Endodontic DDSc StudentMy name is Rob, I began my training in September 2015 and completed in September 2018. Prof Jarad asked me to write a blog about life as a DDSc student at Liverpool, to try and give a flavour of the DDSc from a student’s perspective. I will start by talking through the first few weeks of the course. I did my undergraduate dental degree at Newcastle so was familiar with working in a UK Dental Hospital, but for international students there is a lot to do and get used to on arrival. The university makes this easy and are helpful - the first year begins with an induction week which allows you to sort out student cards, library set up, accommodation etc. The week is not too busy so you have time to get used to your surroundings.

In terms of course structure, the course is tailored to the GDC Curriculum for Specialist Training in Endodontics. In the first 6 weeks you do not see patients, but instead carry out an intensive training course on phantom heads in the Endodontic skills suite. Here, you treat 10-20 extracted teeth using the same equipment and microscope you will be using on clinic. This is a good way to get comfortable with the equipment and get used to working under magnification, and means you are more prepared for treating patients.

Life as a DDSc student

To start, people often ask me if embarking on this training was a good choice. My answer is.. 100%! Carrying out specialist training has improved all areas of my dental skills, not just my Endodontics. The course has a great structure and you exit, “ready for specialist practice.”

However, I won’t pretend it’s easy. Firstly, financially it has been tough (but manageable). I left a job as an associate dentist in a private practice in Manchester. My wife and family were initially a bit sceptical about my decision, but soon saw the benefits and opportunities that would arise following the training. We did have to make some sacrifices (we moved house to pay for my training) and it took me a while to get used to the 1 hour drive from Manchester to Liverpool. I was exhausted for the first 3 months from the 6am alarm, additional driving and the workload, but I soon adjusted to this and it became normal routine. Thankfully my family and friends understood the sacrifices I was making in terms of time, social arrangements, and my reduced income.

In the first year especially, I often went in even earlier and left the office sometimes as late as 9pm. This was because I chose to do all my studying at university rather than at home. Other people did that differently to me, but I would use the time to write letters, work on my research, prepare for the weeks seminars, or work on a presentation.

First Year

In the first year, the main focus on treatment clinics is non-surgical root canal treatment, the ‘bread and butter’ of Endodontic specialist practice. You are also expected to restore your cases, which is very useful to; a) improve your skills in providing indirect restorations, and b) prepare you for the future in terms of advising the referring dentist on the optimal method to restore the tooth after RCT.

Every session is supervised by specialists who find the right balance between supporting you when you need it, and leaving you to work independently. Initially, you utilise their help quite regularly but as time goes on you become more and more independent.

At the end of every session you reflect on how things went and log your case on an iPad using a programme called Liftupp. This gives detailed feedback of each element of a case as shown below, but mostly acts as a log of your cases. This is then used to track your progress, and find if you are missing any elements of training or struggling in any areas.

Supervision

We have a great mix of supervisors to allow you to maximise your learning. Sanjeev Bhanderi works in specialist practice in Manchester and has years of experience providing Endo day in day out. He teaches you how to be pragmatic, efficient and carry out 4 handed dentistry with your nurse.

Kate Blundell also has abundant endodontic experience, and has been teaching at Liverpool for many years. She’s also a believer in hypnosis and relaxation techniques, and is a great calming influence both for us and our patients. She also provides some calming hypnosis sessions before our exams 😄

Obyda Essam completed his Endodontic DDSc in 2017 and then returned to provide clinical supervision. Obie’s strength is that he has been in our position only recently, and so knows what support we need, and also what level of knowledge you will need for your M Endo examinations.

Finally, Fadi is there to push your Endodontic knowledge base, justify your treatment decisions, cheer you up when you have a bad day on clinic and keep you focused and on target with both your clinical and academic progress.

Alongside the treatment sessions, you work on a new patient clinic once per week with different consultants. This allows you to work on your diagnostic skills, see a wide variety of cases, and also work with different consultants. It’s a great way to see the more weird and wonderful cases referred into the dental hospital, and develops you into an excellent diagnostician, which is a key characteristic of an Endodontist.

Equipment

We use Zumax microscopes which have all the features required (good lighting and magnification). Every chair has one, and you soon can’t do anything without it. In time, Fadi plans to add video capabilities so we can record cases and use it for teaching purposes, and so the nurse can see what’s happening under the scope.

Potential students often want to know about file systems and equipment. There’s too much to mention but it’s worth noting everyone gets their own personal kit and chair which makes things more efficient. You have your own ultrasonic motor and Endo success tips, Propex pixi apex locator, Smart X motor, elements heated obturation system, and all the others bits and pieces endodontists need. File wise, we have access to: K files, C files, H files, Profiles, Reciproc, Wave One Gold, Protaper Gold, Protaper Next, XP Shaper, XP finisher, all with matching GP points and a choice of AH Plus or Bioceramic sealers. In terms of bioceramics, we also have access to MTA, Biodentine, root repair material and total fill putty. So everything is covered!

This is great because you get a chance to try different systems, and see what works in your hands. Fadi is always on hand to remind you of the files cost and get you ready for practice, rather than using every file in the building!

Research

The research requirements of the course was probably the biggest shock to me. I thought I could just do a small project and concentrate on my clinical training... wrong!! The doctorate takes up a lot of your time, but at the same time it’s very rewarding to build and carry out your project. Every Thursday is devoted to your research and admin requirements. Fadi helps you formulate your research plan, and manage your expectations to ensure your idea is realistic and achievable for a 3 year timeline. My research centred on patient reported outcomes in Endodontics, using a questionnaire and telephone interviews to collect my data. I have gone from finding this a nuisance project initially, to really enjoying it and being proud of what I achieved. The aim of the research is to allow the postgrad to gain experience with exploring a topic, formulating and carrying out the project and then writing a thesis, but it will be a unique project that adds value to our specialty.

I mentioned admin in the last paragraph, and again there is plenty of this! The main aspects are logging your cases, and writing letters to referring dentists following consultations on the new patient clinic. The logging of your cases is done by filling out a form on an iPad as described earlier, and also a reflective log of all your cases with your photos and radiographs, explanation of your treatment protocol and prognosis and reflections. This is invaluable to learn from your mistakes, and to show future employers your cases.

Seminars and Teaching

Fridays are devoted to seminars. The programme is quite busy in first year to bring us quickly up to speed with our knowledge. The seminars usually last a few hours and focus on a specific topic eg apex locators, irrrigation etc and often require quite a lot of reading and preparation beforehand. The seminar will then consist of a presentation and discussion as a group. The group is generally solely your DDSc Endo colleagues and the presenter, so these discussions are a good environment to understand topics and learn the subject in depth. In the second and third year the seminars become a little less frequent, which gives more time for research and self-directed study.

Second year

In the middle section of your training, you begin taking on larger restorative cases to become more comfortable and competent treating toothwear, advanced perio etc. You also begin your implant training, initially with a series of lectures and practicals, and then with implant placements.

By this point, your research project will be well developed and you will be collecting your data and beginning to write this up. You also spend time each week on the Paediatric trauma clinic, usually managing traumatised immature teeth with a variety of techniques. On this clinic you get used to carrying out root canal on moving patients!

Surgical Training

Surgical training begins in the second year, and consists of Endodontic surgery and Implant placement. This was something I was quite intimidated by, as I had done less than 10 surgicals previously and my suturing skills were rusty to say the least!

However, once again, the supervision is excellent to guide you through the early cases and I soon began to really enjoy this area of my training. The kit available is excellent, and the case mix is also tailored to each student. This makes sure encounter resorptive defects, apical surgery etc but also treat teeth (eg uppers and lowers) which bring unique challenges.

I carried out 12 Endodontic surgeries to manage external cervical resorption and persistent apical infection. Other colleagues have treated surgical perforation repairs, and management of unusual anatomy such as grooves and root defects.

In addition, we carry out 10 implant cases from start to finish. This involves planning, extraction, often a CBCT, and then implant placement using Straumann bone level implants with close clinical supervision to guide us. We then restore the cases, often with long term composite temporaries to develop soft tissues, and definitive implants once aesthetics are optimised.

This has been an invaluable part of our training for a number of reasons;

1. Increased our surgical skills, and comfort lifting flaps, placing implants, using bone graft materials, and suturing skills

2. It has taught us when an implant is feasible and when it’s not, and therefore help guide our treatment planning with regards saving teeth Endodontically.

We always pair up for surgeries so you watch your colleague and effectively double your experience - and act as a useful extra pair of hands for photographs, retracting etc.

Third year

The focus on 3rd year is on finishing your cases, and identifying which areas of your training you still haven’t encountered. Preparation is needed for the M Endo examination, although future students will not need to take their own cases to the exam.

Presentations - Case Based Discussion, Journal Club and external

Weekly journal clubs and case based discussions are carried out. We have tried various methods, but in general a paper is chosen for the group to read in advance and then a small presentation of the journal findings is made, with a discussion of the positives and negatives of the paper. A mixture of classic Endo papers and up to date papers are presented.

Case based discussions are carried out regularly where you have a chance to discuss a case with the group. The case may have gone positively or you may have encountered difficulties, but I find it a useful setting to have an honest discussion with peers about what you could have done differently to make your treatment more straightforward and predictable. It’s often useful to see how other colleagues think and pick up small tips that can help in future.

We also carry out external presentations and these are very useful as you get used to speaking in a group, a valuable skill for our future careers. I was thrown in at the deep end as I presented my initial research project to a room full of consultants from the North West, but I survived! Other students have presented at national and international conferences, putting the Liverpool programme on the map!

Social Scene

This brings me on to the final section which is the trips and social environment that comes with this course. We have a team of 8 DDSc students, >10 nurses, lab support, reception and admin staff, and the course supervisors and consultants all working together in a positive atmosphere.

We go on regular social gatherings which are always great fun - we’ve done meals, trips to the Golf driving range, and next on the list is Go Karting.

We also go to conferences together, which are great fun (and we do some learning 😄). We have been to the ESE conference in Barcelona, Brussels, and Vienna. We travelled to Bern for an ITI week long course, and we have also been to Amsterdam for the ESE educational congress twice.

These are probably the most enjoyable times on the course, as the group soaks up a lot of new information from listening to inspirational speakers from the Endodontic world, but also relax and enjoy each other’s company.

Overall, I couldn’t recommend the course enough, as it has given me the skills for specialist practice in Endodontics, but also allowed me to meet great friends and become part of a successful Endo team at LUDH.

One year on from completing the DDSc, I work in private practice providing Endodontics and restorations of these teeth, and also work at LUDH supervising an Endodontic treatment clinic.

 

Thanks very much

Rob