End of Braces=End of the Specialty of Orthodontics

Regarding the Editor’s Corner by Dr. Robert Keim in the December 2018 issue of JCO: Change is definitely here. We’re all treating with more aligners today than we were a few years ago. It’s not a bad thing. Clear aligner therapy (CAT) is undoubtedly bringing people into treatment who might otherwise never have sought it. CAT is an important addition to our treatment armamentarium. Furthermore, the aligner companies are not the bad guys. They’re doing what companies do in the free market, and they’re doing it well. Hats off to them. My concern is that when the editor of a major journal makes pronouncements that the end of braces is in sight and that there is no case that he would not consider treating with aligners, a lot of people are listening, in our profession and in the industry. These pronouncements raise two major questions: Will the quality of care be the same across the spectrum of cases if this prophecy is fulfilled? Will the profession be better off?

This is where we have to be honest with ourselves. Can we achieve the same level of quality of care, especially with the more severe malocclusions, with aligners as we can with fixed appliances? If not, are we OK with capitulating to patients who demand less conspicuous treatments driven, in part, by effective big-dollar marketing campaigns, in an attempt to maintain our case loads? If the latter is increasingly true, we are seriously jeopardizing the specialty status of orthodontics.

Here is why I think so: You don’t have to be a specialist to provide CAT. This was always true with fixed appliances, but CAT technology provides an easy platform for non-specialists to begin treating malocclusions. Aligner companies provide the training and implementation support for them to do so. They take the same industry-sponsored courses that we take. University-based graduate programs are already teaching CAT, and it may now be introduced into some dental school curricula. A search of non-specialist websites and Facebook pages in most areas will show that more and more are CAT providers. Some are advertising comprehensive CAT for considerably less than the average fees charged by orthodontists. In addition, public acceptance of the non-orthodontist mode of CAT is growing. It is furthered by the direct-to-consumer CAT model that conditions the public to expect that you don’t have to go to an “inconvenient and expensive” orthodontist anymore. Their advertisements appear on television on a daily basis. Even if the direct-to-consumer model eventually fades because of outcomes limited by non-hands-on teledentistry, the branding of orthodontists as inconvenient and expensive will be hard to erase.

In addition, will the top dental students, already burdened by educational debt, opt to undertake a three-year residency in orthodontics, with additional tuition costs of $50,000-80,000 per year, when they can graduate from dental school and start treating all the malocclusions they want? At the university where I have taught part-time, the orthodontic program has been consolidated into a single Department of Orthodontics and Pediatric Dentistry under a pediatric dentist chairman. Could this be a harbinger of things to come?

As specialists, quality of care is the only thing we have to “sell.” If we’re going to survive as a specialty, individually and collectively, we’d better start doing a better job of educating the consumer in exactly what quality of care is and what it is not, and delivering it across the spectrum of malocclusions. This will involve stepping on some toes. Though some may think it extreme to suggest that the end of braces = the end of the specialty of orthodontics, at the very least, there will be far less of a need for the 9,000 specialists currently practicing in the United States and for the programs that train them if Dr. Keim’s prophecy comes to fruition.

TOM BARRON, DMD, MS
Timmonium, MD