Clinical Research

Endodontic Board Certification: A Review of

Factors Affecting the Certification Rate
Emily Case, DDS, Anne Williamson, DDS, MS, William T. Johnson, DDS, MS, Wei Liu, BDS, MPH,
and Fang Qian, MA, PhD

Abstract
Introduction: Board certification identifies clinicians
who possess advanced proficiency and expertise within
their field. Only 23% of endodontists are board certified
S pecialty-specific board
certification identifies
the expertise of clinicians
Significance
Only 23% of endodontists are board certified (the
lowest among all dental specialties). Increasing
(the lowest among all dental specialties). The aim of this who possess advanced
the number of board-certified endodontists is
study was to determine the factors that influence end- knowledge and skills
important in upholding and maintaining endodon-
odontists’ decisions regarding the completion of board within their given field;
tics as a recognized dental specialty.
certification. Methods: A 16-question survey was the certification process
e-mailed to 5073 US endodontists and residents who promotes and maintains
are American Association of Endodontists members. the standard of the profession (1). According to the American Board of Endodontics
Results: A total of 1603 endodontists and residents (2), it allows clinicians to obtain the uppermost level of education in the field of
responded, corresponding to an overall response rate endodontics, understand and practice evidence-based endodontics, make clinical
of 31.6%. Of those respondents, 73.8% felt board certi- decisions and treatment plan with certainty, strengthen their technique and patient man-
fication was important. Among endodontists, 32% were agement, advance their education and career, and add to the notoriety and strength of
board certified, 24.4% had plans of becoming board the endodontic specialty.
certified, and 43.6% had no plans to become board Patients depend on their specialists’ acumen, and the designation associated with
certified. The most common reasons for not pursuing board certification helps instill confidence in patients that they will receive the highest
board certification were ‘‘graduated too long ago,’’ quality care available. As the former president of the American Association of Endodon-
‘‘don’t have time,’’ ‘‘process is too long,’’ and ‘‘not tists and the former director of the American Board of Endodontics (ABE), Joseph
required to become an endodontist.’’ Board-certified Tenca (3) stated, ‘‘The standard set is not mere competence to practice, but a higher,
endodontists were more likely to believe board certifica- more challenging standard, a standard intended to require a continuing commitment to
tion was important compared with their non–board- excellence through intensive and continuing study.’’
certified counterparts (97.5% vs 60.3%, P < .0001), Specialty boards were established to publicly recognize emerging medical areas
and were more likely to have received training at through a certification process. Indeed, all recognized specialties are required to main-
programs that encouraged and provided assistance in tain a certifying board (4); yet, many dental specialists choose to forgo the board
completion of the certification process. Residents were certification process (3, 5). Among medical doctors within the United States, board
more likely to plan on becoming certified compared certification has become the standard; 87.3% are board certified for their specialty
with non–board-certified endodontists (89.6% vs (6). Unfortunately, the corresponding number for dental specialists is significantly
35.9%). Conclusions: Despite widespread agreement lower. By specialty, 87% of oral and maxillofacial radiologists, 70% of oral and maxil-
regarding the importance of board certification, a strik- lofacial surgeons, 65% of pediatric dentists, 48% of periodontists, 48% of oral and
ingly low percentage of endodontists are board certified. maxillofacial pathologists, 33% of prosthodontists, 33% of orthodontists, and a mere
Views provided by endodontists and endodontic 23% of endodontists are board certified (Dr. Mel Mupparapu, personal communica-
residents provide insight that may be used to guide tion, October 2016, written; Dr. Robert Cederberg, personal communication, October
changes that will effectively increase the percentage 2016, written; American Association of Oral and Maxillofacial Surgeons, personal
of board-certified endodontists. (J Endod communication, October 2016, oral; American Academy of Pediatric Dentistry, per-
2017;43:1255–1261) sonal communication, October 2016, oral; American Academy of Periodontology, per-
sonal communication, October 2016, oral; American Board of Periodontology,
Key Words personal communication, October 2016, oral; American Board of Prosthodontics, per-
Board certification, case history, endodontics, examina- sonal communication, October 2016, oral; Margie Hannen, personal communication,
tion October 2016, oral) (7).

From the Department of Endodontics, University of Iowa, Iowa City, Iowa.

Address requests for reprints to Emily Case, Department of Endodontics, University of Iowa, 801 Newton Road W343, Iowa City, IA 52242. E-mail address:
emilycasedds@[Link]
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
[Link]

JOE — Volume 43, Number 8, August 2017 Endodontic Board Certification 1255
Clinical Research

Figure 1. Endodontic board certification survey.

1256 Case et al. JOE — Volume 43, Number 8, August 2017

 Clinical Research
Although board certification is voluntary in the majority of the health incomplete survey responses were included in the analysis; 82.7% of
care industry, the marketplace drives board certification within the medical respondents were currently practicing endodontists in the United States,
field (5). For medical doctors who wish to obtain clinical privileges and 6.8% were retired or no longer practicing endodontics, and 10.5%
join provider panels, board certification is a requirement by most hospitals, were endodontic residents. Among practicing or retired endodontists,
managed care organizations, and health insurance plans (8). The same is 32% were board certified, 24.4% were in the process or planned on
true for many oral surgeons and pediatric dentists, 2 of the 3 dental spe- becoming board certified, and 43.6% had no plans of becoming board
cialties with the highest percentage of board-certified practitioners. For certified.
other dental specialties to which those requirements do not routinely apply, Among respondents who had no plans of becoming board
sufficient incentives are clearly lacking. certified, the 2 most frequently cited reasons were ‘‘graduated too
Research into the certification process for dental specialties has long ago’’ (46.4%) and ‘‘don’t have time’’ (42.9%). These reasons
found that the strongest incentive for becoming board certified is the were closely followed by ‘‘process is too long’’ (36.5%), ‘‘other’’
feeling of personal accomplishment. Conversely, the biggest impediments (35.9%), and ‘‘it is not required to become an endodontist’’
are time commitment and financial costs (9). To date, no research on (35.7%). Respondents were allowed to write in a short answer if they
certification has been performed among endodontists. Two studies selected the ‘‘other’’ category. A total of 218 ‘‘other’’ short answers
among medical doctors have shown a correlation between board were collected and reviewed.
certification and improved clinical outcomes (5, 8). Whether or not According to the survey, 73.8% of all respondents felt board
this is a sentiment held by practicing endodontists is less clear. The certification was important, and 87.7% of respondents reported that
aim of this study was to determine the factors that influence their programs encouraged board certification; 55.8% reported that
endodontists’ decisions regarding the completion of board certification. their programs required them to take the ABE written examination,
66.3% reported that their programs provided assistance in preparing
Materials and Methods a case history portfolio, and 63.8% reported that their programs
Approval for this study was obtained from the Institutional Review provided a mock board examination.
Board at the University of Iowa College of Dentistry and Dental Clinics,
Iowa City, IA. A 16-question survey was developed using Qualtrics soft- Bivariate Analyses
ware (Provo, UT) to collect demographic data as well as information Board-certified endodontists had a significantly stronger correla-
regarding training program–specific advice and individual opinions tion with practice in a group setting (ie, group, academic, or military)
concerning the decision to become board certified. The complete sur- when compared with non–board-certified endodontists (68.8% vs
vey, when tested at the University of Iowa, took approximately 1 minute 54.9%, P < .0001). Significantly more board-certified endodontists
to complete. A copy of the survey can be found in Figure 1. felt board certification is important (97.5% vs 64.4%, P < .0001).
In March 2016, a link to the survey along with a statement of Significantly more board-certified endodontists graduated from a
purpose of this study was sent via e-mail to 5073 board-certified and program that encouraged board certification (94.2% vs 84.8%,
non–board-certified US endodontists and endodontic residents who P < .0001), provided assistance in preparing a case history portfolio
are AAE members. The e-mail list was compiled using the AAE member (74.0% vs 63.4%, P < .0001), and provided a mock board examination
online directory. The e-mail was sent on 3 separate occasions at 2-week (73.0% vs 60.2%, P < .0001). These results are shown in Table 2.
intervals. The survey was resent to only those participants who had not When comparing residents with endodontists, residents were
yet completed the survey. No personal information was collected. Data more likely to plan on becoming board certified (89.6% vs 35.9%,
from the survey were compiled into a CSV file for statistical analysis. P < .0001). Among those who did not have plans to become certified,
Descriptive analyses of demographics and factors affecting end- residents were significantly more likely to list the following reasons:
odontic board certification were conducted for the overall population ‘‘case portfolio is too difficult’’ (35.3% vs 11.8%, P < .05), ‘‘oral
and by board certification status (yes/no). Bivariate analyses were exam is too difficult’’ (41.2% vs 13.7%, P < .05), and ‘‘exams are
performed using the chi-square test and Wilcoxon rank sum test. The too literature oriented’’ (58.8% vs 18.6%, P < .05). These results are
results are shown in Tables 1 and 2. Specific reasons for not provided in Table 3.
becoming board certified for those respondents with no plans of Among the non–board-certified endodontists, those with no plans
doing so were further reported by resident versus endodontist status. of becoming board certified were significantly farther from graduation
Bivariate analyses were performed using the chi-square test or the than those who had plans or were in the process of becoming certified
Fisher exact test. The results are shown in Table 3. (21.8 ! 11.5 vs 6.8 ! 6.7 years, P < .0001). These results are shown in
The Wilcoxon rank sum test was used to compare the distribution Table 4.
of number of years after graduation from endodontic residency between
the group of endodontists who were in the process or had plans of
becoming board certified with the group of endodontists who had no
Discussion
plans of becoming board certified. Note that the Shapiro-Wilk test Only 23% of endodontists are board certified (the lowest among
was used to test the normality of the continuous variable (ie, the number all dental specialties), with that percentage having dropped since the
of years after graduation from endodontic residency). A nonparametric late 1990s. The percentage of board-certified endodontists was slightly
approach was taken after the Shapiro-Wilk test provided evidence of higher among our survey respondents at 31.9%. Regardless, these
non-normality. The results are shown in Table 4. All analyses were numbers are remarkably low, and with a response rate of 31.6%
performed using a .05 significance level. including over 1600 total respondents, our data provide a representa-
tive sample for analysis and discussion.
A total of 73.8% of all respondents felt board certification was
Results important; yet, only 32% were board certified, with an additional
Summary of Responses to Survey Questions 24.4% who were in the process or had plans of becoming board
Of the 5073 surveys sent, 1565 were fully completed, and 38 were certified. Specifically among non–board-certified endodontists,
partially completed (overall response rate = 31.6%, Table 1). All 64.4% felt board certification was important; yet, only 35.9% reported

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TABLE 1. Summary of Responses of Survey Questions for All Respondents
Frequency Valid percent
Are you currently practicing or teaching as an endodontist?
Yes 1309 82.7
No–resident 167 10.5
No–retired or no longer practicing 107 6.8
Total 1583 100
Do you think board certification is important?
Yes 1133 73.8
No 402 26.2
Total 1535 100
Did or does the program you graduated or will graduate from encourage board
certification?
Yes 1193 87.7
No 167 12.3
Total 1360 100
Did or does the program you graduated or will graduate from require you to take the
ABE written examination?
Yes 855 55.8
No 677 44.2
Total 1532 100
Did or does the program you graduated or will graduate from provide assistance in
preparing a case history portfolio?
Yes 1005 66.3
No 510 33.7
Total 1515 100
Did or does the program you graduated or will graduate from provide a mock
board examination?
Yes 974 63.8
No 552 36.2
Total 1526 100
Are you board certified? (Residents not included)
Yes 439 32
No–currently in the process or planning on becoming board certified 334 24.4
No–no plans on becoming board certified 597 43.6
Total 1370 100
Do you plan on becoming certified? (Residents only)
Yes 146 89.6
No 17 10.4
Total 163 100
Why do you choose not to become board certified? (Endodontists with no plans
on becoming board certified, a multiple answer question)
Process is too long 222 36.5
Written examination is too difficult 16 2.6
Case portfolio is too difficult 76 12.5
Oral exam is too difficult 88 14.5
It is not required to become an endodontist 217 35.7
Cost 51 8.4
Intimidated by any part of the examination 86 14.1
Examinations are too literature oriented 120 19.7
Examinations are too science oriented 21 3.5
Don’t have time 261 42.9
Graduated too long ago 282 46.4
Other 218 35.9
Total 608 100
ABE, American Board of Endodontics.

plans of doing so. The magnitude of this disconnect between perceived Indeed, the next 2 most commonly provided reasons for foregoing
importance and actual achievement of board certification is striking and board certification relate to the length of time required. Greater than
warrants attention. Investigation of our data reveals a few important one third of non–board-certified endodontists felt both that the process
contributing factors. is too long and that they do not have enough time to complete it. With a
The most common reason provided for not becoming board certi- certification process that can take several years to complete, it follows
fied was the feeling that too much time had elapsed since graduation. that many endodontists would be discouraged from doing so.
Our data support this response because endodontists without plans Improvements have been made by the ABE to shorten the time
of becoming board certified had graduated significantly longer ago needed to complete the board certification process. Specifically,
than those with plans of doing so. Although there are many possible changes to the case portfolio portion include reducing the number of
explanations for this observation, one possibility is the notion that end- cases from 15 to 10 and eliminating 1-year recalls for diagnosis and
odontists with established practices have less incentive to become board medically compromised case submissions. In addition, the previous
certified and may feel they have less available time to do so. requirement that an applicant must identify with the specialty for 4 years

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TABLE 2. Factors Associated with Board Certification Status
Board certification
No (n = 1106) Yes (n = 441) P value*
Categoric variables, n (%)
What type of practice do you currently work in? (Not available for residents)
Solo 411 (45.1) 129 (31.2) <.0001
Nonsolo 501 (54.9) 285 (68.8)
Do you think board certification is important?
Yes 702 (64.4) 428 (97.5) <.0001
No 388 (35.6) 11 (2.5)
Did or does the program you graduated or will graduate from encourage
board certification?
Yes 785 (84.8) 407 (94.2) <.0001
No 141 (15.2) 25 (5.8)
Did or does the program you graduated or will graduate from require
you to take the ABE written examination?
Yes 615 (56.1) 238 (55.2) .7518
No 481 (43.9) 193 (44.8)
Did or does the program you graduated or will graduate from provide
assistance in preparing a case history portfolio?
Yes 687 (63.4) 316 (74.0) <.0001
No 397 (36.6) 111 (26.0)
Did or does the program you graduated or will graduate from provide a
mock board examination?
Yes 656 (60.2) 316 (73.0) <.0001
No 433 (39.8) 117 (27.0)
ABE, American Board of Endodontics.
*Based on nonmissing values, regarding categoric variables, significance probability (P value) was associated with the chi-square test of the null hypothesis that there was no association between variables of
interest; regarding continuous variables, significance probability (P-value) was associated with the Wilcoxon rank sum test of the null hypothesis that the distribution of the continuous variable of interest is the
same between subgroups of the specified categoric variable; boldface type indicates statistically significant relationship.

before taking the oral examination or submitting a case portfolio has ture changes makes it more difficult for endodontists further removed
been eliminated. Currently, applicants can take the oral examination from residency to achieve board certification. An associated opinion
and submit their case portfolio as soon as they complete their residency also expressed by multiple respondents was the sentiment that there
and pass the written examination. Also, residents may now take the is too great an emphasis on knowing researchers’ names rather than
written examination during their residency training (American Board the substance of their literature.
of Endodontics, personal communication, 2017). These changes allow A number of other individually supplied responses offer additional
an applicant to become board certified as early as the spring following insight. One concern raised by numerous respondents was the current
the completion of their residency. 3-step process. Of the 9 dental specialties, only endodontics,
Finally, the other frequently expressed justification for not orthodontics, and prosthodontics require a case presentation or port-
completing the board certification process was the fact that it is not a folio (7, 10). Notably, these constitute the 3 specialties with the lowest
requirement. As previously stated, most endodontists recognize the percentages of board-certified clinicians at 23%, 33%, and 33%,
importance of board certification. Even still, for many, the anticipated respectively (7). Although correlation does not equal causation, this
benefits do not sufficiently outweigh the perceived burden of the current may be a contributing factor. Indeed, the case portfolio was the most
certification process in the absence of a formal requirement. commonly cited concern among survey respondents who selected
One encouraging statistic within our analysis is the finding that ‘‘other’’ as a reason for choosing not to become board certified;
89.6% of residents plan to become board certified. In comparing the many people stated they had little confidence in the integrity of the
small percentage of residents without plans of becoming board certified process, and some alleged that clinicians have used other colleagues’
with endodontists without such plans, responses more frequently listed cases for their own portfolio.
by residents include the ‘‘case portfolio is too difficult,’’ the ‘‘oral exam When evaluating the certification processes of our medical
is too difficult,’’ and the ‘‘exams are too literature oriented’’ although colleagues, each of the 24 specialties recognized by the American Board
these differences should be interpreted with caution because the sample of Medical Specialties requires some form of a written examination, and
size of residents without plans of becoming board certified was small. As many require an oral examination. Although the number among all
such, the focus of our discussion is centered on the factors for not recognized specialties is less than half, at least 8 of the 10 surgical
becoming board certified among endodontists, rather than residents. specialties require a case review in addition to both oral and written
One of these responses, however, does deserve discussion. examinations (11). In contrast, among the 3 surgical specialties in
Regarding the question of whether the examinations are too liter- dentistry, only endodontics requires the submission of a case portfolio,
ature oriented, the fact that a lower percentage of endodontists reported whereas periodontics and oral surgery, both of which have higher rates
this as a concern indicates that practicing endodontists see the value in of board certification, do not (12, 13).
possessing a thorough knowledge of the literature. Indeed, endodontics Additional information may be gleaned from comparison of the
should be an evidence-driven specialty. However, 1 argument against a board certification processes of the dental specialties with the highest
literature-focused examination that was expressed on multiple occa- rates of certification. Oral and maxillofacial radiology has an 87%
sions among the individual opinions provided within the completed completion rate for their board certification process, which consists
surveys was that the rate at which knowledge and the associated litera- of a 2-part written examination with no oral examination or case

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TABLE 3. Differences between Residents and Endodontists regarding the Variables of Interest
Resident (n = 163) Endodontist (n = 931)
n (%) n (%) P value*
Do you plan on becoming certified or are you currently in the
process of board certification?
Yes 146 (89.6) 334 (35.9) <.0001
No 17 (10.4) 597 (64.1)
Resident (n = 17) Endodontist (n = 591)
n (%) n (%)
Why do you choose not to become board certified? (Endodontists
with no plans of becoming board certified, a multiple answer
question)
Process is too long 9 (52.9) 213 (36.0) .1536
Written examination is too difficult† 1 (5.9) 15 (2.5) .3684
Case portfolio is too difficult† 6 (35.3) 70 (11.8) <.05
Oral examination is too difficult† 7 (41.2) 81 (13.7) <.05
It is not required to become an endodontist 7 (41.2) 210 (35.5) .6320
Cost† 3 (17.6) 48 (8.1) .1640
Intimidated by any part of the examination† 4 (23.5) 82 (13.9) .2816
Examinations are too literature oriented† 10 (58.8) 110 (18.6) <.05
Examinations are too science oriented† 1 (5.9) 20 (3.4) .4543
Don’t have time 5 (29.4) 256 (43.3) .2535
Graduated too long ago† 0 (0) 282 (47.7) <.0001
Other 5 (29.4) 213 (36.0) .5742
*Based on nonmissing values, significance probability (P value) was associated with the chi-square test or the Fisher exact test (marked with †) of the null hypothesis that there was no association between
variables of interest; boldface type indicates statistically significant relationship.

portfolio requirement (14). Oral and maxillofacial surgery and pediat- tween these 2 groups pertain to the programs at which endodontists
ric dentistry have completion rates of 70% and 65%, respectively; both received their specialty training.
certification processes include written and oral examinations without a Overall, 87.7% of respondents reported their programs encour-
case portfolio requirement (13, 15). Of note, as previously stated, the aged board certification, whereas only 55.8% required them to take
high rates of certification within these 2 specialties may be in part the ABE written examination, 66.3% provided assistance with case
attributable to requirements of certification before obtaining hospital history portfolio preparation, and 63.8% provided a mock board exam-
privileges. ination. Endodontists who were board certified were significantly more
Another widely cited concern was unfairness regarding the recer- likely to have received training from a program that encouraged board
tification process. Current ABE guidelines require only those applicants certification, provided assistance in preparing a case history portfolio,
who submitted their preliminary application on or after January 1, and conducted a mock examination.
1997, to recertify every 10 years (16). Many endodontists stated they One limitation of our study is its lack of evaluation of clinical
felt this requirement should be mandatory for all practicing endodon- outcomes or patient satisfaction in relation to board certification
tists regardless of when they were first certified in order to uphold the status. Although board certification is believed by many to be impor-
highest standards of care. tant, it is unclear whether or not board certification status has any
In addition to the study of only those endodontists without bearing on the quality of care or patient outcomes. In a systematic
plans to become board certified, information was also obtained review on the link between board certification and clinical outcomes
by comparing data between certified and noncertified endodontists. among medical physicians, 16 of 33 studies showed a statistically
In total, 35.6% of non–board-certified endodontists felt board cer- significant positive association between certification status and pos-
tification was not important compared with only 2.5% of board- itive clinical outcomes, whereas 3 revealed worse outcomes and 14
certified endodontists. Perhaps the most notable differences be- showed no association (8). The lone related study within the dental

TABLE 4. Number of Years after Graduation from Endodontic Residency by Status regarding Plan on Becoming Board Certified or in the Progress (Yes/No)
Do you plan on becoming certified (not available for endodontists board certified or
in the process of board certification) or are you currently in the process of board
certification (not available for residents or endodontists board certified)?
Total Yes No P value*
Number of years after graduation
from endodontic residency
N 916 330 586 <.0001
Mean (standard deviation) 16.4 (12.4) 6.8 (6.7) 21.8 (11.5)
Median (minimum, maximum) 14 (1, 49) 5 (1, 39) 21 (1, 49)

*Based on nonmissing values, significance probability (P value) was associated with the Wilcoxon rank sum test of the null hypothesis that there is no difference in the median number of years after graduation
from endodontic residency between the subjects who had plans on becoming board certified or were in the process of board certification and the group and who had no plans on becoming board certified and
were not in the process of board certification; boldface type indicates statistically significant relationship.

1260 Case et al. JOE — Volume 43, Number 8, August 2017

 Clinical Research
field was a questionnaire given to pediatric dentists to evaluate qual- Acknowledgments
ity of care and board certification status that found high quality of
care was maintained regardless of board certification status (17). Supported in part by a research grant from the American As-
sociation of Endodontists Foundation and the Department of
To our knowledge, no such study has been performed across dental
Endodontics at the University of Iowa College of Dentistry and
specialties, nor within the field of endodontics, specifically. Future
research into this topic would provide useful information. Dental Clinics.
The authors deny any conflicts of interest related to this study.

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