Team Dentistry v. One-Man Show
There is a troubling trend backward in dentistry today driven by company-owned practices, localized competition in and around popular cities and even advances in technology that may prove to be very detrimental to specialized dental care in the United States, especially in larger urban areas and cities. To better understand this trend and the problems it brings we must review the past going back to the beginning of the Specialties of Dentistry. I will focus on Orthodontics however this is equally a problem with Oral Surgery, Periodontics (gum surgery), Prosthodontics and even Pedodontics.
The modern practice of dentistry began as an all-encompassing field which included oral health, oral hygiene, restorative dentistry, surgery and replacement of missing teeth. Even as recently as the 1930’s, it was commonly accepted that teeth would be lost throughout life until partials or full dentures were used to replace these missing teeth. Gradually medicine improved, Fluoride was introduced into public water drastically reducing decay and materials were developed that could withstand the oral environment so that restorations/fillings could save teeth much longer. Oral health became better understood (via microbiology and immunology) to the point that supporting tissues could be maintained better leaving solid and healthy gums longer and allowing successful treatment and resolution of inflamed, infected and diseased tissues. This eventually led to dentists that could focus on more specific problems, problems that were less common and/or more severe or issues that could not be treated as well in a General Dental practice. These dentists learned how to treat the more severe oral maladies as they developed specialized procedures and equipment based on research and experience, and they ultimately began teaching their methods and passing on their experience to individuals through preceptorships as mentors.
Eventually several “specialties” emerged, some for gum treatment/surgery/grafts, some for removal of 3rd molars and difficult extractions, some for performing root canals and others for mastering very difficult restorative cases/full mouth reconstruction.
In this evolution and progression in dentistry, there was a growing group of “specialists” that were mastering movement of teeth to correct severe rotations (which held more plaque and were ultimately lost at a higher rate than straighter teeth). These early specialists also saw the obvious improvements in esthetics by having straight teeth. Unfortunately it was inherently difficult to move teeth; appliances had to be made custom for each patient, practitioners had to learn the physics of moving teeth in all three dimensions while maintaining the position of other teeth, wires and springs had to be made from different metals to conform to the dental arches and slowly put pressure in teeth, and spaces had to be created to correct more severe crowding or mask skeletal discrepancies. In short, the practice of Orthodontics took specialized knowledge, education, equipment and skills not learned by General Dentists. This is the reason that the very first organized Specialty in Dentistry was established for the practice of Orthodontics and Dentofacial Orthopedics in 1929.
Other fields followed and soon there were Specialties for Oral and Maxillofacial Surgery, Endodontics (root canal dentist), Periodontics (gum surgeon), Prosthodontics (reconstructive dentist) and Pedodontics (children dentist). Over the last 60 years, these fields dropped the preceptorships and required multiple years of additional accredited specialty school after dental school.
So where is the problem you ask? How could we actually go backward? The answer is that we have learned how to prevent many of the issues General Dentists traditionally treated in the past: Fluoride was introduced (first in Grand Rapids, Michigan) in 1945 which reduced the amount of decay in the population, Orthodontically straightened teeth were being kept longer and oral diseases could be cured/controlled/maintained while restorations could be placed in better position than ever before. With this public enlightenment, General Dentists in competitive areas did not have the same volume of restorative work to pay their bills with simple fillings and cleanings. And although more expensive cosmetic restorations and elective procedures fill some of the gap currently, many dentists have also started performing traditionally viewed specialty procedures after taking simple weekend courses on the basics to fill their schedules. I would liken it to never taking the class but working exclusively off the Cliff notes.
So, are all General Dentists that take teeth out, see children or provide limited orthodontics bad for the patient? Of course not; specialists rely on their General Dentist partners to care for the easier cases or to provide the simple straight-forward procedures.
“specialists rely on their General Dentist partners to care of the easier cases or the simple straight-forward procedures”
Can kids be treated at a General Dental office? Of course if the child is not apprehensive and the dentist is trained in pediatric procedures (also there may be no children’s dentist nearby) however children’s teeth are treated differently and a Pedodontist office is geared specifically toward the comfort of children; Pedodontists have advanced training in primary dentitions, early development, children’s sedation and child psychology so many kids are more comfortable at the children’s dentist office and they may receive better care overall.
Same with removal of teeth; not every extraction requires an Oral Surgeon but where a General Dentist may struggle to remove a difficult tooth (wisdom teeth/impactions/fractured roots) an Oral Surgeon will likely remove the offending tooth/teeth under sedation in a more timely manner and with less damage to the surrounding tissues making healing easier.
“Although [General Dentists] may claim years of experience [referring to providing Orthodontics], it very well could be (and likely is to some degree) just repetition of the same mistakes over and over.”
The real problem is that General Dentists not specialty trained don’t actually realize when a case may be difficult (in most cases they don’t have the same radiographic imaging or records to even diagnose a case); it is the lack of experience and lack of specialized education that leads to many misdiagnoses and poor outcomes/relapse of teeth/compromised healing/bad experiences. It is simply hard to know when there is a potential problem if you do not have the education, the proper records or sufficient experience to identify the problem and General Dentists do not keep up with specific literature and research for individual specialties such as Orthodontics. Many times, the General Dentist may leave screening to the even less trained Hygienist and early problems never get referred to specialists until it is too late. These General Dentists that try to offer every procedure (especially Orthodontics) rarely refer a case out to any specialist which can lead to significant future problems due to poorly timed treatment, missed malocclusions, unidentified growth dysplasia and even loss of teeth from a lack of understanding of procedures/ physiology/ physics. Although they may claim years of experience in some specialized procedure such as Orthodontics, it very well could be (and likely is to some degree) just repetition of the same mistakes over and over. There is ultimately a good reason specialty training takes two to three years additional after dental school and after treating up to 100 cases under the guidance of Board Certified Orthodontists from start to finish.
“It is simply hard to know when there is a potential problem if you do not have the education or experience to identify the problem.”
So if you notice your dentist is trying to offer every treatment under the sun with no discussion of referral for things like orthodontics, removal of impacted teeth/wisdom teeth, or referral of children to a local children’s dentist then you may remember the old adage, “Jack of all trades, Master of none” and consider checking around for a General Dentist that works with a team of specialists and is going to send you to the best doctor when you need specialized treatment instead of providing his/her own limited care based on limited knowledge and even more limited self-guided “experience”.
So if you notice your dentist is trying to offer every treatment under the sun … you may remember the old adage, “Jack of all trades, Master of none”
Don’t wait for a referral from a dentist for something that they are not trained to identify as an early problem. The American Association of Orthodontists and the American Dental Association recommend every child see an accredited Orthodontist by age 7. Every child can be seen directly with a Pedodontist or Orthodontist without referral from a General Dentist. Care of your children is best direct with those that are the experts; only they will be able to identify problems early.
The American Association of Orthodontists and the American Dental Association recommend every child see an accredited Orthodontist by age 7
Look for a General Dentist that works with a team of specialists that in your best interests, not the interests of trying to collect for every procedure you may need; after all, whose interests are being served if you and your family are not directed to the best option for specialized treatment? This may take a little asking around in cities but the search will be well worth it in the end and the results will last a lifetime!
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001. He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics. Dr. Waters and his wife of 20 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin. You can learn more about Dr. Waters at BracesAustin.com.