Inside Dentistry
November 2016
Volume 12, Issue 11

If Miraglia sounds like an orthodontist, he says he always wanted to be one. “I was turned on to dentistry as a teenager who had braces. My orthodontist collected baseball cards. I collected baseball cards, and I thought, ‘This is the best! I want to do this.’” After high school, Miraglia found a 7-year dental program at SUNY Buffalo, and he gobbled up the curriculum. But going on to postgraduate orthodontic studies would have required studying for 3 more years and incurring more debt than he was comfortable doing. So after a 1-year residency, he practiced general dentistry for the next 10 years. “I loved that. Didn’t look at it as losing. It was all happiness.” Over time, however, Miraglia and his partners became increasingly aware of how many of their patients were failing to accept the orthodontic treatment they were recommending. They had been referring out all that work, and while some adults would say yes, “some wouldn’t. A fair number of adults won’t wear braces. They understood the benefits…but wearing braces was just not a choice for them.”

Miraglia says by around 2004, he had become aware of Invisalign and felt that “we’d better get going on this. It looked like something that could help all those patients get a better result.” He took a beginning course and all his youthful passion for orthodontics came flooding back. “Basically, I took it to the nth degree. I wanted to learn everything I could.” After about 3 years, he’d become accomplished enough to start teaching. “Now, I teach at the university level. I teach at the residency level.” He also studied wire-and-bracket orthodontics and became particularly passionate about non-extraction orthodontics. “When you’re looking at patients day in and day out for a decade, you start seeing patterns. And one of the patterns I noticed is that adults who had teeth extracted for braces when they were younger tended to have more troubles. So I always wanted to learn about trying to treat patients without taking any teeth out.”

Today at his practice in Westchester County, New York, Miraglia says he devotes 75% of his time to orthodontics and only 25% to general dentistry. His particular niche is treating young children in such a way as to avoid any later need to remove teeth. But he also treats adults using aligners. Because of compliance issues, teens are a mixed bag, he says, with aligners working well for about half of them and braces being a better option for the rest. Miraglia stresses that getting to where he’s at today took years of study. “The skier analogy really applies,” he says. “The green circle is the beginner trail. The blue square is the intermediate trail. And then you have the double black diamond. If you want to ski the double black diamond and it’s your first day on skis, and you’ve had 2 hours with an instructor, that’s not going to go well.”

He says that in the beginning 1-day Invisalign program, “what you’re learning is how to use the system and how to look for the right cases to start with—which are the mildest of mild.” That might mean treating someone who had braces as a teenager but later lost their retainer. “And now they’re in their 20s or 30s, and they’ve had some shifting. Generally, they’re kind of close to where they belong because they’ve had orthodontics before.” It’s a terrible misconception to think a 1-day course can enable one to do much more than treat such easy cases. “If you don’t want to go on, then you only treat what you know, which is very little things. But if you want to go on, we’ve got it. Invisalign is a comprehensive orthodontic technique that can treat a wide range of malocclusions effectively, comfortably, and hygienically. It has more than 300 hours of available continuing education, and we want to teach you more.”

Is Ortho Being Pulled Out of Alignment in the General Practice?

Other general dentists study orthodontics for other reasons. Ian Buckle, BDS, a general dentist based in Liverpool, England, initially referred out all of his patients who needed orthodontic treatment, “but maybe the patient would come back with the teeth not where you expected them to be. Or maybe the orthodontist had different goals for treatment. Often you wouldn’t get what you expected.” He says it was a craving for more control over the results that impelled him to take his first course in using aligner therapy about 12 years ago.

He went on to work with other systems and today approves of the trend of GPs getting involved with orthodontics. “There are a lot of very simple things that we can do in our daily practice. It not only creates another revenue stream for you and allows you to help more patients, but it also enables you to have better conversations with the orthodontist as well, because you have a much better understanding about what they’re able to do and what they can and can’t do.” But Buckle says “once you get past the simpler cases, you’ve got to make a decision: do I really want to get involved and develop an educational pathway that’s going to lead me to an in-depth knowledge about orthodontics? Or do I want to engage with an orthodontist that I can send those more complex cases to?” In his case, he says he wound up going full circle: finding an orthodontist who shares his goals and joined his practice. “As a result,” Buckle says, “I do less of it. I do some Invisalign cases, and obviously I supervise the orthodontic cases as the restorative dentist. But I’m more part of the team now.”

Buckle makes the case that doing simple alignment cases of the sort being done by most GPs is not actually taking business from orthodontists. “It’s almost too simple for them,” he says. Moreover, demand for orthodontic services is growing, with a record number of patients identified in the AAO’s 2014 “Economics of Orthodontics” survey. The share of adult US and Canadian patients has jumped to 27% (a 16% increase over the 2012 figures), and more men are seeking orthodontic treatment too—44% in the most recent survey, versus 30% in past years. Although competition for orthodontists has grown, “In general, orthodontists are doing fine,” says practice-management consultant Roger P. Levin, DDS, founder and CEO of the Levin Group.

Shuman agrees. “Specialists are busier than they’ve ever been, and the reason why is that once the GPs are educated in any of the specialties, they’re smart about the cases they take on. For them, a patient and their family is a lifetime of treatment, whereas for a specialist, it’s one procedure or one treatment. So most GPs are going to take a look and say, ‘This is my comfort zone. This is what I feel comfortable doing,’ and once they’re outside that zone, they’ll refer to the specialist.”

The key, Shuman says, is that because the GPs now have more knowledge of different areas of dentistry, they’re doing more procedures, but they’re also referring out more. He says he saw this in in his own group practice he owned for 10 years where he provided orthodontic services. “I had five full-time hygienists and six GPs,” Shuman explains. “And back in the days when orthodontics was not on the GPs’ radar as much as it is today, patients would go into my practice’s hygiene room and orthodontics would be discussed maybe two out of 10 times.”

With the dawn of the aligner era, “now orthodontics might be looked at in nine out of 10 hygiene appointments… Ultimately, if you have a strong working relationship with your GP, you should get more referrals and be busier than you’ve ever been based on the fact that the GP is now looking at ortho every day. They may be doing more of it than ever before. But at the same time, they should be referring more of it than they ever have, too.”


1. http://amosdudley.com/weblog/Ortho.

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