anxiolysis, inhalation of
nitrous oxide
1,432
1,493
$67,753.00
$45.38
$21.64
$45.00
D2140
1,427
1,485
$114,057.50
$76.81
$22.03
$70.00
D3410
Apicoectomy/periradicular surgery anterior
1,090
1,226
$751,438.60
$612.92
$175.40
$600.00
D3346
therapy - anterior
1,067
1,172
$773,704.00
$660.16
$132.97
$650.00
D2950
1,115
1,170
$175,870.75
$150.32
$53.51
$145.00
D3347
therapy - bicuspid
1,057
1,085
$811,847.45
$748.25
$137.65
$740.00
D3425
Apicoectomy/periradicular surgery molar (1st root)
1,016
1,051
$725,131.90
$689.94
$202.83
$700.00
D0130
1,037
1,050
$66,449.00
$63.28
$20.05
$69.00
120
Top 50 CDT Codes Among Endodontists, 2001 (Cont.)
CDT Procedure Codes
and Descriptions
Summary
Statistics
Num of
Patients
Receiving
Procs
Number of
Procs
Performed
Measures of
Central Tendency
CDT3
Codes
Procedure
Description
D2385
posterior-permanent
950
990
$86,032.50
$86.90
$28.99
$85.00
D3421
Apicoectomy/periradicular surgery bicuspid (1st root)
712
749
$486,315.59
$649.29
$172.17
$630.00
D3332
567
585
$103,446.66
$176.83
$90.30
$150.00
D2330
anterior
492
534
$43,663.00
$81.77
$24.71
$85.00
D3950
480
505
$24,246.00
$48.01
$33.57
$33.00
D0160
454
461
$28,296.70
$61.38
$35.50
$56.00
D4910
procedures (following active
therapy)
429
456
$45,533.00
$99.85
$31.67
$81.00
D3999
331
355
$54,884.18
$154.60
$108.24
$150.00
D3426
(addl. root)
323
352
$59,231.00
$168.27
$98.75
$150.00
D7510
Incision and drainage of abscess intraoral soft tissue
328
342
$38,858.50
$113.62
$54.42
$100.00
D2955
Post removal (not w endodontic
therapy)
289
307
$58,083.08
$189.20
$83.49
$175.00
D2940
Sedative filling
268
282
$18,480.00
$65.53
$31.79
$52.00
D3220
Therapeutic pulpotomy removal,
meds. (excl. final restoration)
215
230
$37,862.17
$164.62
$79.56
$150.00
D3351
Apexification/recalcification - initial
visit
194
230
$53,259.50
$231.56
$109.35
$225.00
D0272
Bitewings - 2 films
200
212
$4,993.00
$23.55
$1.61
$25.00
D4341
Periodontal scaling and root planing,
per quadrant
98
191
$31,448.00
$164.65
$45.79
$180.00
D7110
164
185
$22,384.00
$120.99
$39.08
$125.00
D3960
168
180
$28,900.00
$160.56
$62.00
$150.00
D0270
Bitewing - 1 film
146
150
$2,559.00
$17.06
$5.37
$15.00
D0415
Bacteriologic studies for pathologic
agents
144
149
$5,215.00
$35.00
$0.00
$35.00
121
Total
Charges
Average
Fee
Per
Procedure
Standard
Deviation
Median
Top 50 CDT Codes Among Endodontists, 2001 (Cont.)
CDT Procedure Codes
and Descriptions
Summary
Statistics
Num of
Patients
Receiving
Procs
Number of
Procs
Performed
Measures of
Central Tendency
CDT3
Codes
Procedure
Description
D3331
Treatment of root canal obstruction non-surgical access
134
142
$37,316.00
$262.79
$171.07
$217.50
D7286
Biopsy of oral tissue - soft (all
others)
121
121
$14,602.00
$120.68
$50.37
$105.00
D9430
Office visit for observation (regular
hours) - no other services
114
116
$6,769.10
$58.35
$43.96
$50.00
D3450
110
112
$49,224.00
$439.50
$152.61
$432.50
D3352
Apexification/recalcification - interim
medication repl.
91
111
$12,982.00
$116.95
$55.38
$100.00
D9999
86
88
$11,669.00
$132.60
$97.77
$125.00
D4263
Bone replacement graft - 1st site in
quad.
81
85
$19,380.00
$228.00
$143.17
$200.00
D2150
80
81
$7,566.00
$93.41
$23.88
$80.00
122
Total
Charges
Average
Fee
Per
Procedure
Standard
Deviation
Median
Table A2-4: Selected Summary Fee Statistics by CDT Procedure Among General
Practitioners, for the Top 50 CDT Codes Among Endodontists, 2001
CDT Procedure Codes
and Descriptions
Summary
Statistics
Measures of
Central Tendency
CDT3
Codes
Procedure
Description
Number of
Patients
Receiving
Procedure
D0120
Periodic oral eval.
8,427,900
8,631,340
$248,116,387.20
$28.75
$9.01
$28.00
D0272
Bitewings - 2 films
2,085,540
2,124,600
$53,466,818.20
$25.17
$7.06
$25.00
D0220
1,782,200
1,939,500
$30,908,291.60
$15.94
$5.22
$15.00
D0150
1,502,340
1,544,880
$65,369,855.60
$42.31
$15.75
$39.00
D0230
Intraoral - periapical each addl.
film
800,380
1,470,700
$16,665,889.00
$11.33
$4.18
$11.00
D2385
posterior-permanent
830,920
1,436,940
$144,787,555.20 $100.76
$30.66
$100.00
D2150
Amalgam - 2 surfaces,
permanent
542,560
759,980
$67,170,935.20
$88.39
$21.87
$85.00
D2140
Amalgam - 1 surface,
permanent
453,300
697,080
$47,946,391.20
$68.78
$18.14
$66.00
D0140
Limited oral eval.
642,960
676,980
$27,213,680.40
$40.20
$13.49
$38.00
D2330
anterior
404,480
647,920
$58,616,695.40
$90.47
$27.55
$86.00
D7110
484,680
635,440
$50,995,316.80
$80.25
$25.77
$78.00
D4910
procedures (following active
therapy)
469,680
524,820
$47,443,328.20
$90.40
$21.04
$89.00
D4341
Periodontal scaling and root
planing, per quadrant
175,120
411,280
$57,240,026.40 $139.18
$53.51
$145.00
D9230
Analgesia, anxiolysis,
inhalation of nitrous oxide
201,900
225,840
$28.76
$13.90
$27.00
D2950
185,320
222,600
$33,206,010.20 $149.17
$44.83
$145.00
D9110
Palliative (emergency)
treatment of dental pain minor proc.
145,500
154,960
$61.52
$31.70
$55.00
D3330
117,720
126,460
$76,788,345.80 $607.21
$135.73
$600.00
D3220
Therapeutic pulpotomy
removal, meds. (excl. final
restoration)
76,020
106,480
$9,474,321.00
$88.98
$35.12
$92.00
D0130
Emergency oral examination NOS
93,280
97,420
$4,203,816.60
$43.15
$13.51
$40.00
Number of
Procedures
Performed
123
Total
Charges
$6,495,632.20
$9,533,836.80
Average
Fee
Per
Procedure
Standard
Deviation
Median
Practitioners, for the Top 50 CDT Codes Among Endodontists, 2001 (Cont.)
CDT Procedure Codes
and Descriptions
Summary
Statistics
Number of
Patients
Receiving
Procedure
Number of
Procedures
Performed
Measures of
Central Tendency
CDT3
Codes
Procedure
Description
D2954
Prefab. post and core in
addition to crown
83,940
95,900
$18,984,461.60
$197.96
$53.81
$192.00
D2940
Sedative filling
65,620
76,040
$4,625,701.00
$60.83
$21.29
$60.00
D3320
Bicuspid (excl. final
restoration)
66,100
70,800
$34,284,290.40
$484.24
$115.47
$475.00
D0270
Bitewing - 1 film
56,920
68,640
$905,672.20
$13.19
$6.87
$14.00
D3310
52,980
63,180
$24,945,552.80
$394.83
$100.74
$388.00
D9999
Unspecified adjunctive
procedure
51,360
61,540
$1,540,844.60
$25.04
$56.32
$10.00
D9430
(regular hours) - no other
services
37,940
39,680
$1,634,499.80
$41.19
$16.25
$40.00
D9310
Consultation (dx. serv. by
dentist/physician not provider)
36,440
37,660
$2,417,840.00
$64.20
$36.48
$65.00
D0460
Pulp vitality tests
11,600
13,300
$399,910.40
$30.07
$11.51
$31.00
D0160
eval.
9,100
9,540
$820,828.20
$86.04
$66.53
$65.00
D7510
Incision and drainage of
abscess - intraoral soft tissue
7,120
7,820
$864,923.60
$110.60
$49.30
$100.00
D3960
Bleaching of discolored tooth
(2)
6,600
7,560
$1,054,922.00
$139.54
$112.84
$125.00
D4263
Bone replacement graft - 1st
site in quad.
4,620
6,520
$1,206,800.00
$185.09
$174.84
$170.00
D7286
Biopsy of oral tissue - soft (all
others)
4,360
5,080
$840,137.00
$165.38
$87.80
$160.00
D0415
pathologic agents
4,580
4,940
$73,180.00
$14.81
$33.33
$6.00
D3430
2,160
2,820
$301,380.00
$106.87
$41.17
$100.00
D3348
Retreatment of previous root
canal therapy - molar
1,880
2,020
$1,375,840.00
$681.11
$190.07
$708.00
D3410
Apicoectomy/periradicular
surgery - anterior
1,500
1,620
$697,950.00
$430.83
$145.84
$405.00
D3425
surgery - molar (1st root)
1,140
1,180
$596,740.00
$505.71
$155.87
$500.00
124
Total
Charges
Average
Fee
Per
Procedure
Standard
Deviation
Median
Practitioners, for the Top 50 CDT Codes Among Endodontists, 2001 (Cont.)
CDT Procedure Codes
and Descriptions
CDT3
Codes
Procedure
Description
D3999
Unspecified endodontic
procedure
D3950
Summary
Statistics
Number of
Patients
Receiving
Procedure
Number of
Procedures
Performed
Measures of
Central Tendency
Total
Charges
Average
Fee
Per
Procedure
Standard
Deviation
Median
1,020
1,120
$156,640.00
$139.86
$106.81
$96.00
860
1,020
$53,912.40
$52.86
$38.32
$55.00
D3421
surgery - bicuspid (1st root)
820
840
$386,920.00
$460.62
$150.10
$446.00
D3346
canal therapy - anterior
540
660
$300,660.00
$455.55
$139.92
$450.00
D3347
canal therapy - bicuspid
640
640
$324,120.00
$506.44
$146.37
$497.50
D3426
surgery (addl. root)
580
620
$95,320.00
$153.74
$71.44
$125.00
D3450
600
600
$181,750.00
$302.92
$201.79
$262.50
D3351
Apexification/recalcification initial visit
240
240
$48,780.00
$203.25
$103.01
$225.00
D3352
Apexification/recalcification interim medication repl.
160
160
$20,600.00
$128.75
$84.76
$115.50
D2955
Post removal (not w
endodontic therapy)
140
140
$21,880.00
$156.29
$44.52
$160.00
D3332
100
100
$17,680.00
$176.80
$87.46
$169.00
D3331
Treatment of root canal
obstruction - non-surgical
access
20
20
$9,480.00
$474.00
.
$474.00
125
APPENDIX III: METHODOLOGY
Five ADA sources of data were used for the analyses presented in this report. They are:
1.
2.
3.
4.
5.
Distribution of Dentists in the United States by Region and State (DOD)
Survey of Dental Fees (SDF)
Survey of Dental Practice (SDP)
Survey of Dental Services Rendered (SDSR)
Distribution of Dentists by Region and State
The ADA's Distribution of Dentists in the United States by Region and State is a census of
all known dentists in the U.S., its possessions, and territories and has been conducted
periodically since the 1940s. During the census, multiple attempts are made to contact
every dentist, independent of ADA membership status.
The census is conducted annually using a panel methodology. That is, all dentists are
assigned to one of three panels, and every year one panel is contacted and information is
updated for one-third of all dentists. This panel method of conducting the census was
implemented in 1993.
The conduct of the survey was similar for each of the three years/panels (1997, 1998, and
1999). An initial mailing consisting of a cover letter and questionnaire was sent to dentists
(62,828 in 1997, 66,461 in 1998, and 69,020 in 1999) listed in the ADA's files regardless of
Association membership status, practice status, or licensure. The questionnaire
requested information on the following: primary and secondary occupations; practice,
research or administration area; specialties in which the dentist is licensed; gender; age;
state(s) in which a dental license is held and types of license; and for active private
practitioners, the county, state, and zip code where the primary office is located, the phone
number of the primary office, and their ownership status with respect to their primary
office. If appropriate, dentists were asked to provide their retirement date.
Two follow-up questionnaires were mailed to non-respondents at approximate six-week
intervals. A telephone interview follow-up was conducted with those dentists with
undeliverable addresses and dentists who remained non-respondents after three mailings.
The final adjusted response rates for 1997, 1998, and 1999 were 93.1%, 90.8%, and
85.9%, respectively. Overall, the final adjusted response rate was 89.8%.
Survey of Dental Fees
The ADA’s Survey of Dental Fees (SDF) collects information on dental fees from dentists
in private practice. The survey is mandated by the House of Delegates and is conducted
every two years.
The questionnaire asks dentists to record the fee most often charged for different dental
procedures. As not all procedures can be included in the survey, only the most commonly
126
completed procedures are included. The 1999 SDF questionnaire collected information on
167 fees for the most common dental procedures. The procedure codes for the 1999
Survey of Dental Fees were taken from Current Dental Terminology, 2nd Edition (CDT-2).
The 1999 SDF sample was selected from the ADA's national sampling frame of active
private practitioners, which included member and non-member dentists. The sample,
representing 4.5% of the population, was a simple random probability sample of 6,828
private practicing dentists, of whom 64.6% were general practitioners and 35.4% were
specialists.
The 1999 SDF was initially mailed in May 1999, and two follow-up mailings to nonrespondents were sent in June and August of 1999. To encourage participation from
those who had not returned the survey, telephone calls were made to non-respondents in
September of 1999. Those individuals who were contacted by phone and expressed a
willingness to participate in the survey were included in a final mailing in November of
1999. Data collection was concluded in January of 2000. The final adjusted response
rate of 45.2% excludes those individuals who were retired, not in private practice,
deceased, or had unknown or foreign addresses.
Survey of Dental Practice
The Survey of Dental Practice (SDP) dates back to 1950 and has been conducted
annually since 1982. It is the principal means by which the ADA collects the most
comprehensive and reliable statistical information on the private practice of dentistry in the
U.S.
The SDP focuses on practice characteristics such as the number and frequency of patient
visits, work schedules of dentists, and staff, auxiliary employment, as well as wages,
expenses, and income.
Data collection for the 2001 SDP began in May 2001. Two follow-up mailings were sent to
non-respondents in June and July. After the three mailings, non-respondents were
contacted by telephone in August 2001. Data collection was completed in December
2001.
The sample was adjusted by removing dentists who were retired, deceased, not in private
practice, or not locatable, resulting in a final adjusted overall response rate of 44.6%.
Survey of Dental Services Rendered
The ADA’s Survey of Dental Services Rendered (SDSR) provides statistical information on
the patients treated by dentists in private practice and on the dental services they receive.
The SDSR has been conducted approximately every ten years since 1959.
The questionnaire asked dentists to record demographic information about, and
procedures completed for every patient seen on one day. National estimates on the
number of procedures performed yearly by active private practitioners were calculated
from the information collected by the survey. Separate estimates were constructed for
general practitioners and for six of the ADA recognized specialty groupings.
127
The nomenclature and procedure codes used in the 1990 SDSR were CDT-1 or earlier
codes and those in the 1999 SDSR were CDT-2 codes. Because of the large number of
dental codes, not all procedures could be included in the survey. Only the most commonly
completed procedures were listed on the questionnaire. The endodontic procedures in the
1990 Survey of Dental Services Rendered were:
03110-03120
03220
03310
03320
03330
03340
03410-03440
03450
03460
03960
Pulp cap
Pulpotomy
Root canal therapy - one canal
Root canal therapy - two canals
Root canal therapy - three canals
Root canal therapy - four or more canals
Endodontics, surgery
Root amputation
Endodontic endosseous implant
Bleaching of discolored tooth
The endodontic procedure codes in the 1999 SDSR changed slightly as follows:
03110, 03120 Pulp cap
03220
Pulpotomy
03310
Anterior endodontic treatment
03320
Bicuspid endodontic treatment
03330
Molar endodontic treatment
03410-03426 Apicoectomy/periradicular surgery
03450
Root amputation
03460
Endodontic endosseous implant
3960 Bleaching of discolored tooth
Data collection for the 1999 SDSR began in July 1999. Three follow-up mailings were
sent to non-respondents in August, October, and November. After the four regular
mailings, non-respondents were contacted by telephone in December 1999 and January
2000. A fifth mailing was then sent out in January 2000. A total of 3,371 responses were
received for a final adjusted response rate of 41.4%.
The ADA’s Health Policy and Resources Center (HPRC) maintains a large multi-year
electronic dental claims database. The data is obtained from a large electronic claims
processor or clearinghouse and is sent to the ADA on a monthly basis. Currently, the
database spans the time period from 1997 to the present and consists of procedure level
data on more than 84.5 million patients from 76,000 offices in all fifty states, U.S.
territories, and the District of Columbia. Currently, the database contains 147 million
electronic claims and their accompanying procedure detail from 1997 to mid-year 2003.
The electronic dental claims data included in this study covered the time period of July
2001 to December 31st 2001.
128
Patient and procedure data fields found in the electronic claims database include
identifiers, patient age, gender, dates of service, geographic location, and CDT procedure
codes, as well as corresponding fee data. Encrypted identifiers are used to identify
patients, payers, and providers in the database. The ADA has no method to discover the
actual identity of any participant (patient, subscriber, payer, or provider) in the electronic
claims database. The values of the remaining non-identifier fields are the actual values
processed by the electronic claims clearing house while the identification of the parties
involved is unknown.
Data are added to the database on a monthly basis and is checked for accuracy.
Computer programs check each record for the accuracy of CDT data present, date of
birth, patient or provider zip code information, and other types of errors. Records that
contain errors are flagged so they can be excluded from future statistical analysis as
appropriate. Ongoing assessment of data quality is included as part of the claims
database maintenance process.
CDT procedures codes can be CDT-2, or CDT-3 depending upon the coding conventions
implemented in the field. As part of database processing CDT-2 codes are mapped to their
CDT-3 equivalents. For CDT-2 codes that were discontinued in CDT-3, the CDT-2 code is
retained in the database to preserve the claims record for analysis. Database processing
accommodates all coding conventions used by the field and preserves the integrity of the
data.
CLASSIFICATION METHODS USED TO IDENTIFY ENDODONTISTS AND GENERAL PRACTITIONERS IN
THE ELECTRONIC CLAIMS DATA ANALYSIS
The HPRC electronic claims database offered the opportunity for a highly detailed
examination of dental procedure delivery provided that one major problem could be
solved. For any study of dental procedure data to provide meaningful information, the
provider's submitting data to the database have to be sorted and tabulated by specialty.
The major problem with the electronic claims database was that each provider's area of
specialty was unknown.
In order for the claims database to be used to investigate dental procedures used by
endodontists and general practitioners, a method had to be devised to assign provider
specialty type in the claims database. Any method used for assigning specialty would
have to be based on the demographic, Current Dental Terminology (CDT) procedure
codes, and other types of data already found in the claims database. At the same time,
any source used to develop the method had to have similar data to that found in the claims
database and the dentist or dental office specialty. If these conditions could not be met
then the method of assignment would be little better than an educated guess based on the
types of procedures and patients encountered across time in the database.
Fortunately, a source with common data fields and known provider specialty was found in
the ADA's 1999 SDSR. The SDSR had data on patient demographics, CDT procedures,
and dental specialty. The 1999 SDSR had 3,299 respondents, some 149 of which were
endodontists. All respondents had data about the number and type of CDT procedures
performed by the dentist on the day of the survey. The 1999 SDSR provided the source
129
data for developing a method to classify dental providers as endodontists or general
practitioners in the electronic claims database.
Logistic regression was chosen as the statistical method to assign specialties in the claims
database based on statistical differences in procedure use seen among the specialties in
the 1999 SDSR. The 1999 SDSR data file was split randomly into two equal parts; the
first part was used to develop the predictive model, while the second part was withheld to
be scored later by the finished model for validation purposes. The variables that were
used in the logistic regression model were identified by a preliminary inferential analysis of
the SDSR data. The variables eventually chosen for inclusion in the model building
process were the rates of occurrence for bicuspid and molar root canals observed for the
provider at the day of survey and their squares. The predictive equation resulting from the
logistic regression model achieved a predictive accuracy of 85% in both the development
and validation data files for identifying an endodontist provider and an accuracy of better
than 99% in predicting a general practitioners for an overall accuracy of 99%.
After the logistic regression model was completed the process of identifying endodontists
and general practitioners in the electronic claims database could begin. The first step in
the process was to compute the same set of provider-specific root canal rates as was
used in the 1999 SDSR modeling processing from the dental procedure detail found in the
claims data. Dental providers who had no root canals during the six month time period
where dropped from the analysis. This was done for the time period of July 1st to
December 31st, 2001. After that step was finished, all that remained to be done was to
obtain a prediction of the dentist's specialty. The prediction was calculated by inputting the
values for the bicuspid and molar root canal rates for the dentists in the claims database
into the specialty prediction equation derived from the logistic regression model This
process resulted in each dentist in the claims database receiving a score ranging from
zero to one as to the likelihood of their being an endodontist. A zero meant definitely not
an endodontist and a one indicated a certain endodontist. Predicted scores equal to or
below .5 were assigned to the general practitioner group while scores above .5 were
assigned to the endodontist group. The predictive equation derived from the 1999 SDSR
logistic regression model was used to score the dental providers in the electronic claims
database.
The process described above identified a total of 666 endodontists and 42,707 general
practitioner providers in the claims database for the six month time period of July 2001
through December 2001. The percent of each specialty obtained compared favorably with
the percent found in the 1999 SDSR (2.3 vs. 1.5 percent identified in the claims database).
The lower percent of endodontists found in the electronic claims database was expected
due to the smaller size of endodontists practices in general and their correspondingly
smaller administrative demands.
The administrative demands of endodontists are less burdensome than general
practitioners due to their specialty. Endodontist see fewer patients who almost all require
root canals. Patient billing is done using a much smaller set of CDT codes, so insurance
claims are less complex and easier to file. Typically, lower participation in electronic
claims processing services is seen in smaller dental offices, in those offices with less
complex claim filing demands, or in offices that do not accept insured patients.
130
Endodontists were less numerous in the claims database due to their lower demand for
electronic claims processing services in general.
SAMPLING OF GENERAL PRACTITIONERS
The large number of general practitioners created a data processing problem due to the
sheer volume of claims and CDT detail that needed to be analyzed for the study.
Accordingly, it was decided to implement a five percent random sampling of general
practitioners to create a workable comparison group for the analysis. Statistics presented
for the general practice group would then be weighted in later tabulations and analyses.
After sampling, the resulting number of dental providers participating in the study became
all of the identified endodontists (n=666) and five percent of the general practitioners
(n=2,135).
The resulting sample of 2,801 dental providers contained data about 877,177 patients who
received a total of 2,588,025 dental procedures during the six-month period of the
electronic claims database. For the same time period, a total of 102,050 endodontic
patients were identified. These patients received 166,521 individual endodontic
procedures (CDT codes D3110 to D3999) for an average of 1.63 endodontic procedures
per patient during the six-month period analyzed. Statistics seen for patient and procedure
counts among general practitioners in tabulations will be larger due to the weighting of this
group.
LIMITATIONS OR PROBLEMS FOUND FOR CLASSIFICATION METHODS USED TO IDENTIFY
ENDODONTISTS AND GENERAL PRACTITIONERS
There are three possible limitations found with the electronic claims database itself, and in
the 1999 SDSR survey data used to derive the predictive model used to assign provider
specialty in the claims database that should be discussed. The first is that the 1999 SDSR
procedure data is based on only a single day of observation. A second limitation is that
data in the claims database is not always assignable to a single dentist office. The third
limitation is that the decision to participate in an electronic claims processing service might
be a source of bias in the study. Each possible limitation will be discussed below.
The data from the 1999 SDSR that was used to develop the predictive model for dental
specialty collected procedure data for a one-day point in time. It is possible, but very
unlikely, that some general practitioners included in the SDSR organized their patient
workload so that all of their root canals are done on a single day of the week. If that day
was the same day as the data collection for the SDSR survey, then the general
practitioner would have looked exactly like an endodontist to the model-building process.
The existence of this practice pattern on the day of the survey would cause the general
practitioner to be incorrectly designated as an endodontist. There is evidence that this
practice pattern occurred infrequently (<1%) in the 1999 SDSR and did not result in the
misclassification of many general practitioners.
The limitation discussed above is mitigated by the greater length of the data collection time
used in the claims data base analysis. The claims data used in this study covered 6
months from July through December 2001. Accordingly, general practitioners who
blocked-out days to perform certain types of procedures would not be misclassified in the
claims database because the actual classification would be based on their overall practice
131
during the six month period. The greater period of time used in the claims database
analysis would eliminate any misclassification that arose in the 1999 SDSR logistic
regression model due to a general practitioner's practice pattern.
Endodontists were more likely not to be identified as endodontists in the claims database if
they were in mixed practices. A dental office in the claims database can submit claims for
all dentists in the practice. When endodontists are in practice with general practitioners,
the large and varied number of procedures completed by the general practitioners could
cause the root canal rate to fall below the level needed to categorize the provider as an
endodontist. However, mixed group practices involving endodontists and other types of
dentists are not common. So any bias would also be small.
A final limitation concerns the existence of a selection bias in the claims database due to
providers' decisions to file electronic or paper claims. As discussed previously, lower
participation in electronic claims processing services is seen in offices that do not accept
root canal patients, smaller dental offices, and in those offices with less complex claim
filing demands. Any of these three reasons could introduce a bias into conclusions drawn
from an analysis based on the claims database.
Considering the cost of root canals it is unlikely that dentists would routinely turn away
insured patients in need of root canals. General practitioners conduct an initial
assessment, perform any needed palliative procedures, and either reappoint for root canal
therapy, or refer to an endodontist. Thus, bias introduced into the analysis by refusal to
see endodontic patients would be small.
It is more reasonable for bias to result from the exclusion of smaller dental offices, and
offices with smaller percentages of insured clientele. In the latter offices, filing claims may
be less complex and demand less time. Consequently, those practices may decide to
submit paper claims. Thus, smaller practices and those practices that are less
administratively complex may participate less in the electronic claims database and that
this reduced participation may be a source of bias in the analysis.
The fact that smaller and less administratively complex dental practices participate less in
the electronic claims database does not alone establish the existence of any strong bias in
the results of the analysis. For a bias to exist, the size and administrative of a practice
must strongly influence procedure mix and pricing decisions. However, there is not
evidence in the literature that casemix or prices are related primarily to practice size. If
bias does exist it would be expected to operate in the same way for both endodontist and
general practitioners. Therefore, comparisons of the two groups should not be grossly
misleading.
132
The American Association of Endodontists (AAE) commissioned the study. Three different
survey questionnaires were designed and developed by the Workforce Assessment
Committee of the AAE for use in this study. This study collected data from a national
sample of private practicing endodontists regarding production and delivery of endodontic
care to patients in the U.S. The Survey of Endodontic Practice was used to obtain
information about the practice setting where an endodontist or a group of endodontists
practice while the Survey of Endodontists was used to collect data about the individual
endodontist. Questionnaires were sent to individual practitioners who were asked to
respond to both the practice and the endodontist surveys. An Endodontic Patient
Encounter Form was used for collecting detailed information about the procedures
rendered to patients by the endodontist and their staff on a randomly assigned day in the
practice. One Encounter Form was prepared for each patient and consisted of a line for
recording each procedure, the amount of each procedure rendered by procedure code and
the amount of time spent on each procedure by the endodontist and chairside assistant.
For the final survey, two questionnaires and the patient encounter forms were sent to
2,075 randomly selected endodontists including 1,923 active members of the AAE and
152 endodontists identified as non-members of the AAE by the membership rosters of the
ADA.
133

the economics of endodontics - American Association of Endodontists

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