Black Swan Endo

Oct. 1, 2013
The specialty is in for a big change, but only hindsight is 20/20

The specialty is in for a big change, but only hindsight is 20/20

I am a fan of Nassim Nicholas Taleb, author of the groundbreaking book The Black Swan. In the book, Taleb writes about unpredictable events, such as economic crises — he predicted the crisis of 2008 in the book. He also warned about volatility in Syria: "Dictatorships that do not appear volatile, like, say, Syria or Saudi Arabia, face a larger risk of chaos than, say, Italy, as the latter has been in a state of continual political turmoil since the second war." Taleb focuses on certain kinds of rare and unpredictable events that have a significant impact, and how these events are often explained simplistically after the fact. I believe we are in for a Black Swan event in endodontics. In my view, such a future event is a matter of when it will occur and not if it will occur.

Black Swan Endodontics

As a dental student in 1984, I was taught to never take a rotary instrument in a canal during an endodontic procedure. Fast-forward almost 30 years later: such an action using rotary nickel titanium (RNT) is performed routinely, predictably, and profitably by clinicians.

RNT is a disruptive technology in the endodontic universe, a paradigm shift whose effects are still rippling across the globe. From a clinical perspective, RNT shaping has simplified the procedure and brought more cases within the realm of the general practitioner and overall improved clinical success. From an industry perspective, there are enormous incentives to provide clinicians with ever-improving RNT materials, methods, and file designs. These rippling effects, combined with global economics and a number of other forces, have converged to create a diverse set of facts and trends that make predicting the future of endodontic instrumentation quite challenging, and have left the endodontic industry with a number of important questions.

For example, what will the next disruptive technology to replace the existing materials and endodontic methods look like? If current trends continue with their incremental improvement in materials, will they be toward reciprocation of nickel titanium instruments and away from the rotary version? Have nickel titanium endodontic files become a commodity? If so, what are the implications for the industry? What long-term effect will implants have on the endodontic marketplace? If a company sells both implants and endodontic files, which should they emphasize? The stakes for answering these questions correctly are huge at the manufacturing, sales, marketing, and distribution levels, not to mention at ground zero in the operatory, where it matters most.

While none of us has a crystal ball, owning a small endodontic company has forced me to attempt to answer these questions for my company. In addition to the issues above, is my future in Controlled Memory technology, super elastic RNT, reciprocated endodontic technique, or a combination of these? Planning for the future and seeking out the disruptive technology is a daily mission. As an aside, my personal perspective is unique in that I am primarily a full-time clinical endodontist in private solo practice and own an endodontic instrument company. These are the trends I see emerging from reading the tea leaves. They answer many of the above questions moving forward.

• RNT instrumentation will continue to decrease in price and become more of a commodity with each passing day.

As a clinician, it is clear to me that there is no single method, instrument, or technique that is applicable in every clinical situation and has an absolute superiority to any other. Hence, a pack of my Controlled Memory RNT files that sell for $35 can perform treatment to the standard of a different brand that sells for 25% to 50% more. In essence, if the clinician has the skills to use the instruments correctly, he or she can achieve excellent results using any one of a number of different systems. Marketplace preferences will be increasingly based on price and not superior technology until the next disruptive technology.

Commoditization is happening daily with the end of existing patents on file design and the grinding of nickel titanium. More market players, introducing a greater number of files and systems, means more price competition.

Coincidently, established market forces now sell an ever-increasing number of instruments and systems. More choices exist than ever before. This rate of change will accelerate exponentially. One direct effect of this change will be the cannibalization of existing product sales as more products come on the market. The pieces of the pie will become ever smaller in market dominance.

• Until there is a disruptive technology (the Black Swan event that changes everything), RNT instrumentation and endodontic cleansing and shaping methods will improve incrementally.

In essence, we will remain in a flattening of the marketplace with an ever-expanding number of companies selling an ever-improving set of instruments and treatment methods at lower costs.

Such an expansion of market choices will create both opportunities and challenges for the parties involved. Clinicians will have more choices at ultimately lower prices. Industry players will have to figure ways to stand out in a more crowded marketplace and simultaneously maintain both their quality and profit margins.

• A future disruptive technology is inevitable.

This disruptive technology will change the face of endodontics forever. While change is only a matter of time, it is entirely unknown when this will occur or what it will look like. I believe this technology will be discovered in part by accident, not by intention. The present market leaders are at greatest risk when this Black Swan event occurs if they are not the originators of the technology.

• As an important aside, the nature of the endodontic marketplace will continue to evolve in the current direction with the traditional solo private practice becoming less common.

Corporate dentistry, for better or worse, will continue to grow in size to resemble, in one fashion or another, the larger medical establishment. The implications of this are enormous for the dental industry, as the supply chains for these establishments will be provided only by the largest and most capable agents who can provide a wide range of needed supplies, not just niche products such as endodontic files, regardless of how superior one particular type may be. The little guys like me will find competition increasingly difficult and rely on service and price to compete relative to our larger competitors.

All in all, given the above trends and opportunities, I am optimistic that companies like mine not only have a place, but also will gain market share. All great endeavors started small, and like the Black Swans described by Taleb, we are only one disruptive technology away from an endodontic landscape entirely different from its predecessor. Goliath never thought David had a chance. We know how things worked out for David.

Richard E. Mounce, DDS is in endodontic practice in Rapid City, S.D. He has lectured and written globally in the specialty of endodontics. He owns MounceEndo, LLC, marketing the rotary nickel titanium MounceFile in Controlled Memory© and Standard NiTi. He can be reached at [email protected]. Visit his website at and follow him on Twitter: @MounceEndo.