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What Defines a Specialist?

Shortly after completing my graduate program in orthodontics, I was interviewed by an older orthodontist from my hometown who was looking for an associate to join his practice and eventually buy him out. This was a decision that was of tremendous importance and risk to both of us: he had his retirement on the line, and I had four kids to feed. Given the gravity of our discussion, we probably touched on every imaginable subject relative to the practice of orthodontics, just to make sure that we would be both personally and professionally compatible. Things were going relatively well until the older orthodontist began a diatribe about what he felt had killed the specialty. Being right out of orthodontic school after having run a successful general practice for a number of years, I was unaware that the specialty was dead or even ailing. But my colleague was absolutely sure that the mass marketing of preformed bands had ruined things by making it easier for general dentists to practice orthodontics, and that the invention of straightwire appliances was the final nail in our collective coffin. In short, he believed that progress in orthodontic technology had killed his practice. Needless to say, I did not enter into an agreement with him.

That was almost 30 years ago. My own retirement is now in sight, and I still don't believe that our beloved specialty is either dead or ruined. During those three decades, we have seen some dramatic advances, many of which would have had the potential to make it easier for anyone besides certified specialists--general dentists, pediatric dentists, periodontists, anyone--to deliver orthodontic care. There have been so many "paradigm shifts" over those 30 years that one has to wonder just what it means to be a specialist today. I suppose many people would define a specialist in terms of the possession of some esoteric knowledge that is unattainable by the general practitioners of the profession without additional training. Many who ascribe to this definition abhor any progress that might make it easier to practice their obscure craft. In the mind of the senior orthodontist with whom I interviewed all those years ago, if everyone who delivered orthodontic care had to know how to pinch and cement bands, then GPs could never have "invaded" our specialty.

I've always felt that it isn't the technology itself that defines a specialist, but rather the training, experience, and judgment required to determine just how and when to use that esoteric technology to achieve the best outcome for the patient. In this context, technological progress becomes inherent in the definition, and staying abreast of that progress becomes a point of contrast between the specialist and the generalist. I would argue that clinging to old ways--pinching bands, for example--in the face of superior advancements only serves to diminish the authority and even the respectability of anyone claiming to be a specialist.

In the 30 years since my interview, the area of greatest technological progress that I've seen would have to be the development and widespread application of computer-designed and -manufactured aligners by Invisalign and its competitors. Nothing has had as great an impact on the possibilities for orthodontic care we can offer to our patients. Once again, because this technology is available to both orthodontists and general dentists, it has caused a good deal of consternation within the specialty. But again, I would argue that trying to suppress progress would be the wrong thing to do, for us as specialists and especially for our patients. At the outset, we recognized that aligners had their clinical limitations. Since then, however, improvements in design and performance have resulted in a treatment modality that can now accomplish practically anything we can achieve with fixed appliances. That progress continues, as our current issue demonstrates.

In this month's JCO, Drs. Hiroshi Samoto and Vicki Vlaskalic present a case that perfectly supports my argument about specialists' being defined by more than technology alone. This patient would have been challenging to treat even with fixed appliances, but the results shown here would be admirable for any system. It was the authors' clinical judgment, diagnosis and treatment- planning skills, and practical experience that distinguished the work of specialists in this case. Take a look and see what you think.



2014 JCO Orthodontic Diagnosis and Treatment Study

Every four to six years since 1986, JCO has conducted a survey of U.S. orthodontists to determine the current usage of specific diagnostic methods, treatment techniques, and appliances. The reports of these surveys have become standard references throughout the specialty, and many clinicians have found them useful in making comparisons with their own practices.

The 2014 questionnaire is published in this issue of JCO (pp. 381-388). Besides conventional brackets and wires, the items surveyed include clear aligners, intraoral scanners, CBCT, accelerated orthodontics, and skeletal anchorage.

To ensure the continued reliability of the data, it is critical that as many U.S. orthodontists as possible participate in the Study. For the first time, this year's survey is being conducted online through SurveyMonkey.com, making it easier and faster to complete, as well as more accurate. There are two simple ways to enter your responses:

  • Access the online form at www.surveymonkey.com/s/JCO2014DTsurvey. You can use the questionnaire in this issue as a reference, and you can partially complete your online survey and go back to it as many times as you like as long as you use the same computer (once you hit the "Done" button, you cannot revise your entries).
  • Mail in the completed paper questionnaire from this issue, using the supplied business-reply form. There is no charge for postage, and we will enter the data for you upon receipt.

In either case, your responses will be completely anonymous and confidential. Please complete your questionnaire by Aug. 20. As usual, results of the Study will be published in JCO in the fall and available in our online archive.


Dr. Keim is Editor of JCO; e-mail: editor@jco-online.com.

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