The Disappearance of Excellence: One Orthodontist’s Opinion.

A Guest Blog Post by Prof. Arnold J. Malerman  DDS;  Clinical Professor of Orthodontics at the University of Pennsylvania.

“The difference between a good Orthodontist and a great Orthodontist is attention to detail.” ~ Brainerd F. Swain, DDS

Today marks the start of an interesting series of Guest Blog Posts by prominent figures and authorities in the orthodontic community from around the world, who have graciously agreed to share their personal viewpoints regarding some important issues related to the orthodontic profession, here on The Orthodontic Notefile. The aim of these guest blog posts is to raise awareness and start a wider discussion of varying points of view regarding many debatable issues facing the orthodontic profession today, therefore your participation in the discussion in the comments section below is highly encouraged and welcome.

In the first of these guest posts, Professor Arnold J. Malerman; Clinical Professor of Orthodontics at the University of Pennsylvania, shares with us his personal opinion regarding what he believes to be three major issues facing orthodontists in the 21st century.

 I’ll leave you now to read what Prof. Malerman has to say in this guest post…

Brainerd F. Swain, DDS, one of my mentors, was wont to say that “The difference between a good Orthodontist and a great Orthodontist is attention to detail.”  Dr. Swain was, by every measure, a great Orthodontist.  Over the last 5 decades improvements in Orthodontic Appliances, coupled with improved dento-facial growth and development understanding, has resulted in shorter treatment times, a significant reduction in permanent tooth extractions, and dramatically optimized Orthodontic treatment results.

In the past 15 years, however, 3 factors have arisen that conspire to adversely affect the Orthodontic Community’s drive for excellence.  The first of these is the ubiquitous intrusion of Dental Insurance into the Orthodontic Health Care Delivery System.  Every procedure has a code, and each Insurance Company attaches a benefit payable amount to each code.  Nowhere is provision made for an adjustment based on case complexity.  This creates the mind set among our patients that health care, like a can of soup at the supermarket, is a commodity, not a professional service.  It denigrates how the public perceives both the art and science of health care delivery.  Participation in an insurance plan usually means discounting the practitioners fee, and insurance benefit schedules do not keep pace with real world expenditures.  To accommodate these fiscal problems, practices have to become more efficient, putting pressure on the practitioner to do it cheaper, to be more expedient, to see more patients in less time, and that can adversely impact quality of care.  Do we want acceptable, or would we prefer excellence?

The second factor is the resurgence of removable, rather than fixed, appliance therapy.  Removable and semi-removable appliances are less efficient than clear aligners, and clear aligners are less efficient than fixed appliances.  Considerable research has shown that in the hands of fully qualified Orthodontic Specialists, patients treated with fixed appliances had post treatment results that more closely approached ABO Standards than patients treated with any other type of appliance.  Aligner results may be acceptable, and there is a place for them in the Orthodontic lexicon, but the patient should be made aware of the differences.  Although aligner results have improved over the last 5 years in particular, braces are still the gold standard.  Aligners and braces are not equivalent appliances, and end-of-treatment results are noticeably different.  And as aligners provide considerable improvement, but do not achieve optimum results, the retention phase of treatment is even more challenging than it is with the braces-treated patient.  Do we want acceptable, or would we prefer excellence?

The third, and most distressing, factor is the misguided belief that taking a 2 day clear aligner course at the local airport motel is the equivalent of a 5,000+ hour specialty residency.  Or that completing the 500 hour AGD recognition program, divided among all the specialty areas of Dentistry, is the equivalent of a concentrated 5,000+ hour post-doctoral residency in just one specialty area,  Or that slipping an occasional Orthodontic patient into the schedule between the crown prep and the periodic examination provides the same level of experience as doing nothing but Orthodontics all day, every day.  Learning how to order orthodontic appliances from a lab is not the same as learning how to properly diagnose, treatment plan, and then actually treat the Orthodontic Patient.  Research has shown that while GPs who do Orthodontics on occasion achieve excellent results, the overall level of care in an Orthodontic specialty practice is higher than in a GP practice, with treatment completed in less time, with better post-treatment stability, and generally at a lower cost.  The Orthodontist is trained to recognize normal verses aberrant growth, the arch length compromised case, the dental verses the extended skeletal case, the case that would benefit from aligner therapy verses the case beyond aligner therapy capabilities, and so much more.  Orthodontists do braces, or aligners, or any other Orthodontic Treatment Modality, better than non-Orthodontists.  Do we want acceptable, or would we prefer excellence?

Do we want acceptable, or would we prefer excellence?

As Dentist’s, GP or Specialist, shouldn’t our first consideration be the quality of care we provide for our patients?  As an Orthodontic Specialist I don’t do post-Orthodontic bleaching because I know my GP Colleagues can do it faster, better, and less expensively.  If an Orthodontist can do malocclusion correction faster, better, and less expensively than a GP, isn’t the patient better served by being referred to an Orthodontist?  If the patient is not referred, who benefits?  When did mediocre become acceptable, especially when excellence may be available just around the corner?  I think it is time that we, members of the Dental Profession, return to Barney Swain’s guidelines.

Arnold J. Malerman, DDS, an honors graduate of the Temple University School of Dentistry, took his Orthodontic training at the University of Pennsylvania.  He has been in the private practice of Orthodontics just North of Philadelphia for 44 years, and is a Clinical Professor of Orthodontics at the University of Pennsylvania. His complete CV can be found here.

Editor’s Note:  What is your own point of view regarding these issues?  Please share your opinion with us in the comments sections below.