Solving a Dilemma
The American Dental Association believes that a competitive dental market is contributing to "turf wars" between general dentists and specialists--And among the specialties--and it has formed a Special Committee on Intraprofessional Relations to "mend fences". A competitive dental market is only one aspect of the situation.
One of the problems between orthodontists and generalists is the relationship of education to competency. Orthodontists find it hard to believe that any education short of full graduate university training can prepare one to practice an increasingly complicated discipline. Generalists who do orthodontics tend to think that they can get sufficient education in a number of short courses to treat orthodontic cases they feel competent to handle.
There are orthodontists who believe that more orthodontic information should be given in the undergraduate dental curriculum. Whether that would relieve or exacerbate the problem is debatable. Would more orthodontic training in the undergraduate dental program encourage more or better orthodontic treatment by general dentists, or would it give general dentists a healthier understanding of orthodontic problems and encourage them to refer more to specialists?
There are a number of highly successful orthodontists who feel that helping general dentists who want to treat simple cases and refer difficult ones has been a major practice builder. Some say, "Some of my best referrers are dentists who have tried orthodontics and no longer want any part of the problems and headaches". For those orthodontists, cooperation is preferable to confrontation.
An aspect of the friction between orthodontists and general dentists is the mechanical orientation of dentistry. If therapy is an end in itself, orthodontics may seem to have become easy--bond some brackets, place a straight wire, and watch the teeth move. But therapy, of course, has not become that easy, and therapy is not an end in itself. It is a means to an end, which has been defined by diagnosis that is becoming more difficult as our knowledge of growth and articulation increases.
Another problem is the one that concerns the ADA--that the competitive dental market is affecting the busyness of general dentists, who are driven to treat orthodontic cases for economic reasons. This is not a situation that is going to improve soon. There are still too many dentists in practice. This resulted from an ill-conceived program of the federal government to increase the number of dentists in anticipation of a population increase that did not occur. The program, which began in 1963 and ended in 1981, exchanged government grants for mandatory enrollment numbers. Since the end of the program, there has been a reduction in the number of dental graduates and there have been some dental school closures, including one closure announced this year.
While enrollments have declined, the percentage of people who purchase regular dental care has not been sufficiently increased by increased availability of dentists, by dental health insurance, or by individual and institutional advertising. On the other hand, the movement for unsupervised practice by hygienists and denturists may be growing--making further inroads into dental practice--and advances in prevention and reduction of caries and periodontal problems will continue to reduce demand. It is logical that general dentists faced with decline in income would turn to another branch of dentistry to broaden their income base, and it is unlikely that we will see legislation that will restrict their choice to do so.
Faced with so many dead ends, what should orthodontists be doing to solve this dilemma? We can insist on stringent educational standards for those who want to call themselves specialists, but the number of general dentists who want to call themselves specialists in orthodontics is small. We may believe that much of the orthodontic treatment undertaken by general dentists is inadequate, but evidence about that is largely anecdotal. We may want to restrict orthodontic treatment to those with full university training, but that is not likely to happen soon.
It seems unlikely that an ADA committee is going to find a solution to the complex problem it is addressing. It is possible that time may solve some of the problem. In the near future, dental school enrollments may well decline further. It is becoming difficult to find one qualified applicant for each dental school seat. It would not be surprising to see additional dental school closures. The net effect will be to reduce the number of dental graduates and, ultimately, the relative number of practicing dentists. The difficulty of orthodontic treatment and the specter of malpractice actions may well dim the enthusiasm of untrained dentists to attempt orthodontic cases. The economy may improve and increase the utilization of general dentistry and orthodontics. None of these is a certainty or a quick fix.
In the meantime, there is very little to be gained by the constant bickering between general dentists and orthodontists. It is not going to change anything; it is only going to widen the breach between segments of dentistry that should be working cooperatively. It seems clear that orthodontists ought to cooperate with cooperative dentists; and, where a competitive dental market exists, the orthodontists' only recourse is to compete.
An example of a positive effect of cooperation and reconciliation between orthodontists and general dentists is the program of the Panhandle Orthodontic Study Group described in this issue.