Dr. Lou Berman, Brånemark Award for Lifetime Achievement

When the letter arrived, Dr. Lou Berman assumed someone had made a mistake.

It congratulated him on being selected to write the diagnosis chapter for Pathways of the Pulp, the book endodontists considered their bible. Dr. Berman was a private-practice endodontist in Annapolis, Maryland, with little published work to his name.

Convinced it was an error, he called the book’s editor, Dr. Stephen Cohen, and told him not to worry, but there had been a mistake.

“He says, ‘It’s not a mistake. I’m passing the torch,’” Dr. Berman said.

The chain of events began at a Tulsa Dental conference in Oklahoma, where Dr. Berman had been invited as a key opinion leader. Surrounded by some of the most respected figures in endodontics, he felt out of his league. A chance meeting put him and his wife, Laurie, in a parking-lot conversation with Dr. Cohen. Dr. Cohen needed a section on cracked and fractured teeth for his diagnosis chapter, and he understood that was an interest of Dr. Berman’s. Did he like to write? Laurie answered for him: “Yes, he really likes to write.”

Dr. Berman doesn’t think he slept that night. He wrote and researched until he had about 90% of what Dr. Cohen needed.

From there, he went on to serve as the book’s online editor and then its co-editor, working with Dr. Kenneth Hargreaves, now dean of the UT Health San Antonio School of Dentistry. The text is known as Cohen’s Pathways of the Pulp. It is now in its 13th edition, and Dr. Berman said it is published in 16 languages and used worldwide.

Dr. Berman called the experience life-changing. “From someone who is really just an ordinary endodontist, this was a big deal for me.”

The profession would dispute the word “ordinary.” This year, Dr. Berman received the P-I Brånemark Award for Lifetime Achievement in Dentistry.

The award was created in 2015 to honor the late Prof. Per-Ingvar Brånemark and to recognize exceptional clinicians who have advanced dentistry for society’s general well-being. Past recipients include Drs. Myron Nevins, Tiziano Testori, Istvan Urban, Michael Cohen, Massimo Simion, Maria Lopez Howell, Leslie Fang, Elaine Halley, Lisa Germain and David Sarver.

A Whopping $45,000

Asked which decisions shaped his career, and what he might have done differently, Dr. Berman started with 1983. At the time, he wasn’t married, didn’t have children and had no money. What he did have was an outstanding residency behind him at Albert Einstein Medical Center in Philadelphia and a desire to work for himself. His mother took out a mortgage on her house so he could raise the $45,000 he needed for a two-operatory office, which became Annapolis Endodontics.

A molar root canal cost $320, and he felt guilty charging even that. “All of a sudden I had a patient, and they’re going to pay me money,” he said.

Going out on his own was the decision he got right. The part he second-guesses is what it cost him: he didn’t take a full week off until about nine years in, when he got engaged. That pace held for all 41 years of his career. “It was my baby. I had built it and I always wanted to be there,” Dr. Berman said. “In the years that you have children and spouses, I think that’s where you must make some important decisions as far as work-life balance goes. Young people today are doing a much better job than I did back then.”

There was always something else going on, from teaching to outside business ventures, and those side projects kept him happy. His life philosophy comes down to one idea.

“I always want to feel relevant,” he said. “I always want to feel like I’m doing something that’s important, making people feel better.”

Always Ask Why

The advice Dr. Berman still passes along starts with the people who built his specialty. Just as Dr. Brånemark changed how all of dentistry is practiced, he said, endodontics had its own founding figures. Most dentists know Dr. Louis Grossman of the University of Pennsylvania. Dr. I.B. Bender belongs in the same conversation, and he was one of Dr. Berman’s biggest mentors. Dr. Bender lived to be nearly 100, and the two stayed very close.

What Dr. Bender instilled in him went well beyond technique. “Always ask why,” Dr. Berman said. “If you’re doing something, always ask, why are you doing it this way? And not just because I was taught that way, but why?”

He still asks. During a recent visit with endodontic residents at Einstein, he asked when they brought patients back after an apicoectomy. Four or five days, they told him, and it always looks great. Then he asked what they used to suture. Silk.

If the site looks great in four or five days, why not use gut and skip the suture removal altogether? “They looked at each other like that was sacrilege,” he said. “And they said, ‘Can we do that?’”

Dr. Bender’s second lesson was about money, and Dr. Berman gives young dentists the same advice today: “Don’t chase the buck. It’ll be there. You don’t have to worry about that.”

What Changed, and What Didn’t

Looking back over 40 years of change, Dr. Berman passed over most of the gadgets and named two advances. The first was the surgical operating microscope. When he started, few clinicians used loupes, and those who did worked at 2x or 3x magnification. The microscope offered a range of 5x to 25x. “When you’re looking at something in tenths of a millimeter, that’s pretty cool,” he said.

The next big leap was CBCT, which he called life-changing for diagnosis. Neither advance altered the “arts and crafts” of doing a root canal. What they improved was the ability to make a good diagnosis and manage the case.

Asked whether anything was done better 40 years ago, he turned the question on himself. He used to call every patient, when he was treating four or five a day. By the end of his career, he was seeing eight to 10. “I think I was probably more compassionate back then.”

One practice never changed. Dr. Berman gave away a lot of dentistry. If a 20-year-old came in with a massive toothache and would lose the tooth without endodontic treatment, the conversation was short.

“Have a seat, buddy. I’m going to get you numb. Don’t worry about it,” Dr. Berman said. “That’s one thing that has not changed over the course of the 40 years. And I feel better about that than anything else.”

Knowing Your Limitations

Few colleagues know how much of Dr. Berman’s time goes to expert testimony. He has worked on roughly 150 to 160 cases, focusing on endodontic treatment that ends in serious harm, such as permanent numbness or dysesthesia in the lip and chin.

Dr. Berman won’t take a case unless he feels strongly about it. When he does, he may be brought in a year or more before trial, and the work looks a lot like the rest of his career. He reviews everything, explains the science to the lawyers, and builds demonstratives that show a jury what a root canal is and what happened in that case. “At trial, I teach,” he said. “I teach the jury.”

Across those cases, one mistake comes up again and again: not knowing your limitations. That, he said, is the biggest driver of litigation.

Dentists may also think they have more protection than they do. In his experience, informed consent has been thrown out in almost every case he has worked on. “A patient cannot sign away their right to be treated without negligence,” he said.

General dentists shouldn’t expect a separate yardstick, either: “Your peer may be a general dentist because it was a general dentistry procedure, but what sets that standard is on the specialty level.”

Dr. Berman sees two reasons a dentist might take on a case beyond their ability: “Is it money, or is it ego? And it’s a bad combination for either one of them.”

He would rather see dentists bring in the “varsity squad,” and that conversation doesn’t have to be embarrassing. His suggested script: “Mrs. Jones, I want the best that can happen for you. And this is a challenging case and it can go sideways in so many ways. So, I’m going to send you to one of our specialists.”

The End of Heroic Endodontics

An award named for the father of osseointegration might seem an unusual honor for someone who spent 41 years saving teeth. Asked whether he always felt bound to save every tooth, Dr. Berman recalled his reaction when implants arrived. “I was like, whoa, what’s going to happen to endo?”

The years that followed brought peaks, valleys and a lot of difficult conversations about why anyone would do a root canal when the tooth could be replaced with an implant. Over time, the field found a balance. When the periodontal picture looks good and deep decay has reached the pulp, he said, most clinicians would keep the tooth. Under ideal conditions, the two success rates are close, and most people would rather hang on to a tooth.

Implants also gave endodontists a way out. When a tooth can’t be corrected, or the odds of success are poor, there is now a predictable alternative.

“What has been the best thing for endo, as far as prognosis assessment goes, and the ability to stop doing heroic endodontics? Implants,” Dr. Berman said. “Because of implants, our success rate has gone up, because we’re not attempting as many heroic endodontic cases.”

Life After Practice

Retirement feels pretty good, Dr. Berman said, and he has a message for dentists who can’t imagine stepping away from the chair: “There is life after retirement, I promise you.”

Much of his own retirement involves a keyboard. He played in rock bands before rock was considered classic rock, then stopped because he needed to earn a living. A few years ago, he played a pub in Sweden for about an hour and a half with a band of fellow dentists, including Dr. Bill Nudera on drums. “That was the beginning of freedom for my wife,” he said.

Now he rehearses every couple of weeks and performs live every two to three weeks. A Saturday gig can run until midnight, with another two hours to pack up and drive home.

Asked how he hopes to be remembered, Dr. Berman had a quick answer: “That I was a good keyboard player.”

Then he got serious, citing roughly 60,000 patients treated, his work in the community and his team of about six, whom he gave good jobs, financial security and pension plans. “I really looked out for them as if they were family, because they really were my work family.”

Some of his favorite moments came during everyday errands. A stranger would stop him at the mall or the grocery store, with his children in tow. He rarely recognized them, having last seen them upside down and backwards with a rubber dam on.

“You’re Dr. Berman,” they would say. “You saved my life. I had this huge toothache and you saved it. It’s right here.”

A quick hello, and they were gone, with his kids standing there watching. “That’s the best,” he said.

Not bad for an ordinary endodontist.