THE EDITOR'S CORNER
Orthodox doctrine in health care today insists on the principle that the general practitioner is the primary care unit. Patients entry into health care is through the general practitioner who is the one who evaluates the health care needs of the patient, refers him for specialty care when necessary, and coordinates the treatment program.
In dentistry, as in medicine, when this system works optimally, the patient is served optimally. However, when the GP/specialist relationship is working properly, the patient is not deprived of optimal care with the specialist as a point of entry. In orthodontics, for example, there is a great motivation for the orthodontist to refer the patient to the general practitioner, not least for the amount of dependence he feels on referrals from the general practitioner, but also because he is a dentist who is also interested in providing his patient with optimal care. So, among the vast majority of general practitioners and orthodontists there is not and need not be a conflict over point of entry.
A recent survey of the American Dental Association has shown that slightly over 50% of people visited a dentist last year. At least for the remaining almost 50% who did not visit a dentist, a direct entry through a specialist could have done no harm and indeed on the basis of the reverse referral from specialist to generalist would have done some good for the dental health of people as well as for the utilization of dentists' services.
There is nothing inherently wrong in a direct referral to a specialist. It is what happens after that is important for dental health. If the specialist refers the patient to the general dentist for routine dental care and maintenance, the question of the point of entry becomes moot, unless one were to believe that form ought to prevail over substance.
The average orthodontist has had a full undergraduate dental education. The average general dentist had been incompletely trained in orthodontics. A glance at the ADA publication, Dental Education in the United States, 1976 shows that the median number of clock hours of training in orthodontics in undergraduate dental programs (including lecture, seminar and clinical conference, self-instruction, laboratory, and clinical) was 91 hours. This means that half of the schools offered fewer than 91 hours of orthodontic training in the four-year undergraduate curriculum.
The HEW publication, Assessment of the Occlusion of the Teeth of Youths 12-17 Years (1977) stated rather bluntly--"It also seems apparent that many dentists in general practice do not recommend orthodontic consultations for their patients as often as they should". The basis for this was the finding that orthodontic referrals were made in only 7% of those youths who were classified as "Severe handicap, treatment highly desirable". Parents of youths in this category of need identified 12% as needing treatment and the youths themselves 18%. The study also concluded from this that, "This indicates that, speaking generally, youths and their parents are not bad judges of whether or not someone needs orthodontic treatment".
Thus, there is a gap between theory and practice with regard to point of entry in health care and orthodontists have been reluctant to point out these inconsistencies. As with many things, economics may delineate issues that previously were of little or no concern. There is an obvious and growing need for orthodontists actively to seek an increase in the utilization of orthodontic treatment. This must include public relations programs which may breach the concept of the general dentist as the primary and only point of entry into dental care. This must not be allowed to create a further schism between generalists and specialists.
General dentists and orthodontists have a common purpose which is to provide optimum dental health for the patients in their care. A rapprochement between us is required. We need to communicate with general dentists within the dental organizations (where orthodontists have always been significant participants), within dental publications, and one-on-one. We have a common purpose. We also have common problems and a focus for mutual concerns.
If only approximately 50% of the population visited the dentist last year and if less than 15% of the child population are receiving orthodontic treatment at specialists' offices, neither one of us is doing an adequate job of merchandising our services. One must believe that effective PR programs would result in increased utilization of general dental and orthodontic services. One must believe that the public would be benefited by receiving more dental care and more orthodontic care, and that increased utilization would be the strongest influence toward maintaining or improving dentistry's record of keeping fee increases lower than the increases in goods and services generally. In addition to all this, the predictable consequence of orthodontists not "going public" will be the decline and failure of a large number of orthodontic practices and a threat to the integrity of the specialty itself.
