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.”
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.”
System Alignment
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.”
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.”
