An occasionally irregular blog about orthodontics

Should General Dentists provide orthodontic treatment?

Should General Dentists provide orthodontic treatment?

Should general dentists provide orthodontic treatment?

In this post I’m going to discuss the rather controversial area of whether general dentists should provide orthodontic treatment. I will also risk discussing Short-Term Orthodontics (STO), Six Month Smiles, Anterior Alignment Orthodontics and Fast Braces.

This issue is often raised by specialists and specialist societies. The British orthodontic Society even took out an advertisement to state its position and inform the public.

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I have approached this discussion by considering the overall premise that a general dental practitioner can provide any treatment in which they are competent. This is also true of specialist, who also have varying competencies. Importantly, the decision on whether they are competent is taken by the individual practitioner.

This is also complicated by the varying aims of undergraduate programmes. There is no doubt that these vary throughout the world. In the UK ,the current guidelines suggest that the newly qualified dentist should be competent in diagnosis and assessment in order to refer their patients to a specialist. The Dental Schools do not train student dentists to be competent in providing active orthodontic treatment.

This raises a problem. If a practitioner wants to provide simple orthodontic treatment and does not want to train to become a specialist; opportunities are limited. In the UK there were training schemes, for these practitioners, but these have now discontinued, leaving a void. The “training void” can also be filled by practitioners gaining experience by attending courses to obtain competences and some of these are delivered over a length of time. But practitioners should be wary of the short course that is held over a weekend.

The counter argument, is that in order for someone to recognise that a treatment is “simple” they need to be fully competent in all aspects of orthodontics. In some ways I agree with this, however, it should also be possible for specialists to identify simple cases and provide a treatment plan for the practitioner. Again, in many countries this is standard practice.

Anterior Aesthetic Orthodontics or Short Term Orthodontics

Over the past few years I wonder if there has been an expansion of short 1-2 day courses of instruction and “accreditation” in orthodontic techniques. Some are marketed heavily as new techniques that speed up treatment and this is a selling point to the practitioners and patients.

This introduces an additional “dynamic” to the situation. As we all know, treatment is faster if the aims are simply to line the front six teeth. Indeed, this is a treatment that can be carried out  for adults by correcting the “social six”, sometimes in combination with other cosmetic procedures. Examples of these treatments are posted on this Facebook site. Most of these cases are well treated, however, in my opinion, some  could have been treated with extractions and more complex mechanics .

I have given this concept some thought and I feel that if this type of treatment is carried out within the practitioners competence for an informed adult then risk is minimised. Indeed, some providers review case records for practitioners and prescribe a treatment plan for them to follow. If this treatment is confined to adults there is less chance of harm.

Interestingly this provision has been expanded by other companies,for example, Fast Braces practitioners who state that this method may be used to to treat adults and children. This concerns me because the risks may be increased, particularly, if the inexperienced practitioner is completely sold on the new non-extraction treatment philosophy (which is not new at all). Importantly, in the UK this treatment is mostly provided on a private basis, but it is marketed as a “faster” alternative to conventional treatment, which is provided at no cost on the National Health Service to children. It is also provided according to the prescription and instruction of a remote practitioner or specialist. It is also heavily marketed by advocates. See this video.

This type of provision also raises the issues of who is responsible if a treatment for a child does not go well? It is clear that this is the providing dentist and not the remote instructor.

I would also point out that not all care provided by specialists is exemplary. I have made many errors in my career and not all of my treatment has worked well. However, I cannot help feeling that there is less chance of me making a mistake than an inexperienced dentist working to the prescription of a remote prescriber.

We also need to bear in mind that specialists make unsubstantiated claims on the speed and comfort of treatment, particularly with respect to self ligating systems.

 Summary

Where does this leave us?

This is clearly a difficult situation and I shall attempt to summarize a few important points

  • Practitioners and specialists need to work within their competencies.
  • There is likely to be minimal risk from simple alignment of the anterior teeth in adults by a practitioner who is competent.
  • Most importantly, practitioners (and specialists) should inform patients of their competencies, their training and experience and be honest about the various systems of delivery.
  • We all need to avoid making unsubstantiated claims about the speed and comfort of our treatment.
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There Are 30 Comments

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  1. Kevin,

    I have always found your comments and blogs very interesting and thought-provoking. This one is no different, and is as timely as it is topical. I was one of the lucky few who was ‘enlisted’ into a post-grad training scheme in orthodontics in Northern Ireland. I was privileged to have been taught by the late Prof. Andrew Richardson and he piqued my interest in orthodontic provision in general practice. I have continued to invest in my education and have spent tens of thousands of pounds and many, many days trying to hone my orthodontic skills for the benefit of my patients. I do try to treat from a non-extraction mind-set, but not without realising that on occasion extractions may be indicated. I’m not certain where your slight reluctance to use PSL brackets comes from, I have no doubt you are much more experienced than me, but I have found PSL brackets have been an invaluable addition to my practice.

    Where I have found myself in agreement with our orthodontic specialist colleagues is in the provision of “short term ortho” where a relatively inexperienced practitioner can attend a weekend course and then return to work the next week apparently fully competent with that system. Personally I have never done a short term Ortho course as I cannot get past my own bias against “Impressionodontics” as I call it. I believe I am correct in thinking this area is one of the fastest growing in terms of litigation in dentistry, and that must be for a reason.

    In short I agree with almost everything you have said, PSL brackets aside, and my thanks for an interesting and thought-provoking article.

    Ian

  2. David Manger says:

    Kevin
    Thank you for providing a balanced and well considered view of this, as you point out, complex area.
    I whole heartedly agree that we should all provide treatment with our own competency. Part of the problem, I suspect, is knowing the boundaries of our ability.
    You will be well aware of the concerns raised within the BOS regarding ‘limited outcome’ orthodontics. I have stated on many occasions that the appliances are rarely the issue but, more often than not, the skill of the provider. I am a great advocate of further extended training for non-specialists and am very disappointed that the Diploma in Primary Care Orthodontics is no longer running. Quality teaching is key.
    I believe we should all consider carefully our own abilities and not be afraid to tell patients that the treatment they require is beyond our skill set. This approach will undoubtedly lead to fewer problems in the future.
    David
    Honorary Treasurer BOS
    Past Chair BOS Practitioner Group

  3. Kevin Boyd says:

    Dear Prof. O’Brien

    Glad to see that you brought this elephant into the room. I think it would be of great interest to your readers….this one anyway, if you could dissect out some of the problems you’ve observed in some of these Turbo cases that you think might have benefited from different Tx modalities (“…. in my opinion, some should have been treated with extractions and more complex mechanics .”). And per your conclusion the specialists and non-specialists should recognize their own limitations (“Practitioners and specialists need to work within their competencies”), I’d like to suggest another possibility that specialists and non-specialists should maybe give recognition to: not only should they each acknowledge their own shortcomings per training and experience disparities, primarily for the ultimate benefit of the patients they serve, they (all) should also consider seizing the opportunity to collaborate with one another per their individual expertise. I am a pedodontist and I collaborate with many different orthodontists, general dentists and physicians for the ultimate long-term oral-systemic health benefits of my /our patients. Given what is now understood about the association of certain malocclusion phenotypes to airway health, orthodontists and other clinicians who responsibly provide orthodontic services, should have all the more motivation to work together. Thanks again for introducing this topic on your forum Dr. O’Brien.

    • Kevin O'Brien says:

      Hi, I agree with most of what you say, but I am not 1oo% convinced about airway health etc, as there has not been any high quality clincal research in this area

  4. Of course GDPs should provide Orthodontics – Orthodontics is Dentistry and all Dentists should work both within their competencies AND upon developing them further !!!

    It’s Dentistry, no different to other dentistry disciplines – nothing ‘special’ to see here !!!

    Yours also progressively,

    Tony.

    ps – I cannot hide my disappointment that our Specialist teachers allow recent UK dental graduates to not be ‘actively’ competent in Orthodontics upon graduation 🙁
    Isn’t that THE problem here, defaulting to a problem of creating active ‘incompetence’ clinically?

    • Kevin O'Brien says:

      Thanks for the comments. As you may remember the General Dental Council introduced new guidance to Schools on the content of the undergrad curriculum and the current teaching in Dental Schools reflects this. Furthermore, within most dental school courses there is not sufficient time or staff to provide a large amount of orthodontic training. Final,y, there is a shortage of suitable patients, as we do not get referrals for the simple patient suitable for undergrad teaching.

  5. I am a general practitioner in Virginia. I was taught my first ortho case in a hospital -based externship in 1976, a four bicuspid extraction case. I took a five year PT program in orthodontics with the United States Dental Institute. I also took related courses in “TMJ”. orthopedic, chiropractic, removeable and fixed courses. I have studied neuromuscular dentistry and orthotropics. Hundreds if not thousands of hours. I continue to integrate orthodontics in my general practice in part because it is an integral part of a general practice.
    I agree with your statement that you should be doing treatment that you are trained and qualified to do.
    It is my understanding that almost half of all orthodontics in the US and Canada is done by general practitioners.
    I also understand that under the current guidelines of specialty residencies that graduates have a very limited experience in diagnosing and treating patients to completion, a handful at best. The education behind the anthropologic norms, the etiology of malocclusion, and general health and well-being of the “total” patient, is very limited, and quite lacking in certain aspects. The emphasis on a good arrangement of teeth is primary, not on a great looking and healthy smile.
    I don’t know how the training is done overseas, but I will assume that it is similar. If so, then there are a lot of practitioners out there, as specialists, who are very limited in knowledge and experience. I agree, maybe they should be disclosing their knowledge base to prospective patients. A growing portion of my orthodontic practice, is redoing or taking over other started cases, or doing for patients treatment that others have said can’t be done, or taking over cases that have been poorly treatment planned.
    I, obviously , am in favor of GP’s providing ortho and again, I believe, as you state, that the services should be based on education and ability. However, I would strongly oppose anyone who takes a position against GP’s providing ortho, because the overall knowledge base is limited.

    I have said many times over the years that the orthodontic community has shot itself in the foot by restricting the knowledge imparted to the pre-doc community. All the other specialties open up their specialty to the pre-doc student. Then the student is more knowledgable about the depth of that field and the range of services. By restricting the average DDS/DMD’ s knowledge base there is far more treatment that could be done but is failed to be recognized. To me, that is the fault of the orthodontic community.

    • Kevin O'Brien says:

      Thanks for the nice comment. I am agreement with most of what you say, but I do not think that this is the fault of the orthodontic community. I wonder if this is one of those things that just happened and was not intentional. I think that this was the case in the UK?

  6. Chris Lowe says:

    Hi Kevin

    As you know I ran and owned a full-time orthodontic practice before I was lucky enough to join the orthodontic training programme at Manchester. So, I feel I’m fairly well qualified to comment on this. Yes, I produced some nice results as a non-qualified ortho with a practice limited to orthodontics, but I certainly made mistakes as we all do. So, the burning question is did the formal training make any difference? Well, the answer has to be 100% yes. It’s not just about the practical aspects but also about the critical (scientific) aspects. Do I get it right all the time now? I wish! But I have the skills to critically appraise any mistakes.

    Unfortunately, over many more years than I care to remember, I have seen the results produced by GDPs in non-specialist practices and they can be pretty scary (and, yes, it still continues). Of course, non-specialists working in a specialist practice may well produce superior results (and I do know there are some out there!)

    • Joe Noar says:

      Problem is…. you don’t know what you don’t know!
      In my opinion a specialist education doesn’t ensure good results but it does make them much more likely.

      • Dear Joe,

        As a fellow Specialist (but in Prosthodontics) are you really saying everyone qualify to ‘Specialist’ levels in all dentistry disciplines before even treating patients ???

        So EVERY Crown, Bridge, Denture, Bonding/Wear, Occlusion changing case should come to a Specialist like myself as I am much more highly trained, so GDPs should just refer and not treat ???

        Seriously do you know how silly that sounds 😮

        I understand Chris’s points and again I and other Specialists could say similar from our idealised Ivory Towers and I totally respect his position and choice as a referral practice.

        We do seem to have ‘diagnosed’ the main problem overall – many of those qualifying from say 2016 in the UK are being ‘actively’ dumbed-down wrt not knowing what they don’t know in Orthodontics 🙁

        Thank goodness other dentistry disciplines take a far more progressive and inclusive view !!!

        Until then I guess those qualifying as UK Dentists from say 2016 and those then entering Specialist (Orthodontic) training from say 2018, by implication, will be sadly compromised compared to other Dentistry disciplines, it seems 🙁

        Can you imagine entering Specialist training and never have been ‘actively’ competent to have done even a simple Ortho case 😮

        We’d better hurry up and get a LOT more GDPs trained for Ortho. then !!!

        Yours unimpressed,

        Tony.

        • Nicky Stanford says:

          I qualified in 2007 and had an undergraduate orthodontic education consisting mainly of diagnosing malocclusions with a very limited exposure to clinical orthodontics.

          I don’t think it has hindered me in any way, shape or form during my specialist orthodontic training.

        • Maybe you don’t know what you don’t know !

          I find Nicky’s statement hard to believe….. What is the evidence having almost virgin Orthodontic ‘active’ experience starting Specialist Orthodontic training makes little or no difference ???

          If that is really so, maybe we can have Dental Nurses starting Specialist Orthodontic training direct, if previous clinical orthodontic experience is so irrelavant for Orthodontics ???

          Or maybe have an option at 3rd BDS to be an Orthodontist instead, if they can’t take teeth out etc?

          So maybe Orthodontics IS different to other dentistry disciplines, if that ‘virgin-experience’ clinically were really true?

          Again, I very much doubt it, but it’s not my premis!

          Yours observationally,

          Tony.

        • Kevin O'Brien says:

          This thread of comments now seems to be going very off track, towards Fast Braces etc. I am not sure that anyone else has anything to add on this, so I have decided to close it. This is the first time that I have done this for the blog but I feel that we need to move on. I hope that this is OK?

          Best wishes: Kevin

    • John Serrano-Davey says:

      Hi Chris,

      I hope you are well.
      You will probably remember me from the Chesterfield Royal Hospital days, under the guidance of Jon Sandler.
      There are always two sides to any debate, and my experience tells me Prof Kevin is one of the most open-minded and fair-minded comentators on these issues.
      Having carried out somewhere between 5 and 8 thousand fixed appliance cases, and over 500 Invisalign cases, I still admit that I find it rather hard to accept that I can’t even refer to myself as an “orthodontist” in the UK, despite having done nothing else for nearly 20 years. It’s not a “prestige” thing, more of practical one:
      The conversation usually goes like this:
      “so you are going to be little Johnnie’s/ my Orthodontist then?”.
      “Well I am indeed going to provide the Orthodontic Treatment, but I am a Dental Sugeon, not technically an Orthodontist in th the UK- but my experience is……….”
      “I thought someone who straightens teeth was an Orthodontist…..!”.

      And so on!
      Honestly, there is no longer any chip,on my shoulder, but give the standards I see around the UK, there are huge differences in quality of outcome from all parties: Specislusts, Consultants, GDPs- all of them.
      I have seen (and hopefully produced myself, on occasion, some outstanding results, but I’ve also see woefully unnaceptable outcomes from ALL the aforementioned groups.
      So, in my honest opinion, certain groups ought to think twice before throwing stones! There is often more than a hint of either “protectionism” or “resentment” precluding any actual objectivity.

      Ultimately, the majority of Orthodontic cases are simply NOT “specialist material”, just as not all third molars, or all root canals are either.
      GDPs are proud of their abilities to triage, choose and treat all cases falling within their respective capability levels, and long may it continue!

  7. i agree! Only practice within your abilities . Do not think a weekend course can stand you in good stead. I do CFast but not without all the Damon and FFG knowledge I got form Derek Mahoney after years with Skipp Truitt and Mew input. I am constantly picking up specialist ortho pieces and sending letters to slecialists about my concerns. There simply must be limitations generally. Well said Ian Crutchley

  8. paulbds says:

    Should General Dentists provide orthodontic treatment??

    How about, should orthodontists obtain competency by performing the extractions for their patients

    • Chris Lowe says:

      I’m not sure extractions is “on-topic”. I haven’t taken teeth out for years. However, back then, I could deal with anything. Now, well I’m out of practice. However, I could run rings around some of the colleagues I deal with. But, that’s not my field of expertise anymore.

      As I’ve already said, I know several colleagues in a specialist and non-specialist environment who produce excellent results. Equally so, I know many who produce absolutely awful results. Who knows, perhaps I do?

      What concerns me is the way that certain “acolytes” of specific wire/brace systems denigrate their colleagues. They imply that we are “old-fashioned orthodontists using old-fashioned techniques” and that we’ve never heard of modern technology. Get real!!! We have. We use it all the time. What they imply is, to say the least, defamatory and, in my opinion, is unprofessional and absolutely out of order.

      If I believed that specific systems were infallible I would use them…full stop. I have used many, many systems, believe me! The truth is always somewhere in the middle. If I KNEW that a certain bracket worked EVERY time I would use it EVERY time. It doesn’t exist..yet! I use the latest technology, where appropriate, and get good results..hell, I even take teeth out..well, I get the dentist to, as I’m useless at extractions. Please, please do not think that orthodontists do not question their results on a daily basis. If I knew that a system worked reliably I would use it. Funnily enough I do…..straight wire brackets, without/ with extractions work for me every day. They’re the ones I use! Go figure!!

      Chris

      • Chris Lowe says:

        Tony,

        I will readily admit that my ortho experience pre-specialist training must have helped (Kevin might disagree!). But, as Joe Noar said, we don’t always know what we don’t know. I spent many hours on various courses pre-training and they definitely helped.

        The problem is that SOME people go on a course and then actively have comments on their websites that denigrate orthodontists as old-fashioned and using old equipment etc etc. It is bang out of order and, to be honest, asking for a complaint to the GDC!

        You say there is evidence. Well, Kevin has already suggested an RCT to investigate it. No joy. Let’s see the results. If you are right then I’d love to see some evidence. You say that orthodontist haven’t looked at this. Well, I have! I did a trial with Nicky Mandall on wire sequencing which I co-presented at the British Orthodontic Conference. We looked at various sequences, one of which started with rectangular Copper NiTi wire. Guess what? There was no difference between the sequences to get to initial alignment. This was carried out by clinicians with a whole range of experience from consultants to postgrads. The Viazis bracket has been around for years. If it’s so good then why don’t we use it all the time? Where’s the evidence? Please, please do not tell me that there is no evidence for any orthodontic treatment. As a profession we are trying.

        Chris

    • Kevin O'Brien says:

      This issue has been raised to me before. You are right that this is about competencies. Before I decided to undergo ortho training I was a general practitioner for four years and then I did two years of surgical jobs. As a result, I reckon I could extract any tooth. But this was a long time ago and while I am competent at orthodontics, I am certainly not competent at extractions, prosthetics, restorations and crowns. Could I retrain? Yes, this could be done, but this would mean taking me away from orthodontics which I think is where my clinical skill and knowledge is based.

  9. John Kerrigan says:

    Elephant in the room? More like a herd of elephants! I think that this discussion is losing sight of the most important issue here – the patients. Most patients don’t understand the ins and outs of what is being discussed here – they see “Six Month Smiles” or “Fastbraces” on their Groupon e-mail and say “I’m in!”. Just like patients, we can be susceptible to slick marketing campaigns and flashy websites (self-ligating brackets anyone?) but our duty, Specialist and General Dental Practitioner alike, is to give patients information about what can realistically be achieved within a given timeframe irrespective of the orthodontic “system” being offered. If we fail to do that, then we are not working in the best interests of the very people who enable us to do what we love to do.

    Well done for throwing this one into the ring Kevin – you’re a brave man!

    • Kevin O'Brien says:

      Hi John, thanks for the really helpful comment and you have hit the nail on the head. Yes, I think that the discussion has managed to drift away from the real issues that I was addressing. As a result, I have increased the level of moderation and I will only accept comments that are relevant to the posting. But, I think that I will write a post on undergraduate education next week, so that I can clarify some points.

    • John Serrano-Davey says:

      Hi John,
      I couldn’t agree more. It is the duty of both Specialist Orthodontists and GDPs to provide knowledge, information and evidence to Patients in order to help them arrive at a decision as to “what Orthodontic Treament Option suites THEIR needs”, and point out the consequences associated with taking that decision.
      Whilst the tone amongst “Specialists” ( of hugely variable degrees of competence) is usually “GDPs must be careful to offer Full Orthodontic Options, and refer when appropriate, it does work the other way round too you know.
      Given the clear lack of real scientific evidence that the “miraculous Class 1 finish” is always beneficial over the myriad of other possible outcomes, then Specialists could be seen as equally guilty of failing to fully inform the public as to their options!
      (I well remember when Jon Sandler invited the Prosthodontist John Berresford to address the BOS conference one year, on the topic of “why do you try and finish all your Adult cases ” Class 1″, when they might be Skeletal 2 or 3!
      Didn’t Edward Angle base much of his postulations on the fact that “God liked Right Angles”? Wasn’t there a “Masonic” input somewhere, if I recall?
      No, the “Specialist Orthodontist ” has just as much obligation to assist the patient in deciding if it really is in their best interest to have, say, four healthy teeth pulled from the jaw, titanium mini-screws screwed into their gum, and two years of long and complex Orthodontics, shortening their roots by 2-3 mm, or, perhaps, simply Align the “Social Six”, retain with bonded AND removeable Retsiners, and perhaps even enjoy a nicer profile as a result!
      Food for thought!

      (Kevin- how about opening a thread about ” is indeed Class 1 a valid objective in Adult Orthodontics”?
      Could prove lively!

      Kind regards,

      John

  10. Jayaram Mailankody says:

    Hello Kevin,
    You seem to have stirred a hornet’s nest!
    It is nice to note the facts and emotions expressed in the comments. Variation is the very basis of orthodontics, and as it may apply well to this issue also. It is difficult to give hard and fast rules, as to what should be GP’s cup of tea and what should be the case for the specialist! Even the ‘evidence’ seem to be taking a backseat in the matter ?

  11. Neil Hillyard says:

    Hi Kevin,
    I have been following this topic with much interest and was pleased to see John Kerrigan finally mentioning the patient in this controversial debate. You may recall that I am an adult patient currently 2 years and 4 months into treatment using traditional brackets fitted by a specialist orthodontist. I like to consider myself reasonably well informed and prior to starting treatment, undertook a great deal of research which quickly lead me to dismiss the short term options offered by GDPs. I did not consider the attendance at a weekend workshop sufficient training to be able to diagnose and prescribe a course of treatment that would meet the needs I identified despite the assurances that they were ‘competent’ to do so.

    With clever marketing techniques, remote diagnostic services and pre-prepared indirect bonding trays offered by these companies, an opportunity exists for GDPs to extend the scope of their services provided by offering short term orthodontic solutions to a willing market of unsuspecting patients. This gap in the market has been cleverly exploited and from a strictly commercial point of view, has been introduced into everyday dentistry very successfully.

    I am sure there are many well-regarded GDPs who understand the scope of what they can offer within their level of competence and provide an excellent level of service to their patients within the limitations of the orthodontic solution offered but I also suspect that there are others who do not. I have always taken a keen interest in my progress and frequently discuss, in probably too much detail, all aspects of my treatment plan with my orthodontist. I also regularly visit my GDP who has been very supportive during my treatment but a very enlightening comment was made a while ago when happily discussing my latest adjustment, “we get so little orthodontic training, you probably know more about it than me”. Whilst I’m sure this isn’t strictly true, there was a refreshing honesty to the comment which served to reinforce the relationship with this dentist.

    In much the same way as the use of orthodontic therapists has become more widespread in the on-going treatment of patients in recent times (maybe a topic for another debate), this role was devised and scoped to meet an obvious need that existed. Maybe the opportunity exists for the GDC to review this other emerging need and provide a training or competency based intervention that ensures GDPs can extend the scope of their services provided whilst enabling patients to confidently navigate their way through this sea of uncertainty.

  12. Great discussion about the theme. Here at Brazil, we fight to increase the hours of orthodontics specialization. Recently we achieved with the Federal Council of Dentistry to have a minimum of 2050 hours, but we still have programs with 1000 hours (theoretical classes + clinical practice). Then I see colleagues here saying that because you graduated in dentistry, you should be practicing in all areas without restrictions? What a shame thinking like that.
    First: if you think like that, you are not being progressive at all, because you are putting aside the seeking for science through more study;
    Second: if you want to practice orthodontics, do the same as every one else, earn it through lots of study.

    Best regards,

    Willian da Silva

  13. Noel Stimson - editor Cranio UK journal says:

    As an occasional visitor to your blog I find I am possibly too late to contribute to the blog on “Should general dentists do orthodontic treatment?” which you have now closed as it started to go ‘off piste’ into other issues. However I would like to re-open the original debate if that is possible.
    I agree with you that one should be cautious or skeptical about the many claims of ‘rapid tooth movement’. Your earlier blog about teeth moving at their own pace irrespective of the system used is apposite.

    However the concept of staying within one’s competence in orthodontics seems to make sense, but only up to a point. When you think about it, if we all followed this principle all the time, none of us would make any progress and our professional skills and knowledge would never develop. None of us would be permitted to attempt ‘pushing the envelope’. `we would be restricted to remaining in that little box we were given to exist in when we graduated. The final arbiter in the personal “am I competent?” debate is, as you say, the individual practitioner and that is precisely how it should be; were are all supposed to be intelligent well-trained professionals and it is the kind of decision we are trusted implicitly to make every day. To deny that is a huge insult to entire profession.

    But the most shocking aspect of all this is that you tell us that UK dental schools no longer teach clinical orthodontics to their students! You say that today’s students are only taught to identify malocclusion in order that they can refer the case to a specialist and that that is the limit of their orthodontic ‘competence’. So now any aspiring orthodontist is obliged to go through a training process costing up to £44K a year!

    To whose benefit, one might ask?

    Well, two groups; firstly the dental schools that offer this costly training (I have counted 17). Secondly, the specialists who seem to have engineered a protectionist system where dental graduates have deliberately been denied the opportunity to acquire any degree of clinical orthodontic competence other than to write a referral letter. I find this quite appalling. Tony Kilcoyqne’s response to your blog (Sept 1 2015) would seem to concur.

    So who does not benefit?

    Firstly, the young new dentists who now go out into the world with a highly deficient view of what they are capable of and who have been deprived of the ability to help and care for 75% of their child patients; plus the loss of the personal satisfaction and reputation-building that can accompany good orthodontic results. Secondly, the patients themselves, who now have to traipse off to their regional hospital or specialist practice instead of being cared for by their own trusted local family dentist.

    In essence, there can never be any question that orthodontics is an essential and normal part of primary care dentistry, as are endodontics, paedodontics and prosthodontics, etc. The thought that in the future someone could further invoke the ‘dark side’ and try to hive off all of these as ‘specialist only’ treatment is utterly unthinkable and would completely destroy an entire profession.

    But I have a personal dilemma; whilst I abhor the dental schools’ abdication regarding the teaching of undergraduate clinical orthodontics, I don’t much care for the current teaching anyway. Like so many now, I have a big problem with a system that commonly involves multiple extraction of healthy teeth and segment retraction at the precise moment the face and skull are rapidly growing in the opposite (forward) direction! It makes no sense and I am ashamed that it took me over 20 years to work it out.

    On reflection, maybe it is better not to fill young dental students’ minds with such notions in order that their thinking later might be free enough to accept more progressive and intelligent methods of dealing with malocclusion.

  14. Interesting discussion —in Canada ,it is becoming a “free for all” to the great detriment of patients .
    Does anyone have knowledge of well conducted studies ,rather than opinions ,related to head to head studies on the treatment outcomes between specialists and generalists ???

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