Short course experts vs. specialists
A principal admonition or caution which applies to all health practitioners is given by the Latin phrase primum non nocere - "first, do no harm". Essentially, it warns a practitioner against carrying out treatment unless the practitioner is sure that the treatment will be beneficial to the patient or, at the very least, will do no harm.
Increasingly, in the Community Relations section at the Australian Dental Association Victorian Branch, it has become apparent that general practitioner dentists are providing treatment in areas of dentistry which require a greater level of competence, knowledge and skill than they actually possess. The acquiring of a basic degree in dentistry equips a registered dentist with the right to treat in all areas of dentistry, within their level of ability. It does not mean that a general practitioner can or should, without extensive further experience and training, undertake treatment which requires specialist level of training and expertise.
Orthodontics is one area which, understandably, attracts many general dentists. Short courses are available to enable a general dentist to gain a greater level of knowledge and expertise in this area BUT such courses do not make a dentist into a specialist despite the advertising hype which accompanies many of these courses. Nor, it should be added, does passing an examination for fellowship of international colleges of continuing dental education regardless of how grandiose such colleges may appear.
Some short courses claim to provide 'comprehensive' orthodontic education which will allow dentists to offer orthodontics to their patients at a standard of care identical to that of orthodontists. Orthodontists, of course, complete three years full- time study to achieve the level of competence required of a specialist and that follows on from graduating as a general dentist and working for at least two years as a generalist. Graduation as an orthodontist requires achievement of satisfactory performance in a range of rigorous testing in examinations, case treatments and various dissertations.
Reasons that these short training courses are providing for dentists to start offering orthodontics to their patients include:
- the substantial profits that can be made, and
- that orthodontics is becoming more and more popular.
Nowhere in advertising material have I seen advice that the needs of the patient must come first, although I have seen comments on dentists 'building a better relationship with your clients' and giving them 'a smile they'll love for the rest of their lives' and so forth.
It is hard to be critical of the topics which graduates of these short courses will be exposed to. Such topics would form the basis of the curriculum of the three year specialist training course for orthodontists. It should also be noted that some seminars offered during these short courses are intended to provide sufficient education for the dentist to undertake the necessary orthodontic treatment for a patient who would undergo orthognathic surgery as part of the treatment plan. In itself, there is nothing wrong with such an ambitious education programme but it should be selfevident that it can't be properly taught and learnt in such short timeframes. Whilst such training may produce a practitioner who obtains results 'identical to that of orthodontists' it may also lead to cases ending in the indemnity payment arena.
I recall a case which was settled out of court involving a general practitioner who had undertaken a short course in orthodontics and therefore believed they had extensive experience in fixed appliance orthodontics. The patient had a missing 36 plus a Class II malocclusion with a Division 1 tendency with moderately deep overbite. Minimal lower crowding was present and the lower incisors were slightly proclined but stable. The practitioner, together with a computer software program, diagnosed this patient as dolicofacial and the patient was provided with a very impressive brochure, setting out the diagnosis and treatment approach. The treatment plan offered was to extract two upper premolars and the 46 to balance the missing 36, upper and lower fixed appliances with nitinol coil springs to bring the lower 7s and 8s mesially and to retract the upper anterior segments to a Class I alignment.
Lower anterior brackets with labial crown torque were employed to provide lower anchorage whilst protracting the 7s and 8s. No other anchorage considerations were considered for either upper or lower arches and use of Class II elastics was proscribed, probably because of the dolicofacial diagnosis which, if correct, could mean that elastics would open the bite excessively. [Note - subsequent assessment of the patient's lateral cephalometric radiograph showed that the patient was, in fact, brachyfacial; a point readily agreed to by the general dentist who did not seem aware of how this facial pattern would make the treatment plan more difficult to achieve without major anchorage provision.]
After some 12 months of treatment the patient began to get a bit concerned as they felt that the alignment of their teeth was worsening with increased overjet and about half closure of the lower 6 extraction spaces. The patient sought a second opinion from another general dentist who advised them that the treatment plan was all wrong and that they should consider implants where the lower 6s had been extracted.
The patient was referred to an orthodontist who advised them to obtain up-to date radiographs but indicated from his clinical examination that implants for the re-aligned lower extraction places were a possibility or mandibular advancement surgery once spaces were closed. He was concerned that the mechanics being used were causing retraction of the lower anterior teeth thereby contributing to the increasing overjet. The patient then consulted a friend who knew of another general dentist who also offered orthodontic treatment and so a further consultation ensued with that dentist. The suggestion from this dentist was to remove all appliances, allow the occlusion to 'settle' and then place fixed appliances, optimise the spaces for the lower 6s, place implants and finish to a Class I alignment. The fee was of the order of $13,000 made up of $6,000 for the orthodontics and $7,000 for the implants. This dentist also advised the patient to complain to the Health Services Commissioner which they duly did.
Interestingly, the fee charged by the initial dentist and the quoted fee by the orthodontist were both less than for this general dentist.
The patient was persuaded to seek a further orthodontic assessment from another senior orthodontist together with radiographs, which they did. The final outcome was that the treatment plan would involve closing of spaces in both arches followed by mandibular advancement surgery. Settlement involved the initial dentist refunding all of their fees plus payment of all the fees incurred with surgery including anaesthetist and hospital charges.
What are the lessons in this case? Primarily, the dentist was insufficiently equipped to treat this case. The dentist's lack of awareness of the influence of different facial types on mechanics and inappropriate and inadequate anchorage provision meant that the treatment was not going to achieve its objectives.
Could this case be put down to bad luck or should the dentist have known better than to attempt treatment which was beyond their capabilities? The alarming reality is that the dentist did not know their limitations and believed the mantra put out by the short course providers that, as a graduate of their course they were as capable as any specialist. Hopefully, this misadventure will alert this dentist to the need for more caution, greater knowledge as well as greater care in future diagnosis and treatment planning. The unfortunate part is that, if the dentist had adhered to the dictum 'first, do no harm' and referred the patient to an experienced orthodontist in the first place, the patient would not have had to undergo orthognathic surgery to achieve a good occlusion.
General dentists with a genuine interest in orthodontics should be able to obtain the necessary education to provide competent orthodontic treatment including fixed appliance treatment in simple and straightforward cases. The important words here are simple and straightforward. Unfortunately, no two cases are the same despite the cookbook approach of some short courses. Cases which appear simple at first glance can easily prove to be very complex requiring extensive knowledge and skill to be able to treat properly. The most useful advice to give such general dentists who want to provide orthodontic treatment to certain of their patients is for them to approach experienced orthodontists in their area and ask for advice before and during treatment to ensure that firstly, their treatment plan is appropriate and second, that they really do know how to deliver that treatment plan effectively in the best interests of the patient and not in the interests of optimum profit.
Key learnings:
- Referral should always be an option when presented with a patient who requires a greater level of competence, knowledge and skill than the dentist is able to provide.
- General dentists with a genuine interest in orthodontics should be able to obtain the necessary education to provide competent orthodontic treatment including fixed appliance treatment in simple and straightforward cases. The important words here are simple and straightforward.
- Cases which appear simple at first glance can easily prove to be very complex requiring extensive knowledge and skill to be able to treat properly.
- In this case, if the dentist had adhered to the dictum 'first do no harm' and referred the patient to an experienced orthodontist in the first place, the patient would not have had to undergo orthognathic surgery to achieve a good occlusion.
- Dentists should be cautious when providing treatment in areas of dentistry which require a greater level of competence, knowledge and skill than general dentistry. Whilst short course training may equip a practitioner with the skills to undergo such treatments, it has been demonstrated that sometimes this is more likely to lead to cases ending in the indemnity payment arena.
David Houghton
Community Relations Officer and Professional Consultant, Australian Dental Association Victoria Branch
