Today’s Orthodontics: Creating A Straight Line from GPs to Patients
Clear aligners have opened up a whole new service mix for general practitioners wishing to offer orthodontics to a fast-growing segment of adult patients in their practices with minor orthodontic problems seeking to straighten their teeth without traditional wires and brackets. While training for aligner therapy is available from the manufacturers, there are questions to be considered before a general dentist takes on an orthodontic case. Beyond simple tooth straightening, issues of periodontal health, occlusion, and function of the temporomandibular joint must be considered. This month’s feature delves into some of these issues from both sides of the aisle to give general practitioners an idea of what they need to consider if they’re thinking about adding this modality to their service mix.
On March 10, 2016, a college senior at the New Jersey Institute of Technology reported doing what until recently would have been unthinkable. In a blog post entitled, “Orthoprint, or How I Open-Sourced My Face,” Amos Dudley described how he had straightened his own teeth by 3D-printing a series of plastic aligners for himself on the Stratasys Dimension 1200es machine in his school lab.1 Before-and-after photographs testified to his good esthetic results, and the digital-design student stated that the aligners were “much more comfortable than braces” and “only seemed to put any noticeable pressure on the teeth that I planned to move.” Beating the American Association of Orthodontists (AAO) to the punch, he bluntly warned readers not to try it themselves.
Dudley’s feat did not go unnoticed. Within days, news outlets ranging from Gizmodo to CNN.money and the Huffington Post were touting the accomplishment and the fact that Dudley had spent only $60 for materials. Dudley, in turn, insisted he had no intention of making retainers/aligners for anyone else (“even if you offer money”), elaborating, “I’m a designer, not a manufacturer or an orthodontist.”
If the young digital designer posed no threat to orthodontic specialists, additional startling news about do-it-yourself tooth straightening came on July 28, when Align Technology announced a supply agreement with SmileDirectClub to manufacture “non-Invisalign clear aligners” for SmileDirectClub’s “doctor-directed, at-home program for affordable, simple teeth straightening.” According to Shirley Stacy, Align’s vice president for corporate communications and investor relations, “We are not supplying SmileDirectClub with Invisalign aligners. [Those will continue] to be exclusively available for in-office treatment with Invisalign-trained orthodontists and general dentists.” But starting in October, Align planned to become the exclusive third-party manufacturer for SmileDirectClub aligners, which “include up to 20 stages without attachments or interproximal reduction.” At the time of the agreement announcement, Align president Joe Hogan said in a press release, “When we look at the volume of Invisalign cases, 2% or less fit the SmileDirectClub protocols, which means we expect there to be very little cannibalization of the existing market.” He added, “At-home teeth straightening is only possible with clear aligners, and as the leader in clear aligners, we believe we must participate and help shape this new model.”
Where is the Line in the Sand?
It may be too early to assess the long-term implications of such do-it-yourself and do-it-more-by-yourself-than-was-ever-possible-before tooth straightening. But such developments underscore the relevance of asking whether all general and pediatric dentists should now be offering their patients some kind of orthodontic services—and if so, which ones?
No legal restrictions stand in the way of general dentists providing orthodontic treatment, although they may not call themselves orthodontists. Two to three years of postgraduate training and an advanced degree or a certificate of proficiency are required to identify oneself as an orthodontic specialist. Furthermore, if a dentist is providing orthodontic services, he or she must meet the standard of care being provided by specialists in the community.
Although dentists graduate from dental school with less training in orthodontics than any other specialty, over the past several decades a variety of continuing education opportunities have made it possible for general dentists to acquire some level of orthodontic competence. Progressive Orthodontic Seminars (POS), for example, was founded in 1984 by a general dentist named B. Donald McGann. Frustrated from the limited access to orthodontic classes in dental school, McGann pursued learning about orthodontics both via independent study and through classes at the United States Dental Institute, the oldest American organization offering courses in orthodontics to pediatric and general dentists. He eventually developed a seminar program that today is offered both online and live in more than 40 locations around the world. POS marketing director Crystal Shimabukuro explains that about 7,000 dentists have graduated from the program worldwide, including roughly 150 per year currently in the United States. “By the time students graduate, they can treat or manage about 90% of the orthodontic cases they see in their practice,” she says. “Some decide to stick to the easier ones, but some doctors do pretty much everything.”
The American Orthodontic Society (AOS), another long-established provider of orthodontic education, was started in the mid-1970s by a small group of general practitioners who wanted to learn about orthodontics. Doing so at that time wasn’t easy, says executive director Tom Chapman. “There were few to no orthodontic residencies. Instead, most orthodontists in the 1960s and 1970s got there from a preceptorship, not a residency.” Some were willing to teach GPs about their specialty. Today the Society’s “foundational programs” are held at locations all over the United States. Typically the classes run for five weekends, 2.5 days each weekend, “amounting to about 100 contact hours of CE,” Chapman says.
“We don’t just teach straightening teeth,” he says. “We look at the effect you’re having on the entire facial structure. We recognize that any time you change the positions of teeth in the mouth, it has effects all the way back to the TMJ. It affects the bite. You’ve got to really know what you’re doing.” Although the program is not designed to teach participants how to deal with 100% of what might walk in their doors, “based on the organization’s 40 years of experience dealing with both children and adults who come in with occlusion problems, if general or pediatric dentists go through the comprehensive program and apply the mechanics that we teach them, they will be able to deal with 70% to 75% of the malocclusion problems” that show up in their practices, Chapman says. “We’re not creating orthodontists. We’re creating general dentists who are doing orthodontics. Many of our members do work that is every bit as good as an orthodontist’s. But we tell them the parameters in which they should operate. Beyond that, they should refer to the specialist. There are many cases that a general dentist should not be doing, just as there are endo or perio cases or extractions they shouldn’t be doing. A general dentist has to work within a certain skill set.”
“Over the last decade, general dentists have continued to explore new opportunities to expand their procedural and service offerings to provide more comprehensive care to their patients,” says Bradford H. Clatt, vice president of commercial operations for Dentsply Sirona Orthodontics. “Advances in material science, technology, and education have certainly helped to support the clinician down the path of achieving a multidiscipline-based practice approach. Orthodontics is not unique in this regard, as has been seen with other specialties, such as endodontics and implants. According to the NHANES III survey, more than 50% of adults are candidates for anterior misalignment treatment and the adult population seeking orthodontic treatment is growing at a tremendous rate. General dentists have many cosmetic solutions in the toolbox from which to address these types of cases, so it only makes sense that orthodontics be considered or added as part of any comprehensive treatment plan for a patient.”
Creating the Foundation
The initial costs of entering the orthodontic arena are moderate, according to Chapman, particularly considering that the average orthodontic case runs from $4,500 to $5,500 (depending upon the geographic location). Chapman says tuition for the AOS foundational program is $5,000 (plus any travel expenses). Basic instruments add another $1,500 to $2,000 to what a general dentist needs in order to start offering traditional wire-and-bracket therapy. Chapman says dentists who are serious usually also eventually acquire a cone-beam CT scanner. “We spend a lot of time on diagnosis. And the scanner is the greatest benefit to that.”