Orthodontics 1985-90: A panel discussion

Nicholas A. Di Salvo, D.D.S., Ph.D.* New York, N. Y.

M y assignment on this panel is to discuss orthodontic education in the next decade. While to most of us orthodontic education means the traditional postdoctoral program, one must also consider predoctoral education, continuing education, and special programs in orthodontics, since all of these are interrelated.

At the outset, let us realize that prediction is by nature chancy. Those of us who have tried to predict craniofacial growth know this full well. What I propose to do, therefore, is to identify some of the more powerful forces now bearing upon orthodontic education, to review the effect those forces have already had in the recent past, and to speculate on some of the possible consequences for the future.

Even this modest attempt is fraught with substantial possibilities for error because, in today’s world, pressures can change quite rapidly. Relatively inconsequential matters can suddenly loom large, formidable problems can melt away, and new, unthought-of dif- ficulties can be precipitated.

Another hazard in prediction is one’s own personal bias. Two individuals, observing the same factors, can often project to quite different conclusions based upon wishful thinking. This 1 have tried very hard to avoid. Therefore, my analysis does not necessarily reflect what I would like to see happen but, rather, what I believe will occur.

The role of the university

As we all know, orthodontic education in America began in the early part of this century on a preceptorship basis and evolved over the years to a university discipline. It might be useful, therefore, to recall some characteristics of a university.

The functions of a university are usually identified as education, research, and service. While it is difficult to isolate any one of these functions, or to assign priorities, I believe that education (that is, the transmission of existing knowledge) must be considered a first priority. However, any university worthy of the name must place equal importance upon the gathering of new knowledge, or research. The obvious purpose of these activities is the third element, namely, service to mankind. Ideally, this service function should not be emphasized to the detriment of the other two. If carefully defined, it will not. However, as sometimes defined, it may seriously interfere with the educational process.

For example, the treatment of patients in dental school clinics provides educational

Presented at the annual meeting of the Northeastern Society of Orthodontists in Bermuda, Oct. 20, 1976.

*Professor and Director of Orthodontics, Columbia University.

OOW9416/78/0374-0305$00.50/O @ 1978 The C. V. Mosby CO. 305

306 Di Saho Am. J. Orthod. September 1978

benefits to students and service to patients and, incidentally, generates income. Ideally, these functions should complement each other. However, situations often arise in which they are in conflict. Traditionally, dental schools have given the educational function highest priority. Lately, pressures have developed to emphasize the delivery of more service and the generation of greater income from the school clinics. This can seriously interfere with maintenance of traditional standards of academic performance.

The influence of the Federal Government

Dentistry and orthodontics are integral parts of the health professions group. In all of the health professions, the service function may be defined as the delivery of high-quality health care to the public. Because of the great volume of real and imagined needs of the public in any segment of the health professions, government planners have intruded heavily into the doctor-patient relationship. This intrusion is now being felt in dental education and will probably be the single most important factor affecting dental education in the years ahead.

The latest health manpower legislation contains some provisions which have impact on orthodontic education. For example, it specifies that, in order to qualify for capitation grants (money awards made to schools in the health professions for each predoctoral student enrolled, and upon which the deficit-ridden schools have become completely dependent), the dental schools must assure that 70 percent of new positions in dental postdoctoral programs will be in general dentistry or pedodontics.’ This continues to promote the Department of Health, Education and Welfare policy of increasing the num- ber of dentists produced to provide general dental services at the expense of specialty services.

If this comes as a surprise to you, you should know that, originally, the bill contained provisions making capitation grants contingent upon such things as (I) the institution of a program in Training in Expanded Auxiliary Management (TEAM) and even prescribing in detail what the minimum expanded duties should be; (2) increasing predoctoral student enrollment, on top of increases formerly made to receive federal grants; (3) assuring that a minimum of 20 percent of first-year students would accept National Health Service Corps scholarships, which would obligate these students to practice for a period of years in certain designated dentist-shortage areas; (4) obliging students who did not enter the National Health Service Corps to pay back capitation grants to the Federal Government.

These provisions, although removed in the final draft, may be expected to surface again in the near future, together with other requirements deemed by federal legislators and bureaucrats to be in the public interest. Another deleted provision of the bill called for the development of federal standards for licensure, relicensure, and continuing education for dentists.2

This gives us some idea of the clout which the Federal Government has in influencing all health professions education. In fact, the Carnegie Council on Policy Studies in Higher Education, in a recent “Study on Progress and Problems in Medical and Dental Educa- tion,” stated that government requirements of the kind mentioned “involve unwarranted interference with academic decisions of the schools and a degree of federal control over the allocation of health manpower that goes far beyond interference in any other field.“3

The net effect of Federal Government actions has been a negative one on specialty education. This force will undoubtedly continue unless a substantial proportion of dental rrhootc Ron nfford to take the nosition which the University of Oregon did recently. That

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institution, with the full backing of the Oregon State Legislature, decided to spurn the federal feeding trough in order to maintain some freedom of choice in deciding its future directions. No other institution has followed that lead as yet, and it is doubtful that any will be able to afford to do so.*

It is interesting to note that the so-called “private” educational institutions, such as the one with which I am associated, which, in part, defend their existence by claiming freedom to be innovative and to act as a moderating influence in higher education against the dominance of public institutions, are the very ones now most dependent upon federal support.

To summarize this aspect, I foresee a decline, in the next decade, in the extent of postdoctoral dental education in all of the specialties, pedodontics included, the last because preventive procedures are making significant inroads in decreasing the incidence of caries, the child population is decreasing, and the use of expanded-function auxiliaries seems assured.

The influence of organized dentistry and organized dental education

Now let us turn to the forces of organized dentistry and dental education-the Ameri- can Dental Association (ADA) and the American Association of Dental Schools (AADS). The ADA, by virtue of its accreditation powers, is beginning to exert its influence on orthodontic education, chiefly at the predoctoral level. About a year ago the Council on Dental Education of the ADA appointed an ad hoc committee consisting of two represen- tatives each from the AADS, the ADA, and the Council on Orthodontic Education of the AAO, to draft guidelines for predoctoral orthodontic education, which the committee did.

These guidelines were then circulated to dental school deans and orthodontic depart- ment chairmen for comment. Many of them commented rather loudly. There was over- whelming opposition to the document because it apparently called for predoctoral or- thodontic education at a level of sophistication which differed from that hoped for in postdoctoral programs only in the acquisition of manipulative skills. When one considers that a modern postdoctoral program consists of about 3,000 hours, only 50 percent of which can be clinical (according to accreditation standards), this would appear to require 1,200 to 1,500 hours out of a total predoctoral curriculum of 4,000 hours. No orthodontic department chairman or dental school dean could, in his wildest imagination, conceive of a general dental curriculum which would allot 30 percent to 40 percent to orthodontics at this time.

At a hearing scheduled by the Council on Dental Education at the AADS meeting in Miami early this year (1976), the ad hoc committee defended the guidelines by stating that they were “only guidelines,” not mandates, and that they believed the objectives could be met by a curriculum of 1.50 to 200 didactic hours (presumably any clinical time would be additional).

As a result of this and other input, the guidelines have been revised into a more reasonable document which will be presented for adoption later this year.? It is important to emphasize that although these are “only guidelines,” they are certain to provide the yardstick for accreditation of the schools.4

This, then, illustrates the clout which organized dentistry has over orthodontic educa-

*Currently, a few other institutions are seriously examining the possibility of doing this ?These revised guidelines were subsequently adopted by the Council.

308 Di Salvo Am. J. Or&xi. September 1978

tion. This can only be expected to increase in the next decade. Therefore, we can expect an increasing emphasis on orthodontics in the predoctoral curriculum, and this we should welcome. There is no question in my mind that one of the most important factors involved in the antipathy which dentistry generally has for our specialty is ignorance of orthodon- tics. We need have no fear of patient abuse from increased dabbling by the poorly trained if the increased education time is used to present the subject in an orderly sequence with adequate supervision, just as is done in our postdoctoral programs.

The level of sophistication produced will then be in direct proportion to the time allotted. If some schools decide to allot 50 percent or more of the curricular time to orthodontics, there is no question that a competent beginner in orthodontics can be produced. The University of California Curriculum II program proved that years ago.”

Thus, dental school curriculum committees will have to be made to understand that to produce the level of sophistication required to “do a little orthodontics” requires a considerable amount of time. Then perhaps we can put an end to the requests that we teach students some tooth-moving gadgetry in a few hours in the name of orthodontic education.

Advances in technology and in diagnostic techniques will facilitate the teaching of clinical orthodontic procedures at the predoctoral level. This, together with increasing emphasis at the predoctoral level on subjects now included in postdoctoral programs, will require the modification of the latter to concentrate on the management of the more complex problems.

The role of other factors

These are some of the more important forces that I believe will be at work in shaping orthodontic education in the next decade, but we have not even touched upon other factors. Because of the limitation of time, I can only mention them:

I. Because of the growth of third-party programs, the strong possibility of national health insurance, and the use of expanded-function dental auxiliaries, the practice of general dentistry is becoming more attractive, economically, physically, and emotionally. Thus, the number of graduating dentists seeking to specialize will decrease. This has already begun to happen. 6 This, together with increasing com- petition from hospital residency programs which pay their residents while in train- ing, will lead to strong competition among the schools for qualified students. Dental schools will be forced to reduce the number of openings in specialty pro- grams, and some of the weaker programs may not survive.

2. Multiple-specialty designation will probably become a reality.* It is difficult to say to what extent this will be practiced. It may flourish best in rural areas which often cannot support single-specialty practices. My feeling is that the demand for com- bined programs, such as ortho-pedo, ortho-perio, ortho-surgery, perio-endo, etc., will not be very great, for economic and practical reasons. Nevertheless, we will see a limited number of combined courses developed.

3. Continuing education requirements for relicensure and for specialty board recer- tification will spread for political reasons. This will lead to increased demand for continuing education courses. Schools and dental societies will respond by increas- ing course offerings for economic reasons. However, I believe that this will have

*The ADA subsequently approved the ethical announcement of limitation of practice to more than one specialty ,lrPIl

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little or no effect on the stated objective, namely, to improve the quality of care delivered.

TO put orthodontic education into proper perspective, we should try to project what the practice of dentistry and the specialties will be like in the years ahead. After all, dental and orthodontic education should be preparing students to practice for the next three decades.

For a number of reasons, which cannot be detailed here because of lack of time, I believe that the practice of dentistry will have these characteristics in the next 25 years:

1. The setting of dental practices will be a mix of the present systems, namely, solo and group practices in the private sphere and institutional practices in hospitals, schools, and proprietary clinics. However, the proportion of solo practices will decline.

2. Most dentists will employ expanded-function auxiliaries. 3. Dental practices of the future will deal somewhat less with routine restorative

procedures in the young and more with diagnosis and treatment planning, problems of deformities, periodontal disease control, and infectious and neoplastic disorders. However, sophisticated restorative procedures will continue to be in demand in an aging population.

4. The increasing impact of preventive measures will reduce the proportion of the simpler types of malocclusion (those which are dental rather than skeletal in nature and which are caused by so-called local or environmental etiologic factors, such as premature tooth loss).

5. The generalist of tomorrow will render some of the treatment which is now referred to specialists. Specialists may be proportionately fewer in number but will deal with more complex problems.

6. There will be some restructuring and redefining of the specialties, especially in the area of children’s dentistry.

7. In most instances the dentist-patient relationship will be less personalized. An elite class of practice may arise because of the demand of a minority of patients and practitioners who wish, and can afford, to retain the former type of relationship-a kind of “custom dentistry.”

To summarize, I believe that in the coming decade (I) the extent of education in orthodontics at the predoctoral level will increase; (2) there will be fewer students in postdoctoral orthodontic programs and these programs will concentrate on the more com- plex aspects of care, omitting some of the more fundamental aspects which will be presented at the predoctoral level; (3) there will be more continuing education courses in orthodontics for both general practitioners and specialists; and (4) there will be a limited increase in dual-specialty programs.

REFERENCES I. HR S546, The Health Professions Educational Assistance Act of 1976, Taken from AADS Memo 177, Oct.

4, 1976. 2. ADA News, July 26, 1976. 3. The Carnegie Council on Policy Studies in Higher Education: Progress and problems in medical and dental

education, Taken from ADA Washington News Bulletin 9: 3-4, Sept., 1976. 4. Guidelines for teaching orthodontics in dental education, ADA, CDE, July, 1976. 5. Moore, A. W.: Orthodontic education: Past, present and future, AM. J. ORTHOD. 6% 42-56, 1976. 6. Division of Educational Measurements, ADA Council on Dental Education: 197576 annual report on

advanced dental education, AM. J. ORTHOD. 70: 343, 1976.