These are: orthodontics and dentofacial orthopedics, endodontics, periodontics, prosthodontics, oral and maxillofacial surgery, oral and maxillofacial radiology, oral and maxillofacial pathology, pediatric dentistry, dental public health, and dental anesthesiology.
Table of Contents
2)Endodontics
3)Periodontics
4)Prosthodontics
5)Oral and Maxillofacial Surgery
6)Oral and Maxillofacial Radiology
10)Dental Anesthesiology
Orthodontics and Dentofacial Orthopedics
Orthodontics is the branch of dentistry that deals with malocclusion and dento-facial deformities. Through the use of oral appliances, orthodontists are able to correct crowded, irregular and protruding teeth. Most of us view orthodontists as the dentists who put braces on you when you were a teenager. Of course, there is much more to orthodontics than simply cementing on some brackets and wires. Orthodontists are experts in understanding the growth and development of our craniofacial anatomy. By taking careful measurements from a series of radiographs, orthodontists are able to diagnose the problem by identifying which areas of a person s face are deficient or are growing in excess. This knowledge is then used to develop a plan that can be used to correct these issues. Ideally, most orthodontic adjustments are performed during an individual s adolescent growth spurt as this is the time period when corrections can be made most efficiently and effectively.
While general dentists may become sufficiently skilled to place some orthodontics appliances during dental school and through additional continuing education course work, they usually stick to only basic and minor orthodontic procedures. Those who wish to specialize in orthodontics are required to do a residency program after dental school that lasts between 2 and 3 years where they learn the more advanced orthodontic procedures.
The first steps in orthodontics usually involve taking multiple radiographs. From these x-ray images, structures are outlined and lines are drawn connecting certain anatomic landmarks on the radiograph. Measurements are taken from these lines and points and are compared to standard measurements to assist in the diagnosis of the problem and to help determine the orthodontic treatment that should be used. Orthodontic appliances like braces, retainers and head gear are then applied to rotate and move teeth, expend the dental arches, and inhibit or encourage jaw growth depending on the patient's needs. Sometimes teeth will be removed to make more space for aligning the dental arches. In more difficult cases, orthognathic surgery may be required in which the orthodontist will need to work with an oral and maxillofacial surgeon to correct the patient's problems.
A cephalometric radiograph used for orthodontic analysis.
Orthodontic residency programs are usually among the toughest to gain admission to. Competitive applicants are usually in the top 10% of their class and score in the 90+ range on their NBDE board exams. According to the ADA, there are currently over 9,000 orthodontists in the United States. During 2007 nearly 700 applicants submitted over 7,000 applications to the roughly 250 spots at 40+ orthodontic residency programs participating in the ADEA s Postdoctoral Application Support Service (PASS).
Endodontics
Endodontics is the field of dentistry dealing with the tooth pulp, tooth root, and associated structures and pathologies. The primary procedure involved in endodontics is root canal therapy. General dentists are trained in endodontic procedures, but mostly stick to the straight forward root canals, usually in the anterior teeth. The more complex cases are usually referred to an Endodontist.
Endodontists complete an additional 2 to 3 years of residency training before earning a Master s degree in endodontics. These specialists deal with the complicated cases which general dentists are not experienced enough and/or comfortable enough to treat. These include teeth with especially narrow canals, obstructed canals, extensive branching of canals, and teeth with extremely curved roots known as dilacerations. In addition to the more extensive training and experience in the various endodontic treatments, most endodontists have special technology that general dentists do not have, like endodontic microscopes.
In addition to root canal therapy, other endodontic procedures include draining infections in and around tooth roots, periradicular surgery known as apicoectomies, stabilizing root fractures, and internal bleaching.
The most common endodontic procedure is root canal therapy, which is often referred to as endodontic therapy or simply as a root canal. A root canal is usually performed when a patient has an infection that has reached the dental pulp of a tooth. Infections in the dental pulp will cause inflammation that can cause extreme pain because the pressure is contained with in a bony structure, so there is no outlet. In some cases, the nerve will die and so the patient will not have the normal excruciating pain from this infection, but it still needs to be treated because the infection can spread to form an abscess at the apex of the tooth s root. If the infection goes untreated long enough, it can spread along the fascial spaces to cause massive swelling of the face and can potentially spread to the mediastinum or to the brain. This type of infection can not be cleared by your immune system because the source of the infection is confined to an area with limited access inside the tooth. Antibiotics may help treat associated abscesses, but will not clear an endodontic infection because the limited blood flow into a tooth is not enough to provide sufficient levels of the drugs to the infected area.
To eliminate the infection and prevent further spreading, a root canal must be performed. Access to the pulp chamber is created by drilling into the tooth from the lingual (tongue side) for anterior teeth, or from the occlusal (chewing surface) for posterior teeth. Once the chamber is adequately opened, the canals that contain the nerve, blood vessels and the infection must be cleaned out with small files. The canals are carefully instrumented with files that sequentially increase in size and can be done either manually or via rotary drill. Radiographs are taken throughout the procedure to ensure that the canals are reaching all the way down to the tip of the root so that no remaining infected canal area is left following the procedure. Sodium hypochlorite or another irrigant is periodically injected to rinse out the canals of any debris. Following the cleaning procedure, the canals are dried and filled with a substance known as gutta percha. To finish the procedure the teeth are restored usually with a post, core and crown, although anterior teeth can often be restored with a simple filling placed over the opening. If done correctly, any infection at the tip of the roots will resolve on their own. However, large abscess may need to be incisionally drained and may also require antibiotics.
Placement of gutta percha during a root canal procedure
Endodontic residency is among the most competitive dental specialty programs. In 2006, 240 applicants applied to the 12 endo residency programs that participated in the Postdoctoral Application Support Service (note that there are many more residency programs that do not participate in PASS). Depending on the program, endodontic residency lasts between 2 and 3 years. According to the ADEA, there are over 4,000 endodontists in the United States as of 2006.
Periodontics
Gingivitis simply refers to an inflammation in the gingival tissues - the gums around the teeth appear puffy and red and often bleed. Periodontitis occurs when gingivitis is allowed to progress and involves bone loss around the teeth. Advanced stages of periodontitis result in deep gingival pockets allowing for extreme mobility of the teeth. This disease increases the risk of root caries and may eventually lead to tooth loss if untreated.
Periodontal treatment begins with scaling and root planning. This type of treatment is basically the removal of plaque and calculus from the teeth and can be done with hand instruments and/or ultrasonic electric scalers. In instances where pocket depths around teeth are particularly deep, periodontal surgery may be necessary in order to reach all of the surfaces of the teeth. This involves removing gingival tissue around the teeth and lowering the tissue closer to the bone level. In addition to these basic periodontal therapies, periodontists regularly perform gingivectomies, gingival grafts, crown lengthening, alveolar ridge augmentation, local delivery of periodontal antibiotics, and dental implants.
Currently there are approximately 5,000 periodontists in the United States with an average yearly income of over $200,000. Residency in periodontics usually lasts 2 to 3 years following completion of dental school. For a complete list of periodontic residency programs in the U.S. and Canada as well as tips for getting into periodontics, visit theAmerican Academy of Periodontology.
Prosthodontics
Dentures are the main thing one might think of when hearing the term prosthodontics, but this field of dentistry is much more extensive. Prosthodontics is essentially the replacement of natural teeth with prosthetic teeth. This includes not only complete and partial dentures, but also dental implants, crowns and bridges. Usually this field is broken down further into removable prosthodontics (complete and partial dentures) and fixed prosthodontics (crowns, bridges and implants). As the use of implants has grown in popularity in recent years, the line between fixed and removable prosthodontics has become blurred as many dentures are now retained with implants to provide a more natural feel and function.
General dentists provide prosthodontic care to patients on a regular basis, with crowns and bridges taking up a significant portion of the average dentist s work load. Prosthodontists take on the more complicated prosthodontic procedures including long span bridges, implant supported dentures, multi-unit crown and bridge patients, and any prosthodontic procedure in patient s with difficult to handle jaw relationships.
A three unit bridge and metal frame work for a partial denture
The dental appliances fabricated by the general dentist or the prosthodontist require an exact fit for the patient, so multiple appoints are usually needed. For example, the standard procedure for fabricating your average set of dentures requires 6 to 7 appointments for the patient in addition to many hours of lab work by the dentist and lab team in which multiple stone models are created from impressions, designs are drawn up, wax rims are created to test the fit, and teeth are set in wax for a final try in all before the final denture is created.
A subspecialty of prosthodontics is known as maxillofacial prosthodontics. Individuals trained in this subspecialty are able to create prosthetics to replace missing portions of the head and neck due to traumatic injuries, cancer surgeries, or birth defects. This includes prosthetics for a missing nose, eyes, ears, or anything else in the head and neck region.
According to the ADEA, there are currently about 3,000 prosthodontists in the United States. The average income for a prosthodontist is roughly $230,000 (Source: Journal of Prosthodontics). In 2007 there were 132 applicants to the 20 prosthodontic residency programs that participated in PASS. You can find a list of the prosthodontic residency programs available in the United States at the American College of Prosthodontists website.
Oral and Maxillofacial Surgery
Oral and maxillofacial surgeons are dental specialists most often associated with removal of wisdom teeth. However, these specialists do much more than simply pull teeth – they are trained in a wide range of advanced surgical techniques allowing them to treat various dental and facial conditions, defects, and injuries as well as provide esthetic improvements to the mouth, teeth, jaws, and face.
Oral and maxillofacial surgeons treat patients with varied and complex needs. Oral surgeons provide treatment to patients suffering from painful or impacted teeth, facial pain, misaligned jaws, facial injuries from accidents, cysts and head and neck tumors. In addition, these dental specialists provide reconstructive and dental implant surgery as well as plastic surgery procedures to the maxillofacial region. Procedures an oral surgeon may perform range from the simple removal of teeth to the highly complex complete reconstruction of the face following a traumatic accident.
Oral Surgery Instruments
Training in oral surgery lasts for fours years in a hospital based setting following the completion of 4 years of dental school and prepares the individual for the diagnosis, surgical and related treatment of injuries, defects and diseases in areas that involve the hard and soft tissues of the head, mouth, teeth, gums, jaws and neck. Some training programs offer a 6 year program which allows the resident to also earn an MD degree. Admission into an oral surgery residency program is very difficult with most students graduating in the top 10% of their dental school class with high scores on the NBDE part I and II.
There are about 7,700 oral surgeons in the United States according to the ADA. Oral and Maxillofacial surgeons are among the highestpaid dental specialists and also rank among the highest paid specialists in any medical profession – in the range of $300,000 - $400,000+. For more information on becoming an oral surgeon and oral surgery residency programs, visit the American Association of Oral and Maxillofacial Surgeons (AAOMS).
Oral and Maxillofacial Radiology
As defined by the ADA, Oral and Maxillofacial Radiology is the specialty of dentistry and discipline of radiology concerned with production and interpretation of images and date produced by all modalities of radiant energy that are used for the diagnosis and management of diseases, disorders and conditions of the oral and maxillofacial region.
Using an x-ray machine to take radiographs is an every day part of dentistry and is an invaluable tool in the diagnosis of oral disease. Most dentists have an x-ray machine in each operatory of the office in addition to a panoramic x-ray machine. Standard radiographs include the bitewing images that capture both the upper and lower teeth together and are used to identify cavities, especially interproximal (between teeth) cavities, and the periapical radiographs that capture the full crown and root of the tooth that are used to diagnose problems along or around the root. Panoramic radiographs are taken less frequently and are used to watch developing teeth, especially third molars, and to identify any pathology in the maxilla, mandible or associated structures.
A molar bitewing and a molar periapical radiograph
Some highly equipped offices, like those of oral surgeons, may have more advanced imaging technologies they use like computed tomography (CT), cone beam computed tomography (CBCT), and magnetic resonance imaging (MRI).
Oral radiologists are the experts in using all of these various imaging technologies and interpreting the images. These experts may be called on by general dentists or other dentists to get help with diagnosing or treatment planning from complex cases like those involving TMJ issues, oral pathologies, surgical implants, or orthodontics. Some oral radiologists may have private practices, although most are affiliated with hospitals, dental schools, and research institutions.
Ameloblastoma developing in the mandibular third molar region
The residency for oral and maxillofacial radiology lasts 2 to 3 years following the completion of a DDS or DMD degree. During residency training, prospective oral radiologists will have extensive experience in medical diagnostic radiology, nuclear medicine, radiation oncology, radiation biology, swallowing physiology, radiation physics, radiation biology, radiation risk and safety, and imaging technology including CT, CBCT, MRI and allied imaging modalities. This specialty field is fairly small with only a handful of residency programs and small numbers of applicants compared to other dental specialties.
Oral and Maxillofacial Pathology
Dental specialists in the field of oral pathology deal with the identification and management of diseases affecting the oral and maxillofacial regions. Through careful research involving clinical, radiographic, microscopic and biochemical techniques, these specialists investigate oral pathologies, their causes and their effects. These dental professionals and their examination results are vital to providing the most accurate information on a patient’s condition so the most appropriate treatment can be provided. Oral pathologists regularly receive biopsy’s and tissue and fluid samples and are counted on for everything from identifying strains of bacteria and recommending the type of antibiotics to use, to diagnosing cancer in the head and neck region.
Clear Cell Odontogenic Carcinoma
Oral pathology residency programs usually last 3 years following completion of four years of dental school, with some programs also having an optional 5 to 7 year program resulting in a PhD. There are very few oral pathologists in the USA – some statistics show only about 300 in the entire country! Most oral pathologists work at Universities or at large medical/dental research organizations. For more information on this dental specialty and also to view locations with residency programs, visit the American Academy of Oral and Maxillofacial Pathology or the website OralPath.com.
Pediatric Dentistry
Pediatric Dentistry is literally defined as dental work done on anyone less than 18 years of age. This specialty however goes much more in depth, involving psychological strategies of approaching the younger patient, expertise with dental expectations and resolution of early dental and oral diseases. Because the dental needs of children rarely involve some of the more complicated and time consuming procedures necessary in adult dental care, the amount of time spent per patient is less than it would otherwise be for an adult patient. Thus pediatric dentists see many more patients per day than other specialties.
Unlike other dental specialties, pediatric dentistry allows one to have a lot of fun with creating a theme to the practice since all patients are young children to young adults.
Below is a picture of a office that used a "Safari Jungle theme" very effectively.
Dental Public Health
The role of the dental public health specialist is to promote oral health through community awareness. Dentists involved in public health are responsible for assessing the oral health needs of different populations, developing policy in regards to oral health with local and national government agencies, and providing programs and services to help meet the dental needs of the community and promote awareness. Public health dentists not only promote oral health in the community, but also educate other health professionals and take part in policy decisions regarding public health and the practice of dentistry.
Public health dentists often find positions with dental schools, public health agencies and organizations, and local and national government departments. If you re interested in a career in dental public health, visit the American Association of Public Health Dentistry. The AAPHD also has a list of dental public health residency programs here.
Dental Anesthesiology
American Dental Association s Commission on Dental Accreditation (CODA) voted to accept accreditation standards for dental anesthesiology programs in January of 2007 making dental anesthesiology the newest dental specialty recognized by the ADA. The general dentist provides anesthesia for their patients on a daily basis usually through the injection of lidocaine or another local anesthetic and occasionally use some oral sedation for dental phobic patients. Local anesthesia injections in general dentistry include the inferior alveolar nerve block, the posterior superior alveolar nerve block, the infraorbital nerve block, and numerous local infiltrations among others. Detailed knowledge of the facial anatomy is required as the injections need to be given within a few millimeters of the nerve to be effective.
Dental anesthesiologists additionally administer more advanced anesthesia through the use of pharmacologic and non-pharmacologic techniques including IV sedation and general anesthesia. Most dental anesthesiologists work by providing their services for other dentists who require advanced anesthesia and sedation for their patients or medical monitoring for special needs patients. Some may work in a single office where advanced anesthesia is required frequently, like in an oral surgery practice, while others rotate around through multiple area practices to dentists and dental specialists that require the occasional services of an anesthesiologist.
The training for a dental anesthesiologist requires an additional 2 to 3 year residency following completion of dental school. Completion of residency in a CODA certified program in this specialty requires a minimum of 500 deep sedations/general anesthetics and at least 12 months of full-time anesthesia administration in a hospital setting. For more information on dental anesthesiology, visit The American Society of Dentist Anesthesiologists and The American Dental Board of Anesthesiology. You can find a list of residency programs with ADA accreditation here.
Thanks to Dr. Joseph S. Kim DDS for writing The Pre-Dental Guide, a Guide for Successfully Getting into Dental School
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