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Second Opinion: Delusions of Grandeur by Drs. Adith Venugopal, S. Jay Bowman and Nikhilesh R. Vaid

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Categories: Orthodontics;
Second Opinion: Delusions of Grandeur

Who should rightfully practice the art and science of orthodontics?

by Drs. Adith Venugopal, S. Jay Bowman and Nikhilesh R. Vaid

Grandeur (n.): Splendor and impressiveness, especially of appearance or style.

This word has recently gained traction in the minds of certain general practitioners who practice orthodontics. Is it appropriate for general dentists to offer orthodontics? Should orthodontics be practiced by anyone other than an orthodontist? We’re getting these inquiries more frequently than ever; why is this issue now being revisited with more intensity?

A dentist in good standing is typically approved by most national dental councils and boards to provide dental care in all disciplines. In fact, general practitioners can perform any treatment for which they are qualified. Calling oneself a “specialist,” on the other hand, may be subject to local dental specialty laws that require dentists to complete additional full-time postgraduate training.

As orthodontists, we understand the years of dedication it takes to get into a competitive residency program, from graduating near the top of the class to being accepted. Then there are the two or three years of rigorous training required to call oneself an orthodontist.1,2 It seems reasonable to think that an orthodontist who has received such training is more competent at delivering orthodontic treatment than someone who has not.3

While general practitioners doing orthodontics is not a novel concept, it could be heavily affected by the extent of orthodontic training provided during their undergraduate education. While dental schools’ curricula vary greatly by country, they must ensure new graduates are at least capable of diagnosing basic orthodontic problems. More critically, they must be able to recognize when a patient should be sent to a specialist.4,5

The current national average of 110 hours of predoctoral orthodontics teaching in dental schools in the United States6 demonstrates that dental school programs do not prepare students to deliver complete orthodontic treatment. Regardless, any licensed practitioner in any state is legally permitted to provide any type of orthodontic treatment.

Delusions
Consider the case of an orthodontist or general dentist who decides to offer clear aligners to patients. To offer a specific product, they must first become certified providers, often through a weekend training seminar. They are taught about the product, how to submit records, operate the software, and how to market and dispense the aligners. This training is supposed to also help them analyze the patient’s progress and spot any issues that may arise when the teeth may not move as intended.7,8 Aligners have shown improvements as a treatment modality and are still evolving as a scientifically validated modality. Just as a modality evolves, so should practitioners!9

Are general practitioners sufficiently trained through this certification to correct any iatrogenic consequences that may occur when treating patients with these products?

The surge of direct-to-consumer (DTC) dentistry is another phenomenon that is commoditizing orthodontic care. The consumer is exposed to the concept that no professional is required to stand between them and the delivery of a box of plastic trays.10 However, when you approach commoditization, any profession will try to ideate on measures that can, because as Peter Drucker said, “In a commodity market, you can only be as good as your dumbest competitor!”11

Such notions result in more practitioners and the public suffering from cognitive optimistic bias and the overconfidence effect from the illusion of control.12 It appears all that’s required is to deliver aligners along with suitable instructions and a pious hope that the teeth respond just as they do in the computer-generated simulations.13

In this instance, is the manufacturer of the aligner company to blame for downplaying the risks or failing to mention a sound orthodontic background and training is required before taking the certification course? Or is it the dentist’s fault for pursuing such certifications despite having very limited orthodontic knowledge?

How do we measure the competence of a dentist or orthodontist delivering orthodontic treatment, regardless of their good intentions? Is it true that a specialty certificate ensures perfect results every time? Even specialists don’t always deliver excellent care. We all go through the stages of the Dunning-Kruger curve to acquire a certain degree of proficiency.14 However, it seems reasonable that specialists have considerably lower odds of making the wrong decision than an inexperienced dentist with no or little orthodontic expertise. With that in mind, ask yourself, what is the downside of a bad decision, especially when your patient is in the crosshairs?

While some of the results produced by insufficiently trained general practitioners are appalling, some favorable results are also generated. It’s a matter of reproducibility, then. Are the odds favorable when gambling on your patients’ results?

Orthodontics is a dynamic discipline of dentistry where no exact consensus or one-size-fits-all modus operandi exists; rather, knowledge evolves as evidence becomes available. We are gatherers of options and alternatives from scholarly books, seminars and filtered experiences. The more options we are exposed to, the more experience we gain, and the more solutions we accumulate in our armamentarium.3

Grandeur
This brings us to the concept of grandeur. When general practitioners decide to add orthodontics to their menu of services, treating only a few cases and not intending to become specialists, their treatment envelope is usually somewhat limited.

In several countries, a slew of weekend short courses or continuing dentistry education programs claim to offer “specialization.” Unfortunately, these courses leave, in short order, the attendees with a false sense of confidence with promises of large profits.15 After such short-term orthodontic courses, some practitioners feel invincible and misjudge, often overestimating their competence.

Their cognitive bias of illusory superiority results from training that claims to teach them everything there is to know about orthodontics. When they start treating a few basic cases and observe positive results, a false sense of proficiency is generated. This good fortune adds to their conceits of grandeur, making them feel omnipotent in the field of orthodontics without ever enrolling in a residency program. That is, until they run into a problem they didn’t know existed.

Continuing education enables practitioners to initiate clinical treatment when they are ready. In contrast, students in a graduate program receive official, comprehensive and organized training in which they are exposed to all parts of their discipline—rather than just a cookbook approach—and are tested and evaluated. The dilemma of not knowing what one doesn’t know arises from self-selection of “schooling.” Probably the vast majority of well-intentioned general practitioners—those who have invested time and money in continuing education and who perform orthodontic treatment with the best interests of their patients at heart—are simply oblivious of their diagnostic and technical deficiencies.

Educators versus instructors
An educator is defined as “a person who imparts intellectual, moral and social instructions,” while an instructor is defined as “one who teaches; especially: one whose occupation is to instruct.” There is a distinct distinction between these two words, implying there is a distinct difference between the people to whom we apply them.16

Instructors, during weekend courses, teach GPs only the fundamentals and extend a one-size- fits-all strategy that may serve only a small subset of patients. Educators, on the other hand, develop in students a deep grasp of concepts they will take with them for the rest of their life. This type of education can be obtained only through orthodontic residency and prolonged mentorship.

Although we believe there to be a clear distinction between the two, there is still a lot of room for debate. Additionally, it is inappropriate to falsely accuse our colleagues unless their behavior is blatantly against the ideals of our specialty and only motivated by profit.

Let us now attempt to create a distinction between what is right and when things begin to go wrong. We have delivered numerous keynote addresses and workshops at conferences hosted by domestic and international orthodontic organizations, as well as at gatherings hosted by for-profit organizations that have paid us for our time and expertise. The audiences at several of these events included orthodontists as well as general practitioners or a mix of different specializations the speakers may or may not have been aware of. Does speaking at such events, or explaining to general practitioners or mixed audiences, what an orthodontist is capable of treating and how far we go to take care of our patients make us complicit with opportunistic course providers and organizers who would teach nonspecialists the “how to treat” rather than the “what to look out for/when to refer”? The distinction is obvious.

It is now more important than ever for orthodontists’ websites, and the sites of orthodontic product manufacturers and professional organizations, to arm themselves with biologically sound, scientifically rational and evidence-based facts to combat misinformation, false claims and propaganda from vested interests. Regional orthodontic associations must provide appropriate information about certified orthodontists and evidencebased treatment procedures to ensure that unwary patients follow the correct pathways to a healthy orthodontic rehabilitation. To maintain the best possible standards of patient care, routine clinical audits and appraisals must be conducted on a regular basis. This must apply not only to general practitioners but also to specialists.

Patients are trusting and easily misled to believe that a practitioner is knowledgeable in a field where they have had little training, testing or experience. Orthodontists, as a specialty, should stand up to such iniquitous schemes, and maybe, just maybe, we will be able to save unsuspecting patients who seek out reel orthodontists instead of real ones.17,18

References
1. Thom AR, Graber LW, Maplethorp FA, Vaid NR. “World Federation of Orthodontists: An Orthodontic Umbrella Organization Coordinating Activities and Pooling Resources.” J World Fed Orthod. 2020 Oct; 9(3S):S3–S14.
2. Pangrazio-Kulbersh V, Machado-Cruz R, Liou EJ, Vaid NR, Graber LW. “Orthodontic Board Certifications: Global Perspectives, Challenges, and Evolving Trends.” Journal of the World Federation of Orthodontists, 2022, ISSN 2212-4438.
3. Venugopal A, Vaid N, Bowman SJ. “The Quagmire of Collegiality vs. Competitiveness.” Am J Orthod Dentofacial Orthop. 2021 May; 159(5):553–555.
4. Vaid NR, Ganatra J, Fadia D, Vandekar M. “Undergraduate Orthodontic Education: Is There a Slip Between the Cup and the Lip?” APOS Trends Orthod 2015; 5:91–3.
5. Will LA. “The History of Orthodontic Education: A Century of Development and Debate.” Am J Orthod Dentofacial Orthop. 2015 Dec; 148(6):901–13.
6. McDuffie MW, Kalpins RI. “Predoctoral Orthodontic Instruction and Practice of Recent Graduates in Florida.” J Dent Educ. 1985 May; 49(5):324–6.
7. Gandedkar NH, Vaid NR, Darendeliler MA, Premjani P, Ferguson DJ. “The Last Decade in Orthodontics: A Scoping Review of the Hits, Misses and the Near-Misses!” Semin in Orthod. Vol. 2019; 25(4):339–55.
8. Vaid N, Doshi V, Vandekar M. “What’s ‘Trend’ing in Orthodontic Literature?” APOS Trends Orthod 2016; 6:1–4.
9. Haouili N, Kravitz ND, Vaid NR, Ferguson DJ, Makki L. “Has Invisalign improved? A Prospective Follow-Up Study on the Efficacy of Tooth Movement with Invisalign.” Am J Orthod Dentofacial Orthop. 2020 Sep; 158(3):420–425.
10. Venugopal A, Bowman S J, Marya A, Subramanian AK, Vaid NR, Ludwig B. “The World Wide Web of Orthodontics: A Comprehensive Narrative on Teledentistry Pertaining to the Orthodontics of the 21st Century.” J Orthodont Sci 2022; 11:1.
11. Vaid NR. “Commoditizing Orthodontics: ‘Being As Good As Your Dumbest Competitor?’ ” APOS Trends Orthod 2016; 6:121–2.
12. Kahneman, D. “Thinking: Fast and Slow.” Penguin Books, New York, NY. 2011.
13. Vaid NR. “The Emperor’s New Clothes!” APOS Trends Orthod 2019; 9(1):1–3.
14. Hirschhaut M, Flores-Mir C. “Orthodontic Learning Curve: A Journey We All Make.” Am J Orthod Dentofacial Orthoped 2021; 159:413–4.
15. Kevin O’Brien. “Should General Dentists Provide Orthodontic Treatment?” Available at kevinobrienorthoblog.com.
16. “Educator vs. Instructor: What’s the Difference?” Available at wikidiff.com.
17. Venugopal A, Jay Bowman S, Marya A. “The Webinar Storm.” Br Dent J. 2021 Sep; 231(6):316.
18. Kurian N, Cherian JM, Varghese VS, Sharma P, Varghese MG, Varghese IA. “Real Dentistry Amidst the Reels.” Br Dent J. 2021 Aug; 231(4):206–207.

Author Bio
Dr. Adith Venugopal Dr. Adith Venugopal is an associate professor of orthodontics at the University of Puthisastra, Phnom Penh, Cambodia, and an adjunct professor of orthodontics at Saveetha Dental College and Hospitals in Chennai, India. He also has a private practice at Pachem Dental Clinic in Phnom Penh. Venugopal has published several scientific studies and clinical reports in international peer-reviewed scientific journals, and has been the keynote speaker at many international orthodontic congresses. Email: avgorthodontics@gmail.com



Dr. S. Jay Bowman Dr. S. Jay Bowman is in private practice in Kalamazoo, Michigan. He is an adjunct professor in the department of orthodontics at The University of Michigan, a diplomate of the American Board of Orthodontists and a fellow of the International and American College of Dentists, and has served on the examining committee of the Eastern Component of the Angle Society of Orthodontists. Email: info@kalamazooorthodontics.com



Dr. Nikhilesh R. Vaid Dr. Nikhilesh R. Vaid is the current president of the World Federation of Orthodontists. He is a former professor and vice dean of the European University College in Dubai, United Arab Emirates, and has private practices in Dubai and Mumbai. He has lectured in more than 50 countries and for organizations such as the American Association of Orthodontists, the International Orthodontic Congress and more. Email: orthonik@gmail.com


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