Should general dentists provide orthodontic treatment (revisited)?
In this first post of 2018, I am going to discuss whether general dentists should provide orthodontic treatment. I have decided to revisit this because of the recent advertising campaigns run by some of the specialist societies, in which they highlight the differences between a specialist and a general dentist.
The first point that I would like to consider is that a general dental practitioner can provide any treatment in which they are competent. This includes orthodontics. Importantly, the practitioner decides whether they are competent and the treatment is within their scope of practice.
While this concept is widely accepted, it is influenced by the aims of undergraduate programmes. These vary throughout the world. In the UK , current guidelines suggest that the newly qualified dentist should be competent in diagnosis and know when to refer their patients to a specialist. The Dental Schools do not train student dentists to be competent in providing active orthodontics.
This raises a problem. If a practitioner wants to provide simple orthodontic treatment and does not want to train to become a specialist, then opportunities are limited. I cannot help feeling that this leaves a “training void”. In some countries practitioners can get experience and attend courses to obtain competence in simple treatment. Some of these programmes appear to be good and specialists run them with high level mentoring. However, others are a greater risk and these tend to be delivered over a weekend. These are widespread and are sometimes run by the “fringe” practitioners. This adds another layer of complexity to this issue.
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. 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.
Recent advertising campaigns
Recently, some of the specialist orthodontic societies have run advertising campaigns to educate the public in the advantages of seeing a specialist. I have inserted two screenshots of advertisements issued by the Ontario Society of Orthodontists and the American Association of Orthodontists.
I thought that the AAO advert was rather controversial and I showed this to some of my general practitioner colleagues. They felt that it was patronising, particularly with the use of the phrases “cleans teeth” and “fixes cavities”. They strongly suggested that if our local specialists put this up in their offices they would stop referring patients.
The Canadian one is less confrontational. Importantly, they point out that generalists and specialists should work together to benefit the patients. I am not sure how effective these campaigns have been, but at least these societies are making an attempt to clarify this issue for our patients. The EOS and WFO are completely silent on this.
The short orthodontic course
I wonder if the target of the specialist society advertising has been the “short orthodontic course”. Subjectively, I feel that there has been an expansion of short 1-2 day courses and “accreditation” in orthodontic techniques. Some educators market “new techniques” that speed up treatment. This is a selling point to the practitioners.
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 specialists do not always provide exemplary treatment. 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.Importantly, 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 and accelerated orthodontics using vibratory devices.
Where does this leave us?
This is 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 our treatment.