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
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
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
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
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’
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
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 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
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
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15. Kevin O’Brien. “Should General Dentists Provide Orthodontic Treatment?”
Available at kevinobrienorthoblog.com.
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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:
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.
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: email@example.com