Dr. Alex Jacobson on the Challenges in Orthodontic Education Today

DR. GOTTLIEB Alex, what do you consider to be your greatest challenge as an orthodontic department chairman today?

DR. JACOBSON The greatest challenge as chairman is to determine what should be taught to the undergraduate student in orthodontics--the extent of orthodontics that should be taught to the general practitioner.

DR. GOTTLIEB What are your guidelines for what that should be?

DR. JACOBSON It is almost a cliche that we could give them as much orthodontics as they can absorb, if we had the faculty and the time. But with those constraints, the amount of orthodontics that can be provided in predoctoral programs is very limited.

DR. GOTTLIEB Is a graduate of a predoctoral program equipped to practice any orthodontics?

DR. JACOBSON It depends on the individual and the amount of exposure he or she has been given. At the University of Alabama, we try to expose our students to as much undergraduate orthodontics as possible, but in many schools orthodontics is relegated to being a minor subject. One of the unfortunate situations is that the moment they get out into the real world dental graduates find that they have a deficiency in orthodontic training and seek knowledge elsewhere.

DR. GOTTLIEB But even if a program has a relatively large amount of time devoted to orthodontics, what can you teach in the undergraduate program that will permit graduates to have a level of competence to treat people, to be fair with the public?

DR. JACOBSON Gene, all undergraduate programs are so pressed for time. As a former chairman of a curriculum committee, I am somewhat acquainted with the problem. Right now, on average, the total hours of undergraduate instruction (according to figures given in 1986) is 4,076. Between 1976 and 1986 the basic sciences occupied 18% of the curriculum, and there has been no change in that time. Behavioral sciences comprised 3% of the program between 1976 and 1986. No change. The clinical disciplines occupied 79% of the curriculum time in 1986, with a 21% increase in hours--about 400 hours--between 1976 and 1986. It is the only one that has increased. The amount of undergraduate instruction in orthodontics is about 107 hours on average nationwide. This means that 2.6% of the total curriculum time is devoted to orthodontics. There is very little instruction that can be given in 107 hours. The amount of orthodontics you can give is limited to a certain amount of diagnostic and preventive procedures and, if possible, enough information to enable a student to identify the difficult cases and possibly treat the "simple" cases. I know your next question is going to be, "What constitutes a simple case?" I haven't got an answer to that one, because to determine a simple case requires an expert. That's a Catch-22.

DR. GOTTLIEB We have a tendency to think there are answers for every problem, but is there an answer to this problem? Given the desire on the part of dental graduates to offer a broad spectrum of services and the fact that the law permits them to do anything in dentistry, what answer is there if an undergraduate is undertrained to do almost anything in orthodontics?

DR. JACOBSON They are going to do orthodontics and we have to accept that. There is an adequate number--some people say an overabundance--of dentists, and the disease pattern has changed to where restorative procedures no longer dominate. Practitioners are looking for other sources of income, and they are exploring other areas such as periodontics, endodontics, surgery,orthodontics, and esthetic dentistry.

DR. GOTTLIEB Where are they going to get this education in short courses that is going to be so good that it can satisfy the need?

DR. JACOBSON We know that orthodontic programs limit their intake of individuals, which means that a number of capable applicants who are not being admitted to the advanced education programs are seeking information elsewhere. A lot of general practitioners are taking short courses in orthodontics offered by individuals who are out on the circuit with a technique or something else to sell. For some, this can be a lucrative source of income. Unfortunately, most of the courses offered are appliance- or technique-oriented. As a result, many practitioners are concentrating on appliance therapy rather than on diagnostic or biologic procedures. This could mean a disservice to patients and possible creation of a two-tier system. Now, there are many practitioners who will not accept a two-tier standard in their practices, and they are making every effort to obtain good information and to provide good services. These individuals need to be commended. Unfortunately, as in all disciplines, including orthodontics there are those who are doing excellent work and there are others who are performing less than adequately.

DR. GOTTLIEB Should the universities be meeting that need, rather than the entrepreneurs?

DR. JACOBSON The way I see it right now, there ought to be ongoing-type university courses. It is difficult to conceive that adequate courses can be conducted in motels during weekends. It would have to be continuing hands-on instruction over an extended period. But I don't think many, if any, university departments or schools have the available personnel and time to deliver this type of information. So again it's a Catch-22. Who is going to provide this information?

DR. GOTTLIEB If that is the case, what do you think should be the priorities for undergraduate training under present circumstances?

DR. JACOBSON Diagnostic procedures and biologically oriented programs. We are trying to expose the undergraduates to our advanced training programs as observers and part-time assistants to the post-doctoral students. Direct contact and observing what the postdoctoral students are undertaking and the problems that they are encountering may be a way of providing sufficient insight to enable undergraduates to select their cases. In addition, a seminar-type teaching system will provide further information and insight into the subject of orthodontics. Instruction in practical procedures alone is like giving someone a hammer; then everything looks like a nail. That is an inadequate type of instruction. Even then, we feel that the constraints of time are going to limit the amount of information that can be disseminated.

DR. GOTTLIEB If you were able to add orthodontic subjects, what would you add? Clinical orthodontics?

DR. JACOBSON Clinical orthodontics, yes, but I don't think it's a matter of providing a typodont program such as we give our advanced students before they start treating cases. About three months is devoted to practical procedures in the advanced orthodontic program. The rest of the time is devoted to diagnostic procedures and gaining advanced knowledge in the biologic sciences. This is where the time is needed, not how to use a hammer.

DR. GOTTLIEB Is it your feeling that the more information that dentists have in their undergraduate program, the more respect they will have for orthodontics, and they'll refer more of the difficult cases at least?

DR. JACOBSON Hopefully they will be able to identify difficult cases and incipient malocclusions, and be sufficiently informed to be able to refer appropriate cases and maybe treat simpler cases. We have to maintain a healthy relationship with general practitioners, and specialists have to become more specialized. Right now, I think all orthodontists are not receiving too many so-called easy cases. They are getting the more demanding type of case. It was reported at the 1987 AAO Workshop in New Orleans on the "Changing Face of Dentistry" that 55% of the orthodontics in this country is being done by the generalist. It is not going to decrease. However, I have had reports from individuals that a number of general dentists who have been doing orthodontics are cutting down on orthodontics, doing the simpler procedures and referring the more complex procedures. If true, that is a hopeful sign.

DR. GOTTLIEB Apart from difficulties in diagnosis, there are some unforeseen problems that arise during treatment. In a sense, diagnosis is a continuing process.

DR. JACOBSON Yes. The specialist is able to identify when the treatment is not responding and can make an in-course adjustment, whereas the generalist very often--not always--works on a treatment plan and anticipates that it is going to succeed. He may have sought advice and will continue treatment not realizing that growth may be mitigating against treatment.

DR. GOTTLIEB Remember Dr. Donovan, who came out with a kind of mass preceptorship in which it is said that he oversaw 20 or 30 or more general practitioners? Do you see anything like that developing in orthodontics?

DR. JACOBSON I think if the generalist would communicate more closely with the specialist and if they can establish a rapport and a relationship, that would be a tremendous advance, provided the orthodontist played a fair game and said, "This is something that you can handle" or, "We are running into potential problems here. This needs to be referred". If they have confidence in each other and a good relationship, maybe something like that could develop.

DR. GOTTLIEB More of a one-on-one relationship between orthodontists and generalists?

DR. JACOBSON I have got some dentists who do come and ask if this is something that they can handle, and we are only too happy to encourage them to treat those cases we think they can handle, and we will help them.

DR. GOTTLIEB There are plenty of indications that this works in a private practice. I know it worked for me.

DR. JACOBSON It worked for me in private practice as well. I had very good relationships with a number of dentists. If we can get to that state of affairs, it would be healthy for the profession and for the public that we serve.

DR. GOTTLIEB I have found pedodontists to be a devoted group, but the question is, "Is their training adequate to do the job?"

DR. JACOBSON We have had a number of pedodontists apply to our program in orthodontics and we have accepted a few. They wish to practice orthodontics and feel if they are going to do it they intend to become competent. I know a number of them who confine their practices to restorative procedures in the morning and orthodontics in the afternoon, and they are doing a tremendous job.

DR. GOTTLIEB Failing retraining of pedodontists in orthodontics, are we creating three-level orthodontics in this country right now?

DR. JACOBSON Hopefully we can get to a one-level orthodontics, where interested generalists and pedodontists will do what we regard as good orthodontics, because they will be held to the same standards of care as the specialist.

DR. GOTTLIEB There are many places in the country where that is supposed to be true, but it has not been a deterrent.

DR. JACOBSON Unfortunately so--and hopefully it will not be litigation that pressures such changes.

DR. GOTTLIEB That is really not the way for change to come about.

DR. JACOBSON Decidedly not.

DR. GOTTLIEB I have heard it said that the academic quality of applicants to graduate orthodontic programs is declining. Do you believe that is true?

DR. JACOBSON On the contrary, the caliber of students is tremendous. Most of our applicants have advanced degrees in addition to their dental degrees. They may have a master's in biology or have taken a general residency program or done some extra work in addition to their primary degree. These are enthusiastic, high-caliber individuals. When we went to a three-year program, I thought the number of applications would diminish. If anything, it has increased.

DR. GOTTLIEB You went to a three-year program?

DR. JACOBSON Yes. I believe that graduate programs must be increased in length because of the tremendous explosion of knowledge in the various areas such as adult orthodontics, temporomandibular joint, and orthognathic surgical procedures. We need an environment in which faculties are dedicated to research and graduate students are challenged by the new knowledge in biology and advanced technology. It is time to extend the length of most graduate programs to three years to include and give more attention to basic biology and meaningful research. In this way we are going to develop true specialists in orthodontics who will undertake to do the major procedures. When we went to a three-year program, I thought our application pool would drop and we would get a few really dedicated individuals, but it has increased. When we asked these students how they would react if they were accepted in this program and in a two-year program, almost all responded that a year in their life now is of small consequence and they would rather have a good background in orthodontics.

DR. GOTTLIEB What are the advantages of a three-year program over a two-year program on the academic side and on the clinical side?

DR. JACOBSON I believe students should be challenged with the new knowledge and the new technology and be able to be much more biologically oriented without compromising their clinical skills. With the constraints of time, a three-year program leading to a master's degree is mandatory to accomplish that. To earn a master's degree, they are required to study advanced subjects and do original research. On the clinical side, they are able to see clinical cases through from beginning to end in a three-year program. Many of those who have received a master's degree in the past for a two-year program feel they may have been compromised in their clinical training, and those who haven't achieved a master's I think have missed something. There is a concern that they may not be as discriminating in their reading and in their ability to assimilate information. Many program directors may not agree with me, but that is what makes it a free country.

DR. GOTTLIEB Is there a relationship between academic ability and ability to practice orthodontics?

DR. JACOBSON I think these students are very academically oriented as well as clinically competent.

DR. GOTTLIEB Should the university programs have one clinical technique rather than a variety of them?

DR. JACOBSON I think a technique is not necessarily the main focus. If people are proficient in one or two methods of moving teeth after having diagnosed the case, I think you have achieved your objective. Most programs today are edgewise-oriented with modifications of the bracket inclinations and angles. It doesn't matter how you move teeth as long as you know what you are doing and are trained proficiently in one or two specific techniques.

DR. GOTTLIEB Plus a lot of peripheral techniques--headgear, Herbst, lingual, etc.

DR. JACOBSON That goes along with the training.

DR. GOTTLIEB Are you able to give the students experience with new techniques and new materials?

DR. JACOBSON We encourage the use of new materials, and the supply houses have been very good to us in that respect.

DR. GOTTLIEB What non-clinical subjects do you cover?

DR. JACOBSON Students need to be exposed to muscle physiology and a certain amount of pathology, particularly of the temporomandibular joint. Biology and body chemistry are intimately related to orthodontics. The biology and physiology of the body must be thoroughly understood along with growth and development, statistics, scientific methodology, behavioral sciences, etc.

DR. GOTTLIEB Do your diagnostics get into functional analysis?

DR. JACOBSON Oh, sure. That is a basic part of muscle physiology.

DR. GOTTLIEB I want to run down a list and ask you, considering the importance of the subjects on the list, whether you can cover them in your program. Patient motivation is first.

DR. JACOBSON We cover that by teaching certain motivation techniques.

DR. GOTTLIEB How about practice management?

DR. JACOBSON Most of the material on practice management is given by visiting lecturers. This is not a formal course, rather it is an informal lecture series.

DR. GOTTLIEB TMJ diagnosis?

DR. JACOBSON One full day a week during the entire three-year program is devoted to TMJ therapy and diagnosis.

DR. GOTTLIEB Lingual orthodontics?

DR. JACOBSON Lingual orthodontics is done on selected cases simply to expose the students to lingual orthodontics.

DR. GOTTLIEB Surgical-orthodontic diagnosis and treatment?

DR. JACOBSON Tremendous amount. We have a very strong surgery department and, as a result, we do a lot of orthognathic surgery.

DR. GOTTLIEB Adult orthodontics?

DR. JACOBSON A lot of adult orthodontics. To cover all these areas almost mandates an extended program.

DR. GOTTLIEB Sterilization and disinfection?

DR. JACOBSON This is one of the problems that the school as a whole is wrestling with just as the profession is wrestling with it. We have kept abreast of all the developments. Masks, gloves, eyeglasses are mandatory in all our clinics, and there is a special area set aside for HIV-positive patients. We are required to treat HIV-positive patients.

DR. GOTTLIEB Do you do a blood workup on all patients?

DR. JACOBSON We do a physical workup and history.

DR. GOTTLIEB Are the students exposed to interdisciplinary case management?

DR. JACOBSON Yes. We enjoy a good relationship with the pediatric dentistry, periodontics, fixed and removable prosthetic dentistry, and surgery departments.

DR. GOTTLIEB Do you get into setting up on articulators and exchanging articulators with prosthetic people?

DR. JACOBSON We don't exchange articulators, but we do have close contact with them. We do articulate selected cases, and we are cognizant of the advantages and shortcomings.

DR. GOTTLIEB Do you teach ethics?

DR. JACOBSON We hope we teach ethics by example. There are courses in ethics in the undergraduate curriculum.

DR. GOTTLIEB How about alternative forms of delivery of dental care? Do the students get an understanding of what is going on in the outside world?

DR. JACOBSON Decidedly. Students are encouraged to attend meetings. Visiting and part-time faculty expose them to what the outside world is all about and what they can anticipate. They are alerted to and very aware of the world they will enter.

DR. GOTTLIEB With the difficulty that students have in setting up their own private practices on graduation, do you find students going into employment in these alternative delivery practices?

DR. JACOBSON I know of no graduates of our department who have sought employment in alternative delivery practices. On the other hand, relatively few are going into solo practices now because it is very difficult for a young person to establish a solo practice. Most of them are being absorbed into partnerships or associateships or getting into group practice. To start on your own and get referrals is not easy nowadays, particularly since generalists are doing so much orthodontics themselves.

DR. GOTTLIEB Young graduates are usually in debt when they get out of school. Then they face the expense of establishing a practice and the difficulty of getting referrals.

DR. JACOBSON Right.

DR. GOTTLIEB And there are not very many associateships available.

DR. JACOBSON Not that many; however, they are available.

DR. GOTTLIEB Is the federal government still as involved as it was in dictating to schools the size of classes, curriculums, etc.?

DR. JACOBSON No. That no longer applies.

DR. GOTTLIEB Are government funds still going to dental schools?

DR. JACOBSON State funds are there, but they are somewhat insufficient. Research money and other money has to be attracted to schools nowadays in the form of grants for original research. So most schools are hurting.

DR. GOTTLIEB In some schools I hear complaints about students being involved in private practice while they are going to school.

DR. JACOBSON This is another issue that is being debated in our school at this very moment. Students are hurting financially and some feel that they should be allowed to earn income provided it does not compromise the program in any way. There is a heady debate right now. Some are vigorously opposed to students doing any work outside the school. Others feel that they should be able to handle it and cite themselves as examples of being able to do both. It is a very delicate issue. Up to now our students have not been allowed to moonlight, but that may change.

DR. GOTTLIEB It is said that there are more women and minority students coming into orthodontics. If it is happening, it seems to me to be a very slow process.

DR. JACOBSON I think we can say that more minorities and women are getting into general dentistry. As a result, the increase is percolating to the post-doctoral programs.

DR. GOTTLIEB My only solid information is derived from our biennial practice studies. The increase in number of women appears to be small.

DR. JACOBSON I think it will grow. There are some talented women students entering programs.

DR. GOTTLIEB Do women have any more right-brain proclivities than men in relation to orthodontics?

DR. JACOBSON No, I don't think so. I think those who are capable are capable.

DR. GOTTLIEB Some months ago I wrote an article for JCO called "Dr. Mason Chooses an Associate". I had the field narrowed down to three applicants. One applicant was technique-oriented, he liked the work, he liked wirebending, he considered that the road to success in orthodontics was to be a good wirebender. The next fellow was interested in management and salesmanship, and the next fellow was people-oriented. So each one had a bias. The readers were asked to vote for which one Dr. Mason should take on. Do you have any feeling about where the emphasis should lie among the three major focuses?

DR. JACOBSON Unfortunately, the most capable orthodontists are not necessarily the most popular orthodontists because they are not necessarily people-oriented. They may be the most proficient, the most knowledgeable, but very often those who have the biggest practices--if that is a measure of success--are those who have got the personalities, who are people-oriented, and who can sell themselves to their patients. It does not necessarily indicate their ability in orthodontics.

DR. GOTTLIEB Do you look at applicants from that point of view?

DR. JACOBSON We like to have an applicant who can relate to people, who has leadership qualities, who has the academic ability, and is clinically proficient. We are able to make that determination to a certain extent from interviews and from their school record.

DR. GOTTLIEB Are students becoming more entrepreneurial these days?

DR. JACOBSON I believe so. I believe the profession is heading that way.

DR. GOTTLIEB You see orthodontics evolving from a tooth-straightening profession to a more biologically oriented profession.

DR. JACOBSON Much more so, because I see us interacting very heavily with the medical profession. That is a healthy sign because we are part of the medical profession. We are talking about the heads neck, joint, face. Teeth are not separate entities like little ivory pegs embedded in the head. We are today talking to the ear, nose, and throat people, to the plastic surgeons, to neurosurgeons about various types of pain and TMJ pains and disturbances, and we are relating much more favorably with the medical profession. That is precisely where we should be.

DR. GOTTLIEB What do you think of the concept that dentists and possibly orthodontists should be seeing patients in infancy and become involved in their diet and perhaps other concerns?

DR. JACOBSON I don't think we are equipped to advise them on diet or dietary deficiencies. I think the pediatrician is the one equipped to handle this. Ideally we'd like to be aware of infant growth from an early age. But from a practical point of view, what mother is going to bring an infant to see the orthodontist? It is unreasonable, and what about other patterns--the psychological aspect, the emotional development of the child? There are other facets to a child growing up. If an abnormality is developing, a skeletal deviation, maybe that would be the time to identify it and possibly help that child. We can get involved orthodontically, at age 7, but it is logistically impossible to see all 7-, 8-, 9-year-old children regardless of whether or not they have problems.

DR. GOTTLIEB What about later? Do you think orthodontists ought to be involved in the nutrition of older child patients and adult patients?

DR. JACOBSON Again, I don't think we are nutritionists. I know there is a lot of talk about holistic treatment, but are we equipped to be omniscient?

DR. GOTTLIEB In line with your visualization of a more biologically and medically oriented orthodontics, could you see a time when tooth straightening may be done by general practitioners for the most part and orthodontic specialists step up to the next plateau, so to speak--maybe doing the most difficult cases and the medical management of this complex system?

DR. JACOBSON It would be nice if we could define what routine orthodontics is. We use that word very loosely. If we could define what routine orthodontics is, and the generalists would confine their treatment to routine orthodontics and the specialists confine their treatment to more sophisticated orthodontics, that would possibly be the answer to a lot of our questions. Of course, there are still going to be many specialists who are going to do very simple procedures and many generalists who feel they are capable of doing more complex procedures. There is no thin line to be drawn. There is a wide gray area.

DR. GOTTLIEB Orthodontics has been described as an art in search of a scientific basis, and most of our scientific basis seems to be in clinical research. Basic research has been a stepchild. Do you see basic research moving to the fore and possibly becoming primary?

DR. JACOBSON I think we are underestimating basic research. Basic research developed bonding materials that changed the face of orthodontics and of dentistry. Basic research gave us fluoridation, which changed the disease pattern. Basic research is changing the pattern of periodontics, and right now there is a lot of basic research in the area of muscle physiology, which is going to change a lot of our concepts of muscle behavior and muscle pattern. So I think for too long we have been underestimating basic research.

DR. GOTTLIEB Because of our unfamiliarity with it?

DR. JACOBSON That's right. Basic research has changed more things in dentistry than anything else. What has changed dentistry more than fluoridation?

DR. GOTTLIEB Maybe what we should have is a popularization of basic research by having a simplification, if you will, of the relevance of basic research or the potential relevance to the practicalities of clinical orthodontics.

DR. JACOBSON The Flexner model of teaching that was established in medicine and dentistry in 1910 stressed lectures, memorization, and laboratory procedures. It divided medical and dental school into two distinct parts--the first half devoted to basic sciences and the second half devoted to clinical sciences--two separate entities. There is a move afoot to integrate the two. Right now growth and development are just exams to be passed to get to the next stage of clinical procedures. Everything else is subordinated to the qualitative and quantitative clinical requirements. If we can eliminate that and start our students thinking, we'd get into the first level of change. That's what we need.

DR. GOTTLIEB What areas do you think of that ought to be researched enthusiastically at this point?

DR. JACOBSON One of the interest areas is in the behavioral sciences, because of the psychological aspect of orthognathic surgery and TMJ disorders and pain. Also the basic sciences such as muscle physiology. What are we doing with the changes we make? How are the muscles reacting? Dentistry is really an empirical science. We do things, find they work--often by accident--then we try and determine why they worked. It should be the other way around.

DR. GOTTLIEB Has the increase in malpractice activity affected the functioning of the orthodontic department?

DR. JACOBSON Decidedly. We don't necessarily have a big insurance problem, but people are alerted to the informed consent situation--what informed consent is, how much you tell patients, and what the possible problems are. It is a matter of protecting oneself or even being overprotective at times. Defensive orthodontics has joined defensive medicine, which in a way is most unfortunate.

DR. GOTTLIEB Do you want to make some prophetic statement on the future of orthodontic education?

DR. JACOBSON Organized dentistry is going to have to get together and formulate some agreement as to what should be taught at schools. There should not be a dichotomy of thought about what constitutes routine orthodontics.

DR. GOTTLIEB Alex, on behalf of our readers I want to thank you for taking the time to discuss the challenges and concerns in orthodontic education today.