October 24, 2019

Orthodontics and the General Dental Practitioner

I have posted before about the role of the general dentist in orthodontic treatment.  This guest post is by Tif Qureshi who is a general dental practitioner (GDP) who provides orthodontic treatment for his patients.  I thought that it was interesting and relevant. I do not totally agree with his views, but they are interesting and we should consider them. This is one of a series of posts that I will be publishing on controversial areas of orthodontic treatment.

Introduction

This blog post is about a controversial area of dentistry.   I will start by stating

“I would not sit in the chair of a general dental practitioner who did not at least understand orthodontics. Ideally, they should   be able to carry out some limited objective orthodontics.”

Why do I say this?  Because, when we understand the implications of Bob Little’s studies into relapse.  Along with the effect of continued tooth movement, combined with the concept of a changing envelope of function. We can understand why there are many patients who arguably, needlessly have crowns and veneers placed on repeatedly chipping front teeth.

What are the problems?

The problem is that the implications of Little’s study are not widely understood. I feel that  “relapse” is a red- herring of a term. This is because the studies showed that reduction in arch width and length leading to crowding occurred whether patients did or did not have orthodontic treatment. As a result, I wonder if instead of “relapse” perhaps we should use the term ” continued tooth movement”.

I want to suggest that the only people who seemed to have grasped the concept and understand the functional and occlusal changes that come from continued tooth movement are GDPs. This is because they have long term relationships with their patients and follow up with photography and detailed documentation. I know only a few orthodontists who follow their patients for life.

However, I concede that long term follow up by orthodontist is not practical. Unfortunately,  in most countries, there are limited funds or orthodontic education for general dentists, and it is they who need to maintain orthodontic treatment.

Most General Practitioners who see patients over many years can testify that relapse may cause far more than just cosmetic problems.  Indeed, the collapse of canine width, loss of guidance, constricting envelopes of function, tooth wear, deepening bites, fremitus and bone loss all come as a result of continued tooth movement.

Now, does this mean that general dentists should be able to carry out orthodontics on every patient? Absolutely not.

Solutions?

Orthodontic companies and aligner providers have created products that allow general dentists to treat the whole malocclusion.  However, it is unlikely that most general practitioners can carry out a proper facial, skeletal and dental orthodontic assessment and diagnosis.

As a result, even if individual “orthodontic systems” have limited goals, companies must educate dentists correctly and provide mentorship from specialists. Therefore, general dentists should understand what they can and cannot treat.

I suggest that with education and mentoring help with case selection and execution, general dentists can carry out some Ortho with limited objectives safely.

Furthermore, if those objectives include removing a constricting envelope of function to avoid the eventual placement of a crown, then I would argue that every dentist should have this ability. Without it, we are complicit in damaging our patients.

Dedication

I want to dedicate this Editorial to my dear friend.  Dr Anoop Maini a UK dentist who has helped general dentists carry out orthodontics to a higher standard for the right reasons- and recently passed away at the age of 49.

Conflict of interest

Tif is a clinical director and chairman of the board of IAS Academy

Kevin O’Brien spoke critically on the risks of limited objective orthodontics at the IAS Symposium in 2018. He received travel, accommodation expenses and an honorarium of which supported the costs of his blog.

There may be many comments on this post, I will approve them as soon as I can.

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Have your say!

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    I entered specialist orthodontics after 5 yrs of general practice. I feel that this helped me deal with concerns expressed as above.
    I fully realise this may not be a possible course of career progress nowadays.The cost of education,relatively,is much ,much higher now and just keeps growing,year by year.

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      I should add that I don’t see this as a GDP vs orthodontist piece.
      And actually clearly not every GDP has grasped the concept of functional consequences of crowding – or we would probably see far less repeatedly chipping teeth get replaced with crowns – instead of ortho to stabilise OJ – !
      But because of the way ortho is delivered it is far more likely that aware GDPs are going to see those changes over time on patients who have treatment and those who receive none at all.- I believe our system of treatment should have an element of remote monitoring that helps treating Orthodontists see treatment years on (of course Dental Monitoring etc can help with this )

      Thanks for sharing anyway Kevin

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        From all the comments, one can only conclude that only some orthodontists should do orthodontic treatment. And virtually no GDPs should, as they fail to grasp even the most basic concepts and are keen to create or believe in explanations totally devoid of evidence.

        GDPs who “believe” in Fast Braces and concepts like Orthodontitis (TM)*, should never touch a patient. If they believe this nonsense, they are likely to believe in bizarre restorative concepts too. The same applies to orthodontists who “believe” in Carriere, Damon,

        They don’t know that they don’t know! It is a fine example of the Dunning Kruger effect.

        * See publications by Anthony D Viazis in predatory journals

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    As an orthodontist : ex academic and now in primary care (I declare my interests & associations with Tif Quereshi as a colleague, friend and co-owner of IAS Academy)

    My thinking is very much aligned with Tif on this. I have for many years been frustrated by GDPs who keep replacing incisal edges to see them break off due to occlusion… yet do nothing to correct the problem. We see the cosmetic ‘gurus’ veneering upper incisors due to wear whilst leaving the lowers untouched – ignoring the cause.

    I believe that we as orthodontists should be talking with patients and colleagues about PREVENTION of crowding and its associated wear. That post orthodontics we PREVENT relapse with retainers and we should consider preventing late incisor crowding in those patients with well aligned arches. We know the evidence from Little, Mills etc that the incisors move forward throughout life and intercanine width trends to collapse due to medial drift, hard and soft tissue change….
    So let’s talk about crowding and a constricting envelope of function as an age change and its PREVENTION

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    I wish to challenge the concept of stability in this editorial. I have been in practice for 37 years practicing the Tweed Philosophy (e.g. uprighting incisors, finishing flat in the anterior, not expanding canines, maintaining original arch form, etc.). I rarely dismiss a patient and continue to see routinely those who come for yearly check ups. Many patients I treated over 30 years ago continue to be seen as we develop a personal relationship. I contend if the treatment objectives listed above are followed, long-term stability is routinely achievable. Unfortunately, with today’s “modern” techniques with preformed archwires and pre-adjusted brackets individualization of treatment has become less of a focus. Given the debt that most new orthodontists have accumulated, production becomes paramount. The skill required to manipulate the appliance becomes very difficult to develop as the time required to become a competent wire bender is not available. I would submit that real orthodontists should be able to produce results far surpassing that of the general dentist on a routine basis. I hope the detritus is cleared from the profession and the focus will once again be on the art of orthodontics which is supported by the scientific evidence. But until the financial hurdles that have been created and the universities pay salaries that will attract competent clinicians the future is bleak

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    One needs to have a very good understanding of orthodontics to know what a simple case is. This unfortunately excludes most GDPs, who attend a weekend course promoted by KOLs with vested interests.

    Would one extrapolate to GMPs and suggest that we avoid those who do not do a little cardiac surgery? Then again orthodontics is not life and death. So why not dabble?

    The cartoons provided by the digital orthodontic systems are often as unrealistic as as a Daffy Duck cartoon. Only with a real knowledge of forces and tooth movement can realistic results be obtained.

    It is hard to be critical of orthodentists when specialists use and believe the advertising of Acceledent, Damon, Carriere …….. and the public are happy to go to the direct to consumer orthodontic products.

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    As a general dentist with some additional training I agree it is important to have respect for inclusion of this treatment in treatment planning. It seems cosmetic dentists wanted to bypass the idea for so many years with ‘drilling them straight’ approaches, then some orthodontists became alarmed when shorter term orthodontics gave patients a middle ground approach (perhaps ending clinically somewhere as many patients do following orthodontics with an orthodontist with less than ideal follow-up or retention protocols- less than perfect but still better than before)…I suspect there are some gp’s that are better at ortho than some specialists but on average I trust a specialist to do this part better. What may be a powerful approach that is a real world answer for many is the combined use of bleaching, bonding and braces – an approach I know is growing quickly in the UK and one I have used with some success for a long while. There are things that can be learned from this discussion and simple annual retainer checks by an orthodontist would be a simple start.

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    GDP’s educated in orthodontics, whether they provide orthodontic treatment or not is a good thing. Expecting to get that education from orthodontic companies is folly. They are in business to sell appliances to anyone to use any way they see fit. It doesn’t matter to orthodontic companies whether or not their appliances are used properly or not.

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    I would be interested to hear Tif’s views on these following comments to his guest blog:

    In his introduction, he states that “I would not sit in the chair of a general dental practitioner who did not at least understand orthodontics.”
    As if that would be a bare minimum, understanding orthodontics that is, when for qualified orthodontists worldwide, there is a humbly-held understanding that despite how much has been published in the orthodontic, evidence-based literature since the specialty’s inception over a 100 years ago, there is still much that remains unknown. So, is it either fair or relevant to expect a GDP “to at least understand orthodontics”?

    Tif makes reference to Little’s research on long-term stability that I remember depressingly reading in the American Journal of Orthodontics as an orthodontic registrar in 1981 and he suggests the term “relapse” is a red herring term for which “continued tooth movement” would be a better substitute. He also suggests that it would seem that only GDPs have grasped the concept of functional and occlusal changes associated with continued tooth movements.
    However, I would dispute this because the age-related changes to the occlusion of untreated normal occlusions were first described by two orthodontists, Sinclair and Little, in the American Journal of Orthodontics in 1983, for which they coined the term “maturation”.
    Professor Behrents (another orthodontist) then published on the consequences of “incessant” adult craniofacial growth on the hard and soft tissues of the face throughout all of adult life in 1989 and more latterly in 2013, Tsiopas N et al published their findings in the European Journal of Orthodontics on adult dental arch dimensions and incisor irregularity after 40 years of follow-up. So I would counter that orthodontists have long established the existence of and subsequently have come to fully understand the implications of age-related maturational changes upon the occlusion and facial dimensions.

    And it is precisely the difference between slowly developing “continued tooth movements” or “age related maturations” and rapid “relapses” that can occur in unstable, short-term, orthodontically treated cases, which have suffered the loss or failure of a retainer, that led The Faculty of Dental Surgery of The Royal College of Surgeons of Edinburgh to raise its concerns and issue both caution and advice on the importance of patient consent to such patients, in a couple of publications in the British Dental Journal in 2013 and 2014.

    Finally, after being involved with a formalised GDP, Orthodontic Clinical Assistant 2 year training programme for over a decade in the early part of my consultant career, I would whole-heartedly agree with Tif’s suggestion that “with education and mentoring help….. general dentists can carry out some Ortho with limited objectives safely”.

    I just wonder whether what I would classify as being adequately “educated and mentored”, with centralised, didactic teaching and interactive discussion days amongst both tutors and clinical assistants on a monthly basis and with weekly sessions of direct, hands-on clinical supervision by a consultant, is quite the same thing that can be offered through IAS.
    Especially when one considers that the GDPs upon completion of their IAS “training” will be returning to their practices that are remote from their former mentors, unlike the historic clinical assistant schemes, where dentists local to the training consultants, upon completion of their 2 years of training, would have the availability of continued, face to face support with their local consultant, as would their patients, should the need arise for an examination to help guide an appropriately informed treatment choice.

    One could counter-argue that a lot of this support can be remotely offered electronically, but I just wonder on which might be the more effective and supportive.

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    PS
    Could Tif also define exactly what he means by “a changing envelope of function” and explain how this can be both accurately and reproducibly measured?

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      Hello Robert,

      The envelope of functions is as defined by Pete Dawson
      Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems. 2nd ed. St Louis, MO: Mosby; 1989:28-55, 434-441.

      This as Im sure you are aware is the pathway the incisors take while moving in function, then returning to their centric stop- the tooth anatomy and critically overjet should be correct so the envelope of function is not obstructed- As described by Gorden Christensen.( Three Rules of Occlusion Jose Ruis LuizDDS) (a correct OJ and ideal OB also allows for sufficient posterior disclusion on the anterior slide -decrease activity and the amount of force applied to the anterior guiding teeth is greatly decreased when correct – Studies by Mann , Chan and Miralles J Prosthet Dent. 1987;57:494-501.)

      Of course these are ideal scenarios we try to achieve in restorative approaches.
      But when one observes teeth potentially relapsing or perhaps teeth that were never even treated over a period of time, it is clear that this “envelope of function ” can in some cases become constricted. This is quite common of course in untreated, class 2 div 2s- as OJ is reduced it very visible, predictable pathway wear becomes evident on the lower incisal edges/ /upper incisors palatal. In other scenarios could also potentially cause fremitus, or when occluding against a crown, excessive tooth surface loss.

      A very typical and recognisable scenario, to many GDPs is the repeatedly chipping anterior tooth.
      Many cases I have seen treated, when composites have repeatedly fail, often have a reduced OJ. Crowns are commonly placed, by dentists who failed to identify the changing tooth position and resultant constricting envelope.
      Of course this is all theoretical combined theory two researched areas, – Littles studies, and Dawsons Envelope.
      Thus the concept of “changing envelopes of function”

      Quite simply and I certainly concede there is not enough evidence and study on this combined theory . It is highly apparent to GDPs who are aware of it, and have long term groups of patients with documented follow up becoming as predictable as TSL worsening , or gum recession in excessive brushing cases.
      As mentioned it does require long term reviews, and will only be seen by clinicians who do see their patients again.
      Measuring it can be done visibly, particularly with reducing OJ, and close examination of teeth, examining dynamic changing tooth contacts in function. and on an articulator. , however digital scanning and patient monitoring software already exist that can monitor TSL and changing tooth position over periods (3 Shape patient monitoring for example) and are likely to make this far more apparent to the next generation of dentists

      I do feel the point of the editorial has been slightly lost and become a GDP VS ortho debate- and that is not what was intended- It really was fundamentally about the fact that there are highly likely some patients who do not understand their teeth are slowly moving receiving restorations from dentists who are also unaware that teeth may slowly move- and as a result a simple mechanical error is being made, and teeth are potentially being cut down unnecessarily. I and a growing number of dentists have found this problem has been solved by using minor ortho when appropriate , and bonding and teeth which would regularly chip, stop doing so once a correct OJ and more ideal OB is retained.

      Hope this helps
      Kind regards

      Tif

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    Surely PR Begg’s 1950’s observations on the lifetime changes of the human dentition is worth a read. How quickly we forget ‘older’ publications. Begg’s research points to changes to be expected. Without understanding normal we can hardly be expected to understand the abnormal.

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    I would argue that “continuing tooth movement” ( I like the term BTW) is not the “cause” of “collapse of canine width, loss of guidance, constricting envelopes of function, tooth wear, deepening bites, fremitus and bone loss”. I especially disagree with the implication that continuing tooth movement is a significant causative factor of incisal wear and cause patients to ” needlessly have crowns and veneers placed on repeatedly chipping front teeth”. Billions of people in this world have mal aligned incisors and only a very small percentage have excessive incisal wear. Incisal wear and most of the other conditions mentioned comes mainly (IMO) from parafunctional habits and the excessive bite force that is generated by these habits. Coincidentally, these same parafunctional habits tend to exacerbate the aforementioned continuing tooth movement. I do exams on many, many adults with NO history of orthodontic treatment and excessive incisor wear (even with excessive OJ) and no one has ever spoken to them about protecting their teeth. That said, I appreciate the measured, thoughtful tone of the post. I agree with the conclusion of GP’s and some limited treatment, but that is not the reality. For many GP’s doing ortho, a computer simulation or telephone consult prior to accepting an IDB set up is an acceptable diagnosis and treatment plan and give them the qualifications to treat any case.

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    Hi Kevin – my comments are moderated so could I submit this slight correction for the few typos.
    Kind regards,
    Tony.

    Dear Tif,

    Firstly thank you for writing this short blog and dedicating it to our mutual colleague Anoop Maini who was taken from us far too early.

    I am going to be somewhat controversial here and say not only are you correct about the advantages GDPs have in the overall delivery of ‘Optimum’ care, if I can put it this way, but they should be more involved with using Orthodontics more routinely as part of the many strands of dental care delivery.

    Orthodontics is DENTISTRY and is no more ‘special’ than the other discipline sectors in Dentistry.

    Yes a Specialist Oral Surgeon will generally have better experience and obtain a superior result than an ‘average’ GDP in extracting a tooth or multiple teeth – their assessments, abilities, training hours/quality and outcomes will ALL be superior to most GDPs and frankly nobody would be surprised at that – though some GDPs as they become more experienced will lessen the differences between the Specialists and GDPs overall.

    This is perfectly normal and acceptable – we know it would be CRAZY to say ALL Extractions should go to a Specialist Oral Surgeon because even sometimes what appears to be a simpler case can hit some complications – well guess what MOST Specialists would then help out their colleagues constructively, we would all learn from each other, improve and more people would have more access to Dentistry with the Specialists seeing the more complex or unusual cases.

    I could say the same for Crown and Bridgework – are we really saying ALL Crown cases single and multiple should be referred to a Specialist because they are better – what about Endo or Paediatric Dentistry or Perio – are Specialists in these disciplines any more or less ‘special’ than in Orthodontics, especially Orthodontics for ADULTS where growth factors have ceased – or as Tif says AHA or have they ???

    Thank goodness teeth DO move as frankly that is often the ‘forgiveness’ factor that allows most Dentistry to adapt in the bite or improve from past defects or even post-Orthodontically, allows the bite to ‘settle’ and adapt comfortably.

    I appreciate certain people very powerful and influential in Orthodontics were probably driven by ‘ideals’ to get everyone having Ortho to only see Specialists; thus Ortho virtually disappears from the Undergraduate curriculum and nobody is incentivised to still keep teaching it practically at UK Universities (though clinical experience is now low in many other clinical sectors too!) – at post-graduate level GDPs are constantly scared into ‘unless you do it to Specialist level you’ll be sued or struck-off’ warnings by some Specialists who clearly are not pro-GDP Ortho, shall we just say at this point. Thus almost everything is focussed upon funnelling everyone into Ortho Specialist training, or leaving most in a void.

    I put it to you all that that is a GRAVE error, be it a deliberate unspoken strategy or occurring by neglect/default and frankly NO OTHER Speciality in Dentistry would do such a limiting thing to general dentistry – indeed you cannot move for other Speciality organisations offering further GDP training and support constructively to EMPOWER GDPs to do more and offer more and refer appropriately !!

    I know many great Orthodontists who are very helpful and supportive of GDPs getting involved more and yes, when colleagues occasionally get stuck or a case turns more complex than expected, they are right in there helping and showing their great experience and frankly great Professionalism in supporting their GDP colleagues to get better and better constructively.
    How it should be in the public interest overall surely?

    However if you asked/surveyed most GDPs do you feel those in charge or power within the Orthodontic Speciality are as enabling and supportive of GDPs doing more Ortho, as are our other Specialities are in Oral Surgery, Endodontics, Restorative, Perio or Paedodontics??

    What do you think the answer would be and WHY ??

    I really think Orthodontic Societies need to reflect upon this and some need to get off their high-horses frankly; I mean that in the nicest and most progressive way. Orthodontics is Dentistry and Specialists are a very important part of that, but not exclusively.

    I actually fear this situation has maybe contributed to the worrying trend to now TRY and even avoid their GDPs for Orthodontics and the sudden growth in DIRECT ONLINE ‘aligner’ treatments not even involving a direct clinical examination and ongoing monitoring by a Dentist directly 😮

    Coming back full circle, Tif’s point about GDPs being the reviewers and stabilisers of the mouth/patient Holistically, where GDPs are already managing/observing tooth movement and adaption whether they like it or not, is key to appreciating Orthodontics is a significant ‘string’ to the Dentist’s bow, when looking at what can be done when, Optimally.

    Maybe more Orthodontists could enable GDPs and more GDPs could enable Orthodontists how to take teeth out, just the simpler ones of course, the more challenging/complex can still go to our Specialist Oral Surgeon colleagues too ??

    Thank you Tif and Ross and many others who are about empowering GDPs responsibly, constructively and continually – thankyou also to all those Specialists who do educate and empower GDPs to do more, more frequently in ALL disciplines including Orthodontics – it does mean Specialists will gradually see less of the simpler or ‘easy’ cases I know, but by raising general awareness/ability it should also result in more appropriate referrals and more constructive working together for the public to access these treatment benefits directly from THEIR Dentist and the Specialists that support them.

    Our deceased colleague Anoop Maini was a great example of this ‘enabling’ attitude responsibly, in the public interest overall.

    Yours also Synergistically,

    Tony.

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    I am a GP who has been teaching Orthodontics for over 20 years. I would be the first to admit the average GP doing Ortho is doing mediocre-terrible work. I do not accept this from my students. But there are those that are dedicated, thoughtful, analytical, and skilled to perform orthodontic treatment to the level of a Specialist. They have the ability to deferentially Dx and treat the most complex cases. They use customized variable torque brackets and customized ovoid, tapered, and square archwire shapes. They understand anchorage and the bio-physics of a mouth. Cl II cases are treated with a combination of dento-alveolar advancement, extraction tx, mandibular re-positioning when appropriate, and with orthognathic surgery when indicated. These are clinicians whose work does not end upon de-banding but continues with before/after ceph overlays. Cases are followed up in retention as we see these patients for many years and sometimes inter-generationally.

    We have all seen brilliantly talented and conscientious Orthodontists. But most are limited to straightening teeth, placing power chain, and using Cl II elastics. I sometime wonder if they have a Masters degree in “rubber bands.”
    When they don’t know what to do in a Cl II case the “Hail Mary” treatment of placing a Herbst, Carriere Motion, or the current ju jour Cl II corrector in vogue. Anytime there is a bad result blame patient compliance. And when they see anything difficult they immediately prescribe a surgical tx plan. I have a vast collection of orthodontic cases that were disastrously treated by orthodontic Specialists.

    There is ample room for GP’s and Specialists to raise their level of care…

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    Great article, Tif and Kevin. Completely agree.

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