Houston general practitioner Juan Echeverri, the current president of the AOS, concurs. He says he began to get involved with orthodontics around 2005, but he only acquired his own cone-beam machine about 4 years ago. Now he says he tells patients, “It’s like having a very detailed GPS that tells me how to get from Point A to Point B without damaging any other structures. We can go behind those gums and see what’s there without having to open the patient up. It’s like doing the procedure before you do it.” Echeverri urges any GP who can afford to buy a cone beam to do so. “We use it all the time to diagnose to help in the diagnosis of multiple conditions, situations, and possible pathological issues.”
Chapman says the AOS foundational program does not include any instruction in aligner therapy. He says his organization has nothing against aligners, but they cannot solve all orthodontic problems, and their use is already being taught well by the aligner manufacturers. Chapman acknowledges that, “the introduction of aligner therapy to the general practitioner probably did more than anything else to stimulate the interest.” That’s a good thing, he believes. His organization takes the stance that every general and pediatric dentist should be doing “whatever form of orthodontics they’re comfortable with.” Many of the GPs who enroll in the AOS program “want to increase their services. They see the problems with crowding. They see the malocclusions. And they know they’re referring this. A lot of times they need more revenue in their practice, and they see orthodontics as an opportunity. Also a lot of dentists realize that once they’ve built up a patient base, the patients would prefer not to be referred.”
While the development of modern aligners may have galvanized general dentists to get involved with orthodontics, the early relationship between Align Technology and general dentists was tumultuous. Founded by Stanford business students Zia Chishti and Kelsey Wirth in the late 1990s, Align initially sold its clear plastic Invisalign System aligners exclusively to orthodontists. Early in 2001, however, the company was named in a class-action lawsuit filed on behalf of all licensed US dentists (excluding orthodontists). It alleged that Align was violating US antitrust laws by selling only to the specialists. That summer Align settled the legal action by agreeing to broaden distribution to GPs and to train and certify 5,000 GPs annually for 4 years.
In 2006 ClearCorrect, based in Round Rock, Texas, began offering an alternative choice for clear aligner therapy. According to Ken Fischer, DDS, the orthodontic specialist who serves as ClearCorrect’s clinical advisor, the end results are the same. He also says that Align and ClearCorrect each offer some distinctive benefits. For example, all of ClearCorrect’s customer support and manufacturing takes place in the United States. Fischer further explained that ClearCorrect is now offering an online presentation of each patient’s setup that can be sent to the patient electronically. “So the patient can bring it up on their smartphone and actually see what their treatment is going to be like.”
The Age-Old Question: Treat, or Refer?
Fischer argues that, “general dentists, because of the nature of their title and their training, should perform any service for their patients that they are capable of providing by virtue of their education and experience.” He says the key “really comes down to the general dentist’s integrity in referring those cases to a specialist that they are not educationally qualified to treat.”
While also supportive of general dentists doing orthodontics, Lou Shuman, DMD, CAGS, stresses the importance of proper training and case selection. “I created the clinical education curriculum for the GP, and I lectured to GPs for years,” says Shuman, an orthodontist who worked as clinical vice president at Align for 7 years. “Although Align has created unbelievable technology and software to help guide you, it’s not just plug-and-play. The more complex the case, the more you need to know.” Shuman’s experience in training the GP community has made him keenly aware of the pitfalls inherent in tackling the wrong case.
“You don’t just hand clear aligners to a patient, send them home, and have everything work magically,” Shuman says. Using the system well “requires clinical understanding, education, and experience, especially if you’re going to do more sophisticated cases. You need to look at the full-blown dentition. Sometimes what seems like fixing a small issue could involve a much larger underlying orthodontic problem,” he says. “The orthodontic community wants to know that every patient is being evaluated from molar to molar. When general dentists are trained to evaluate cases this way, they can select the proper ones to treat, versus those to refer, and everyone wins.”
Clatt wholeheartedly agrees. “It is imperative that each clinician establish where they truly are in the continuum of ‘adding orthodontics’ to their practice,” he says. “Over the last decade, many GPs have been trained and tried, but it is a minority who have truly integrated ortho into their practice as a full-service offering. That leaves the balance somewhere in between.” He stresses that ensuring clinical success with orthodontic treatment begins with proper patient case selection. Technology and material science are enabling factors in the space today, but balancing that against education, experience, and general comfort in treating orthodontic cases will be what defines clinical success. “From anterior ‘social six’ misalignment to full, comprehensive orthodontics, establishing your own parameters will likely define where you truly are in the ortho continuum,” Clatt explains. “There’s an old saying of crawl before you walk, walk before you run…. Having a strategic relationship with an orthodontist who is willing to support the GP in return for the patient referrals that are outside the GP’s treatment parameters never hurts, either. When adding orthodontics to a general practice, from a service offering perspective, increasing patient education to focus on the movement of the teeth is important. Providing an offering that is esthetically pleasing will be key. Embracing technological advancements in digital imaging and treatment planning will enable the practice to offer patients orthodontic treatments more efficiently.”
DeWayne McCamish, DDS, MS, who has been an orthodontist for 44 years and has a private practice in Chattanooga, Tennessee, is the current president of the AAO. He says the organization’s position has been and continues to be that orthodontists are the most qualified individuals to provide orthodontic treatment, and bad things can and do happen when non-orthodontists enter that realm. While he concedes that non-specialists can treat some minor orthodontic problems, he says for all medical and dental care providers, “Our oath of allegiance and our ethics dictate that we provide patients with the very best treatment possible.” The potential for increasing one’s practice revenue by offering additional services should not be a reason for providing patients with care that’s not the very best possible. “One way to assess that,” he advises, “is to ask, ‘Is this something I would do for my own child?’” Why should GPs start doing orthodontics, he asks, “when you have specialists available who have had 2 to 3 years more training in how to create beautiful healthy smiles, who when they start know the endpoint, and if any problems develop along the way, they have the tools in their toolbox to help them deal with the problems?”
McCamish acknowledges that some patients may be satisfied with the orthodontic treatment they receive from their general dentist. “But they don’t come to me. I see the ones who are unhappy.” Such patients “lose all respect for their practitioner, and they change dentists. Dentists can go in and align teeth, but alignment doesn’t necessarily make them fit together right. To go in and align teeth without paying attention to the occlusion is not the way I’d want to see a member of my family treated.”
Ben Miraglia, DDS, could not agree more about the critical importance of proper occlusion. “Our teeth were all designed with shape and size and anatomy—little points and little grooves—on purpose. When they come together perfectly, they actually protect each other and their surroundings, while destroying the food. But if they’re in the wrong place—crowded or overlapping they come together without the right bite—teeth can put force on each other in the wrong directions, and that breaks down the enamel. It can destroy the gum tissue and cause recession. You can get abfractions. You can have bone loss. You can have mobility and even break teeth.”