Endodontic Practice Patterns Across Practitioner Profiles in France: A Cross‐Sectional Survey

ABSTRACT

Aim

To compare clinical activity, technology adoption, and care delivery and to investigate contemporary endodontic practice in France across three predefined practitioner profiles: endodontic specialists (ES), endodontically oriented practitioners (EO), and general practitioners (GP).

Methodology

A nationwide cross‐sectional electronic survey was conducted in 2022 among French dentists listed by the Société Française d'Endodontie, with 1744 practitioners invited to participate. The questionnaire, adapted from a validated Australian survey, comprised 56 items covering demographics, work habits, use of technologies and materials, and perceptions of clinical activity. Reporting followed CROSS, CHERRIES, and STROBE guidelines. Practitioners were classified as ES, EO, or GP based on objective criteria: proportion of endodontic activity, referral patterns, and use of magnification. Descriptive statistics and between‐group comparisons were performed using Chi‐square tests or non‐parametric methods when appropriate (α = 0.05).

Results

A total of 452 responses were analysed (response rate 25.9%): 124 ES (27.5%), 122 EO (27.0%), and 206 GP (45.5%). Significant intergroup differences were observed in training, workload, access to care, and clinical protocols (p < 0.001). ES reported the highest adoption of magnification, cone‐beam computed tomography (CBCT), rubber dam isolation, rotary glide‐path preparation, chelating agents, warm obturation techniques, and bioceramic materials. EO demonstrated intermediate but increasingly specialist‐aligned practices, whereas GP showed greater heterogeneity and lower uptake of advanced technologies. Across all groups, perceived failure rates were low; tooth fracture and restorability issues were the main reasons for tooth loss rather than endodontic failure.

Conclusions

Comparison across three predefined practitioner profiles highlights distinct patterns of clinical activity, technology adoption, and care delivery in French endodontic practice. Although practitioner profiles were defined a priori, the observed differences in clinical activity, technology use, and referral patterns support the clinical relevance and internal coherence of this classification. EO emerge as a pivotal intermediate group bridging general practice and specialist care and contribute substantially to the management of complex cases. These findings support the relevance of this tiered practitioner framework and argue for structured training pathways and improved referral coordination to optimise access to high‐quality endodontic care.

1. Introduction

Endodontic practice has undergone substantial evolution over the past two decades, with global trends showing widespread integration of magnification, rotary nickel–titanium (NiTi) systems, electronic apex locators, CBCT, and calcium silicate–based biomaterials (Cheung and Parashos 2023). Beyond the availability of these technologies, clinical outcomes in endodontics increasingly depend on how consistently evidence‐based protocols are implemented in daily practice, including decision‐making processes, workflow organisation, and adherence to recommended clinical standards.

Recent cross‐national surveys have therefore shifted focus from isolated technical choices to broader patterns of clinical practice, highlighting important variations in training background, access to advanced technologies, and care delivery models between practitioners (Al Raisi et al. 2019; Brown et al. 2020; Kirkevang and Sørensen 2025; Mergoni et al. 2022; Patel et al. 2025; Sacha et al. 2021; Segura‐Egea et al. 2021; Sørensen and Kirkevang 2021). Within Europe, studies from Italy, Germany, Spain, the United Kingdom, and Scandinavian countries describe a general move toward evidence‐based instrumentation and irrigation strategies, while consistently reporting substantial heterogeneity among non‐specialists and mixed‐practice clinicians.

Analysing practitioners' work habits provides valuable insight into real‐world endodontic care, allowing identification of gaps between recommended guidelines and routine clinical practice. Such data are essential for informing targeted continuing education programmes, refining undergraduate and postgraduate curricula, and improving referral pathways between general practitioners and more endodontically focused clinicians. At a healthcare system level, understanding these practice patterns contributes to optimising the organisation of endodontic care and promoting equitable access to high‐quality treatment (Cheung and Parashos 2023; Girgis et al. 2020; Zaugg et al. 2019).

Beyond technical procedures and technology adoption, contemporary endodontic practice also involves practitioner‐related and patient‐related dimensions that may influence real‐world care delivery. Previous national surveys have incorporated not only technical procedures, materials and equipment, but also referral patterns, case selection, perceived clinical activity and practice‐related constraints, supporting the relevance of a broader approach to describing endodontic practice (Girgis et al. 2020; Zaugg et al. 2019). In dentistry, professional stress, workload, job satisfaction and patient‐related factors have been shown to influence clinical experience, professional behaviour and care delivery (Collin et al. 2019; Le et al. 2021; Pouradeli et al. 2016; Song and Kim 2019). In endodontics specifically, treatment is often technically demanding and may be affected by perceived case difficulty, treatment time, patient anxiety, gag reflex, limited mouth opening and other chairside constraints (Eachempati et al. 2019; Huang et al. 2024). These factors may influence treatment feasibility, case selection, referral behaviour, and the willingness to manage complex cases. Assessing practitioner perceptions and patient‐related constraints alongside clinical procedures therefore provides a more comprehensive understanding of how endodontic care is delivered in routine practice.

The French dental care system operates under a hybrid model combining mandatory national health insurance, which covers basic dental care at regulated fees, with complementary private insurance that plays a major role in completing patient coverage. Dental care is predominantly delivered in private practice, with public hospital and university settings mainly involved in complex care, training, and research. Clinical practice is guided by national recommendations issued by the French National Authority for Health (Haute Autorité de Santé, HAS). Notably, endodontics is not formally recognised as a specialty by the French National Dental Council: practitioners with advanced postgraduate training (CES or Master's degree) remain registered as general dental practitioners, regardless of their clinical focus. It is estimated that approximately 400 out of nearly 50 000 dentists in France dedicate their practice exclusively to endodontics. In France, no recent nationwide analysis has examined contemporary endodontic work habits across the dental workforce. Based on a classification model inspired by a Swiss national survey, practitioners can be categorised into three predefined profiles: Endodontic Specialists (ES), Endodontically Oriented Practitioners (EO), and General Practitioners (GP) (Zaugg et al. 2019). In this context, the term ‘Endodontic Specialist (ES)’ used in this study refers to a practice profile defined by objective criteria and the three‐tier classification (ES, EO, GP) provides a pragmatic framework to capture meaningful differences in training, scope of practice, and involvement in endodontic care across the French dental workforce. In a country where endodontics is not formally recognised as a dental specialty, the existence of distinct practitioner profiles remains poorly documented. The three‐tier framework used in this study—Endodontic Specialists, Endodontically Oriented Practitioners, and General Practitioners—was therefore not only a classification tool, but also a pragmatic model to explore whether different levels of endodontic involvement correspond to distinct patterns of training, clinical activity, technology adoption, access to care, and perceived professional constraints.

The aim of this study was to describe contemporary endodontic practice in France and to assess the relevance of this tiered‐practitioner framework by comparing clinical activity, technology adoption, care delivery, and perceptions of practice—including perceived causes of failure or tooth loss, professional stress, and patient‐related constraints—across the three predefined practitioner profiles.

2. Materials and Methods

2.1. Design of the Questionnaire

This study was conducted through a collaboration between the University of Nantes, the ReCOL association (Réseau de Recherche en Odontologie), and the Société Française d'Endodontie (SFE), and was designed as a practice‐based, cross‐sectional, questionnaire‐based survey, conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines and the Checklist for Reporting Results of Internet E‐Surveys (CHERRIES) guidelines for online surveys (Eysenbach 2004). This study was approved by the French national authorities regulating confidentiality (CNIL, Commission Nationale Informatique et Libertés, No. 2232858 v 0) and all participants provided informed consent before participating, and data collection was anonymous and voluntary.

The questionnaire comprised four sections covering: (i) demographics, (ii) work habits, (iii) technologies and materials used, and (iv) perceptions of clinical activity. It was adapted from a 2020 Australian survey (Girgis et al. 2020), enabling direct comparison with previous findings. The instrument consisted of 56 items across 16 pages. The questionnaire consisted mainly of closed‐ended questions with predefined response options (single‐choice or multiple‐choice). Several items used ordinal scales to assess practitioner perceptions (e.g., stress level and perceived causes of treatment failure). A small number of open‐ended questions allowed respondents to provide additional information where necessary. Items were framed to capture practitioners' own clinical choices rather than case frequency.

A pilot version was first administered to six individuals outside the study population to assess the clarity, relevance, and comprehensiveness of the themes and items. Minor modifications were made accordingly, and the final version was approved for online distribution. In May 2022, the questionnaire was disseminated electronically to practitioners via a French mass‐emailing platform. To ensure completeness, an automated prompt required respondents to address any unanswered items prior to submission. To prevent duplicate submissions, each participant received a unique personalised survey link, allowing secure access and enabling respondent‐level tracking. The estimated time required to complete the e‐survey was approximately 15 min. The full questionnaire is provided in Appendices S1 and S2.

2.2. Selection and Size of Sample

The mailing list of French practitioners (N = 1744) was obtained from the SFE and covered registrations between 2004 and 2021.

Practitioners were classified into three groups according to predefined objective criteria:

1. Endodontic procedures representing ≥ 75% overall clinical activity;

2. Regular receipt of referrals for endodontic treatment;

3. Use of magnification (operating microscope, loupes, or endoscope).

Dentists fulfilling all three criteria (including the use of an operating microscope) were classified as Endodontic Specialists (ES). Practitioners meeting at least two of the three criteria were considered Endodontically Oriented practitioners (EO). Practitioners meeting fewer than two criteria were categorised as General Practitioners (GP).

This classification was established before statistical analysis and was intended to operationalise a tiered‐practitioner framework adapted to the French context, where endodontics is not formally recognised as a specialty. The purpose was to determine whether these predefined profiles corresponded to meaningful differences in clinical practice, technology use, referral patterns, and care delivery. The classification of respondents was not performed from the mailing list. The mailing list was used only as the sampling frame to invite practitioners. Respondents were subsequently classified according to the predefined objective criteria derived from their questionnaire responses.

2.3. Statistical Analysis

Completion of all items was mandatory to ensure a fully analysable dataset, in accordance with CHERRIES recommendations. To avoid forcing respondents into inaccurate answers, each question included a ‘Don't know/Don't answer’ option, which represented < 1% of all responses. These responses were considered non‐informative and excluded from statistical analyses. During data cleaning, items subsequently identified as ambiguous, inconsistently interpreted, or presenting excessive heterogeneity were removed from further analyses to preserve internal validity. Likewise, questions that did not yield distributions suitable for statistical comparison (e.g., extremely unbalanced categories or uninterpretable free‐text entries) were excluded.

Data were exported into Excel, then imported into RStudio (version 2024.04.2) for analysis. Descriptive statistics were computed for all variables. Group comparisons were performed using two‐tailed Chi‐square tests or non‐parametric alternatives when appropriate. Variables used to define practitioner profiles were not interpreted as independent comparative outcomes. The significance level was set at α = 0.05. p‐values < 0.05 were considered statistically significant. Ranked questions were treated as ordinal variables. Ranking data were summarised using rank distributions and mean rank scores for each item. When applicable, comparisons between practitioner groups were performed using non‐parametric statistical methods appropriate for ordinal data. Because the survey design prevented missing data, complete‐case analysis was performed across all variables. No formal a priori sample size calculation was performed, as this study was designed as a descriptive cross‐sectional survey aiming to characterise current endodontic practice patterns rather than to test a single primary hypothesis. All eligible practitioners within the predefined target groups were invited to participate, and the achieved sample size allowed meaningful descriptive analyses and between‐group comparisons.

3. Results

Respondent characteristics are presented in Figure 1. A comparison of sociodemographic, clinical practice, and technical variables across practitioner groups is provided in Table 1. Detailed results for all variables are reported in Appendix S2.

FIGURE 1.

Flowchart.

TABLE 1.

Comparison of sociodemographic, clinical practice and technical variables across practitioner groups (ES, EO, GP).

	ES (n = 124)	EO (n = 122)	GP (n = 206)	p
Gender
Female	47 (38%)	44 (36%)	108 (52%)	0.004
Male	77 (62%)	78 (64%)	98 (48%)
Age
25–35 years	43 (35%)	53 (43%)	81 (39%)	0.1
35–45 years	46 (37%)	37 (30%)	52 (25%)
45–55 years	23 (19%)	19 (16%)	35 (17%)
> 55 years	12 (9.7%)	13 (11%)	38 (18%)
Time devoted to endodontics
0%–25%	0 (0%)	16 (13%)	120 (58%)	< 0.001
25%–50%	0 (0%)	61 (50%)	76 (37%)
50%–75%	0 (0%)	44 (36%)	10 (4.9%)
75%–100%	124 (100%)	1 (0.8%)	0 (0%)
Endodontic referrals
Yes	124 (100%)	122 (100%)	22 (11%)	< 0.001
No	0 (0%)	0 (0%)	184 (89%)
Magnification use
Yes	124 (100%)	121 (99%)	153 (74%)	< 0.001
No	0 (0%)	1 (0.8%)	53 (26%)
Patient recruitment area
The firm	3 (2.4%)	18 (15%)	66 (32%)	< 0.001
The city	15 (12%)	23 (19%)	55 (27%)
The department	36 (29%)	51 (42%)	61 (30%)
The region	70 (56%)	30 (25%)	24 (12%)
Commonly performed procedures
Endodontic surgery	7 (5.6%)	9 (7.4%)	11 (5.3%)	< 0.001
Preservation of pulp vitality	10 (8.1%)	24 (20%)	124 (60%)
Orthograde retreatment	98 (79%)	67 (55%)	33 (16%)
Initial endodontic treatment	9 (7.3%)	22 (18%)	38 (18%)
Years since graduation
< 5 years	15 (12%)	26 (21%)	37 (18%)	0.022
5–10 years	25 (20%)	30 (25%)	51 (25%)
10–20 years	51 (41%)	36 (30%)	49 (24%)
20–30 years	23 (19%)	16 (13%)	34 (17%)
> 30 years	10 (8%)	14 (11%)	35 (17%)
Endodontic training
Internship/DU	64 (52%)	41 (34%)	7 (3%)	< 0.001
CES/Master	35 (28%)	31 (25%)	11 (5%)
Other	24 (19%)	48 (39%)	155 (75%)
None	1 (0.8%)	2 (1.6%)	33 (16%)
Delay for routine care
< 4 weeks	34 (27%)	51 (42%)	107 (52%)	< 0.001
4–8 weeks	44 (35%)	35 (29%)	65 (32%)
> 8 weeks	46 (37%)	36 (30%)	34 (17%)
Emergency acceptance
Yes	85 (69%)	108 (89%)	201 (98%)	< 0.001
No	39 (31%)	14 (11%)	5 (2%)
Pre‐endodontic build‐up
< 25%	11 (9%)	11 (9%)	98 (48%)	< 0.001
25%–50%	18 (15%)	31 (25%)	42 (20%)
50%–75%	35 (28%)	32 (26%)	17 (8%)
> 75%	60 (48%)	48 (39%)	49 (24%)
CBCT availability
Yes	117 (94%)	94 (77%)	120 (58%)	< 0.001
No	7 (6%)	28 (23%)	86 (42%)
Instrumentation
Continuous rotation	99 (80%)	83 (69%)	138 (67%)	0.052
Reciprocation	25 (20%)	38 (31%)	67 (33%)
Instrumentation sequence
Multi‐file	81 (65.9%)	63 (52.1%)	113 (55.1%)	0.066
Single‐file	42 (34.1%)	58 (47.9%)	92 (44.9%)
Glide‐path technique
Systematic	57 (46%)	54 (44%)	48 (23%)	< 0.001
None	65 (54%)	68 (56%)	158 (77%)
Irrigation—Chelating agent
Yes	93 (75%)	99 (81%)	111 (54%)	< 0.001
No	31 (25%)	23 (19%)	95 (46%)
Irrigation—NaOCl
Yes	100 (81%)	103 (84%)	177 (86%)	0.4
No	24 (19%)	19 (16%)	29 (14%)
Obturation technique
Warm/Thermoplastic	90 (73%)	91 (75%)	115 (56%)	0.002
Cold/Single‐cone	30 (24%)	25 (20%)	79 (38%)
Sealer type
Bioceramic	35 (28%)	30 (25%)	29 (14%)	0.3
Zinc oxyde eugenol	66 (53%)	66 (54%)	140 (68%)
Epoxy resin	22 (18%)	20 (16%)	27 (13%)
Immature teeth management
Apexification	94 (76%)	87 (71%)	107 (52%)	< 0.001
Revascularization	28 (23%)	16 (13%)	10 (4.9%)
Does not treat	2 (1.6%)	19 (16%)	88 (43%)

Note: Variables used to define practitioner profiles (proportion of endodontic activity, receipt of referrals, and use of magnification) are presented as classification criteria and were not interpreted as independent comparative outcomes.

3.1. Response Rate and Demographics

A total of 452 responses were collected (response rate 25.9%). Practitioners aged 25–45 were the majority across all groups. GP had the highest proportion of respondents over 55 years old (18% vs. 9.7% ES; 11% EO). Male predominance was observed among ES (62%) and EO (64%), whereas women constituted a slight majority among GP (52%, p = 0.004). Among ES, 62% reported having reoriented their practice to endodontics within the last 10 years.

3.2. Satisfaction of Classification Criteria

After the flowchart and demographic characteristics, the three classification criteria were further detailed. ES fulfilled all three criteria, with ≥ 75% of clinical time devoted to endodontics, regular receipt of endodontic referrals, and systematic use of magnification including an operating microscope. EO were also characterised by referral‐based activity and almost systematic use of magnification, but differed from ES mainly by a lower proportion of time dedicated to endodontics and less systematic access to an operating microscope. GP met fewer than two criteria: most devoted less than 50% of their activity to endodontics, did not receive endodontic referrals, and when magnification was used, it was mainly limited to dental loupes rather than operating microscopes.

3.3. Training and Workload

Training differed markedly between groups (p < 0.001). Structured postgraduate training was reported by 80% of ES, 59% of EO, and only 25% of GP. EO typically dedicate 25%–75% of their clinical activity to endodontics (86%), whereas only 42% of GP exceed 25%.

Weekly workload ranged between 30 and 40 h for most practitioners (ES 57%, EO 58%, GP 65%). ES most commonly saw 10–20 or 20–40 patients weekly; EO and GP managed significantly higher volumes (40–60 patients in 36% of EO and 50% of GP).

3.4. Access to Care and Emergency Services

Significant differences were observed in access times (p < 0.001). GP offered the shortest access times for routine treatments with 52% providing appointments within 4 weeks, followed by EO (42%) and ES (27%). Delays exceeding 8 weeks were predominantly reported by ES (37%). Emergency coverage was nearly universal among GP (98%) and EO (89%) but less frequent among ES (69%).

Management of traumatic dental injuries differed significantly (p < 0.001). More than 10 trauma cases per year were treated by 58% of ES, compared with 22% of EO and 27% of GP. ES and EO provided the fastest responses, with 25% and 29%, respectively, treating trauma within 2 h, whereas only 18% of GP reported such rapid intervention.

3.5. Distribution of Endodontic Procedures

Procedure type differed markedly between groups (p < 0.001). ES predominantly performed orthograde retreatments (79%), EO showed mixed caseloads, while GP mainly managed vital pulp therapy (60%) and primary root canal treatments (18%). Surgical endodontics remained rare. Regarding interappointment intracanal medication use during orthograde retreatment, the majority of ES reported using it rarely (73%), with 11% using it frequently and 14% never. Management of immature teeth showed group‐dependent strategies (p < 0.001). Apexification using bioceramics (MTA, Biodentine) was widely used among ES (76%) and EO (71%). Revascularization was more frequently used by ES (23%), followed by EO (13%), and very rarely by GP (4.9%). In contrast, GP relied more frequently on calcium hydroxide (44%), and 43% reported not managing immature teeth.

3.6. Use of Technologies and Materials

Rubber dam use differed significantly across groups (p < 0.001): 99% of ES reported systematic use across all endodontic procedures, compared to 84% of EO and 53% of GP. Among GP who did not report systematic use, the vast majority indicated selective but procedure‐appropriate use, applying rubber dam for root canal treatments, vital pulp therapy, and retreatments, rather than abandoning its use altogether. Pre‐endodontic reconstruction (PER) differed significantly across groups (p < 0.001): ES (48%) and EO (39%) performed PER more frequently than GP (24%). Among Endo‐Oriented Practitioners (EO), 99% used optical aids, whereas only 74% of General Practitioners (GP) reported using them. Among GP, 13% used a microscope. In contrast, 51% of EO practitioners combined both loupes and a microscope.

CBCT availability was highest among Endodontic Specialists (ES) (94%), followed by EO (77%) and GP (58%). Similarly, routine CBCT use (> 75% of cases) was reported by 27% of ES, 19% of EO, and only 5% of GP.

Instrumentation strategies showed significant differences (p < 0.001). Systematic rotary glide‐path preparation was reported by 46% of ES, 44% of EO, and 23% of GP. Continuous rotation was the predominant shaping method (ES 79.8%, EO 68.6%, GP 67.3%), whereas reciprocation was more frequent among EO and GP.

Irrigation practices varied in terms of volume and chelator use. ES used > 6 mL per canal in 73% of cases compared with 62% of EO and 39% of GP (p < 0.001). Chelators (EDTA/citric acid) were used by 75% of ES and 81% of EO, but only 54% of GP (p < 0.001). Sonic activation was the most common activation technique across all groups, whereas laser activation was rare (< 4%). Among practitioners using an activation system (n = 313), sonic activation was the predominant method among ES (63%) and EO (65%), whereas GP showed a comparatively higher proportion of ultrasonic activation use (40% vs. 31% for both ES and EO).

Obturation techniques differed significantly (p = 0.002). Warm vertical compaction and thermoplastic techniques were used by 73% of ES and 75% of EO, but far less frequently by GP. ZOE sealers remained the most commonly used across all groups, particularly among GP (68%). Bioceramic sealers were more common among ES (28%) and EO (25%) than GP (14%).

In surgical endodontics, bioceramic materials used for retrograde fillings were used by 77% of ES and 70% of EO, versus only 38% of GP. Regarding direct pulp capping materials, bioceramic materials were used by 100% of ES, 97% of EO, and 84% of GP, while calcium hydroxide was reported by 0%, 3.3%, and 16%, respectively (p < 0.001).

3.7. Complications and Perception of Failure

Complications were commonly reported across all practitioner groups, with only ~3% reporting none. Among Endodontic Specialists (ES), shaping‐related complications (including canal stripping, ledge formation, and apical transportation) were the most frequently reported operative events (37%), followed by instrument fracture (34%). In contrast, instrument fracture was the most frequently reported complication among Endodontically Oriented practitioners (EO, 35%) and General Practitioners (GP, 32%). EO showed a slightly higher incidence of sodium hypochlorite extrusion (9%). GP more frequently reported obturation errors (21%) and intraoperative tooth fractures (14%).

Reported reasons for tooth loss varied significantly between groups (p < 0.001). Tooth fracture was the most frequently cited reason by both ES (44%) and EO (46%). In contrast, GP reported periodontal disease as the leading cause (33%), followed by fracture (24%) and non‐restorability (23%). Endodontic failure is rarely cited as the main cause of tooth extraction with only 5.3% GP, 4.1% of EO and 15% of ES, respectively reporting it as the primary reason.

Perceived failure rates were low among ES (98% reporting few/very few failures) and EO (100%). GP reported slightly more failures, although still low overall (≈5%).

3.8. Perception of Activity

Stress levels were highest among EO (80%) and GP (79%), compared to ES (65%, p = 0.004). ES cited referrer pressure more often (23%), whereas patient pressure was dominant for GP (44%) and EO (31%). Administrative workload was a frequent stressor in all groups. Workload satisfaction was comparable across groups: ~50% felt ‘appropriately busy’, while ~50% reported being ‘too busy’. Underbooked practitioners were rare (< 8%). Among patient‐related behavioural constraints, anxious patients were most frequently ranked first across all groups (ES 58%, EO 70%, GP 66%), followed by gag reflex (ES 31%, EO 22%, GP 25%) and limited mouth opening (ES 10%, EO 8.2%, GP 9.7%).

Over half of the ES (58%) and EO (54%) reported difficulties related to calcified canals, canal C anatomy, or locating secondary canals (e.g., MB2), compared to 43% of GP. Additionally, access cavity challenges, particularly in the presence of inlay cores or fibre posts, were cited by 17% of ES, 26% of EO, and 34% of GP.

4. Discussion

In France, endodontic care is mainly delivered in private practice, with most root canal treatments performed by general dental practitioners. Specialist care relies largely on informal referral networks, while a growing number of practitioners have progressively oriented their clinical activity toward endodontics through continuing professional education.

The overall response rate in our study was 25.9%, which is comparable to that reported in a similar national survey in Switzerland, where a 33.2% response rate was achieved through conference‐based distribution (Zaugg et al. 2019). Given that the number of EO practitioners is equivalent to that of ES, this suggests that a substantial pool of trained clinicians exists both among full‐time specialists and part‐time endodontic practitioners. This supports the notion of distinct professional profiles, namely full‐time endodontic specialists and part‐time endodontic practitioners.

Differences in age distribution suggest that specialization in endodontics may be more common among younger practitioners. The growing limitation of practice to endodontics among ES and EO appears to have accelerated over the past 20 years, which may be linked to the age distribution of respondents and the timing of their professional orientation. This may also suggest a trend toward earlier specialization in endodontics among younger generations, reflecting evolving career paths and a growing interest in focused clinical practice early in professional life.

A significant gender imbalance was observed in respondent population, particularly among ES and EO where low female representation was noted. Similar trends have been reported in other regions, Switzerland (Zaugg et al. 2019), U.S. (Savani et al. 2014), Australia (Girgis et al. 2020). Despite increasing gender parity in dental education and general practice, the field of endodontics remains largely male‐dominated. This imbalance may be explained by multiple factors, including career preferences, perceived challenges related to work–life balance, and persistent gender norms influencing specialty choice.

Clear differences emerged in training pathways. ES benefit from the most formal and advanced university‐level training while EO represent a mixed profile, with many having pursued structured continuing education; and GP rely more heavily on informal or experiential learning. This stratification underscores the critical role of non‐university continuing professional education in maintaining high standards of care, particularly for non‐specialists (Cheung and Parashos 2023).

Regarding access to care, ES appear to have more limited availability, likely reflecting high demand and more complex treatment‐planning protocols. They also attract a broader patient base from more distant regions than EO and GP. In contrast, EO display a hybrid profile: their access times are closer to those of GP for both routine and emergency care, yet their clinical equipment and expertise often mirror those of ES. Evidence from the London NHS context supports this view: EO routinely manage intermediate‐level cases within primary care, easing pressure on specialist clinics (Ghotane et al. 2015).

Management of traumatic dental injuries was infrequent across all practitioner groups, with most EO treating fewer than 10 cases annually and ES up to 20. These figures align with epidemiological estimates indicating a 1%–3% prevalence, mainly in young patients (25). However, readiness appears limited: only 25% of ES and 18% of GP reported managing cases within the critical 2‐h window, highlighting gaps in emergency access. Patients may preferentially seek hospital or university clinics, where expertise is more accessible. Overall, private‐practice capacity seems insufficient, supporting the potential value of dedicated dental trauma centres to enhance timely and equitable care.

While ES appear to report more treatment failures, this likely reflects the complexity of the cases they handle. In most cases, the main limiting factor is not the quality of the root canal treatment itself, but the restorability of the tooth, due to issues such as periodontal breakdown or vertical root fractures (Mehta et al. 2025). Many studies show that fracture and periodontal breakdown are leading extraction causes, explaining higher failure counts in specialist caseloads without implying inferior endodontic skill (Ek et al. 2023; Touré et al. 2011). Tamse (2006) suggests that GP may under‐recognise fractures (Tamse 2006). Recent review underscore that ferrule effect and coronal seal dictate long‐term survival. This aligns with our interpretation that restorability, rather than pure endodontic failure, limits success (Mehta et al. 2025).

EO report levels of professional pressure comparable to GP, despite often handling more technically demanding cases. This trend may reflect the dual burden carried by EO: they manage complex endodontic treatments similar to specialists, yet often without the organisational infrastructure and formal recognition. Overall, dentists tend to report moderate to high levels of job satisfaction, with specialists generally being more satisfied than general practitioners. The five least satisfying aspects of the profession appear to be personal time, stress, income, practice management, and professional time (Le et al. 2021). A study in the UK found that 54.9% of dentists reported high levels of work‐related stress (Collin et al. 2019). In Iran, 58.9% of practitioners frequently experienced stress, with higher scores among general dentists with less than 10 years of experience (Pouradeli et al. 2016). In Korea, key stress‐related factors included income, working hours, job satisfaction, and sleep quality (Song and Kim 2019). In Lithuania, personal time, patient and colleague relationships, work organisation, and workload were identified as major factors affecting job satisfaction—although they were considered secondary to opportunities for professional development (Puriene et al. 2007).

The use of optical aids reveals two distinct profiles among GP: fully GP, and those who are more endo‐oriented without formal specialization. The combined use of advanced optical aids among EO practitioners supports their positioning closer to the specialist model. These results are consistent with previous studies showing that endodontists are significantly more likely to use magnification tools like dental operating microscopes and loupes, which enhance precision during root canal procedures (Cheung and Parashos 2023; Orafi and Rushton 2013). This technological gradient reflects differing clinical demands and training levels, and supports the idea of an intermediate, EO group that bridges generalist accessibility and specialist‐level instrumentation.

The use of CBCT was significantly lower among GP. Barriers to adoption include financial constraints, limited access to equipment, and insufficient training (Orafi and Rushton 2013). However, preoperative CBCT use was high among ES and EO in our study, with nearly two‐thirds reporting CBCT use in more than 50% of cases., suggesting a high level of integration of three‐dimensional imaging in French endodontic practice. This comparatively frequent use contrasts with reports from other countries. For example, Girgis et al. reported more rare CBCT use, generally due to high costs associated with the CBCT machine (Girgis et al. 2020). In the UK, Patel et al. described CBCT as ‘commonplace’ among specialists, although not always in accordance with best‐practice guidelines, highlighting ongoing training needs (Patel et al. 2025).

Our findings also indicate that glide‐path preparation has not yet become standard practice across all practitioner categories. While its systematic integration is more common in specialist protocols, broader adoption remains limited, possibly due to time constraints, cost considerations, or lack of training (Ajina et al. 2022; Berutti et al. 2009). Similarly, reciprocating instruments, despite their potential advantages, have not gained significant traction in clinical practice, indicating limited adoption among practitioners. For shaping canals, the preference for continuous rotation across all practitioner types confirms its status as the dominant technique (Ng et al. 2008). A review published in the Australian Endodontic Journal found that reciprocating and rotary instruments offer comparable efficacy, but highlighted a lack of high‐quality clinical evidence and clinical adoption still favours rotary systems (Puleio et al. 2024).

Despite differences in training and specialization, practitioners across all groups appear to converge in their preference for sonic irrigation activation. Systems such as the EndoActivator are widely favoured, particularly by general practitioners and endo‐oriented clinicians. These findings are consistent with those of Zaugg et al. (2019) in Switzerland, where sonic systems were the most reported irrigation activation method across generalists and specialists.

For immature teeth, a clear shift toward apical plug techniques using bioceramic materials such as MTA, Biodentine, or CEM is noted in specialist and endo‐oriented practices. This is likely due to the predictability, biological compatibility, and reduced treatment duration of these materials, allowing single‐visit apexification with similar success rates to traditional methods (Guerrero et al. 2018). In contrast, nearly half of general practitioners still favour calcium hydroxide (Cheung et al. 2023), reflecting a more traditional, multi‐visit approach aimed at inducing apical closure. These differences may reflect disparities in postgraduate training, access to newer materials, or conservative clinical habits in general practice settings.

ES predominantly use bioceramic materials, whereas EO and GP more often rely on traditional or adhesive techniques, reflected by their lower bioceramic use (51% and 46%). This suggests a restorative‐driven rather than biologically driven approach in general practice. Bioceramics, however, remain the gold standard for direct pulp capping (DPC) among ES and are increasingly adopted by EO, with GP showing the greatest margin for improvement. These trends align with a recent survey reporting higher odds of DPC (OR = 5.81) and calcium silicate materials (CSM) use (OR = 8.07) among endodontists, with MTA used by 67.1% for DPC (Li et al. 2019).

Beyond material choice, orthograde retreatment represents a major clinical challenge not specifically addressed in our survey. In particular, coronal disassembly (e.g., removal of posts, cores, and restorations) is a key determinant of case complexity and decision‐making, especially for general practitioners. As highlighted by Zanza et al. (2023), retreatment involves multiple technical and restorative challenges requiring dedicated protocols. However, as our questionnaire did not include items on disassembly strategies, this aspect could not be explored. Future surveys should incorporate variables related to restorative status, disassembly approaches, and case selection to better characterise retreatment practices and identify training needs (Zanza et al. 2023).

A 2025 U.S. study showed specialists outperforming general dentists in use of high‐magnification optics, rubber dam, apex locators, ultrasonic activation and single‐visit protocols, again paralleling the gap we found between ES and GP, with EO bridging much of that divide (Nosrat et al. 2025). UK data on 435 general‐practice cases revealed that 28% were highly complex, underscoring the need for an intermediate practitioner capable of tackling such cases without full specialist referral, precisely the niche filled by EO in our cohort (Essam et al. 2022). Educational evidence supports this trajectory: a recent British Dental Journal review emphasised postgraduate training and emerging technologies as key drivers of confidence and competence, reinforcing the ESE 2023 quality‐guideline mandate for continuous professional development (Longridge et al. 2025). Taken together, these studies confirm the relevance of a three‐tier model. Our data fit within an international pattern where an ‘endo‐oriented’ stratum absorbs a substantial share of complex work, alleviating specialist wait times (> 8 weeks in our study) while exceeding general‐practice standards defined by the ESE. They also highlight persistent gaps, particularly in CBCT adoption, glide‐path standardization, and bioactive material use, suggesting that societies such as the SFE could broaden DU‐level courses and interactive formats to meet the unmet educational expectations expressed by our EO and ES respondents. A central objective of this study was to assess whether a tiered‐practitioner framework could meaningfully describe the organisation of endodontic care in France. The results support the clinical relevance of this model. ES showed the most specialised profile, characterised by referral‐based activity, advanced technologies, and more complex procedures. GP represented the broadest and most heterogeneous group, with greater involvement in primary care and emergency access. EO occupied an intermediate position, combining accessibility closer to that of GP with clinical equipment and treatment patterns approaching those of ES. This gradient suggests that EO may constitute a clinically relevant intermediate tier within the French endodontic care system. The significant differences observed across practitioner profiles in clinical activity, technology adoption, and referral patterns provide indirect validation of the three‐tier classification framework used in this study. In a country where endodontics is not formally recognised as a specialty, these findings support the existence of a de facto tiered system of care delivery and argue for its usefulness in understanding access to care and referral organisation within the French dental landscape.

This study presents several limitations. As a self‐administered survey, it is exposed to social desirability bias, notably the tendency to overreport recommended practices such as rubber dam use or to underreport failures. This phenomenon is well‐documented in survey‐based research, particularly in healthcare settings where respondents may seek to align their answers with perceived professional norms (Krumpal 2013). In addition, selection bias cannot be excluded, as participation may have been more attractive to highly engaged practitioners with a particular interest in endodontics, potentially leading to an over‐representation of clinicians with higher levels of training or technological adoption. More specifically, as participants were recruited exclusively through the mailing list of SFE, the study population likely overrepresents practitioners with a higher level of involvement in endodontic practice than the general dental population. Reported practices reflect perceived rather than objectively measured competence, and a gap between self‐reported behaviours and actual clinical performance cannot be ruled out. Furthermore, the item assessing perceived failure frequency relied on a subjective ordinal scale, and individual interpretations of categories such as ‘very few’ or ‘too many’ may vary considerably across practitioners, limiting the comparability of responses across groups. Additionally, some questionnaire items grouped distinct clinical techniques into a single category (e.g., single‐cone and cold lateral compaction as one obturation option) thereby limiting interpretative precision and preventing cross‐referencing of obturation technique with sealer type at the individual level. Practitioner classification relied on self‐reported information, although grounded in clearly defined criteria, and the national representativeness of the sample, despite its size (n = 452), cannot be fully guaranteed. Moreover, some other variables (e.g., specific bioceramic materials, NaOCl concentrations, or success criteria) could not be assessed in depth (Tourangeau and Yan 2007).

5. Conclusion

This cross‐sectional survey showed marked differences in endodontic practice patterns across three predefined practitioner profiles. ES reported greater endodontic involvement, more frequent referral‐based activity, higher levels of postgraduate training, and wider adoption of advanced technologies and specialised protocols. EO occupied an intermediate position, with several clinical and technological characteristics closer to ES than to GP, while GP showed greater heterogeneity and maintained an important role in access to routine and emergency care. However, because respondents were recruited from the SFE mailing list and data were self‐reported, the results should be interpreted as reflecting practice patterns among practitioners with an interest in endodontics, rather than as fully representative of all dentists practicing in France. These findings support the relevance of a tiered‐practitioner framework for describing endodontic care in France. In the absence of formal specialty recognition, this model helps identify distinct levels of endodontic involvement and may inform training pathways, referral coordination, and access to specialised care.

Author Contributions

Christia Aoun: methodology, writing – original draft, writing – review and editing. Orly Petipa: data curation, methodology, writing – review and editing. Hugo Billy: conceptualization, project administration, software, data curation, writing – original draft. Cauris Couvrechel: conceptualization, software, writing – review and editing, validation. Brigitte Grosgogeat: methodology, project administration, writing – review and editing, validation. Alexis Gaudin: methodology, conceptualization, writing – review and editing, validation.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1: Questionnaire used in the 4‐part study.

Appendix S2: Descriptive summary table of participant characteristics by practice profile.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.