At the beginning of Dr. Gordon Christensen’s March JADA article, "Orthodontics and the General Practitioner," he wonders, "Why has orthodontic therapy been accomplished primarily by specialists, while general dentists accomplish most of the treatment in the other specialty areas?"
He also writes, "A few general practitioners have taken short courses on some aspects of orthodontics and have accomplished limited orthodontic therapy. Others have taken longer courses and have upgraded their orthodontic education to a level at which they are able to accomplish most areas of orthodontic therapy."
Dr. Christensen obviously does not understand the complexity of orthodontic therapy. It is impossible to provide the necessary skills and training to undergraduate dental students during their limited time at dental school to allow them to properly perform orthodontic therapy.
Our specialty is similar to oral and maxillofacial surgery in that it requires extensive knowledge and skills that are acquired via academics and guided hands-on training at a university program that must be followed by years of daily practice. The obvious is not necessarily correct in our treatment planning. We are typically modifying the entire occlusal schemes and functions of patients, many of whom are children, as we integrate growth and development into our therapy.
Dr. Christensen recommends that general dentists, who have questionable training in orthodontics, begin uprighting molars and consolidating spaces between teeth in adult, periodontally involved cases, which have posterior bite collapse. These are very difficult people to treat.
Why does Dr. Christensen recommend that generalists perform orthodontic therapy when there are so many well-skilled and university-trained orthodontists available? Why should a general practitioner place himself at greater risk for malpractice suits when he must achieve the same standard of care as the orthodontists in his area?
If treatment is not done to the regional standard of care because of a lack of skill and training, what recourse would a general dentist have? Is experimentation on patients by general dentists poorly trained in orthodontics reasonable? This article seems to suggest that it is acceptable.
I would not want to be treated for correction of a malocclusion by a general dentist who has not had training in an ADA-accredited postgraduate program. It is my understanding that Dr. Christensen is respected and renowned in the general dental community for his knowledge of dental materials and restorative procedures. However, the situations that he describes, including molar uprighting and maxillary incisor spacing, are usually more involved than the simplistic approach he describes.
Typically, spacing is caused because of tooth-size discrepancies, missing teeth, tongue thrusting, bite depth problems and parafunctional problems, in addition to lip posture and habits and skeletal malocclusions. It can be very difficult to upright molar teeth since typically bicuspid and cuspid teeth have moved into the missing tooth space. The entire occlusion usually needs to be corrected as the molars are uprighted to properly prepare the arch to receive an implant or other restoration. Temporomandibular joint, or TMJ, periodontal and occlusal problems can and do occur as teeth are uprighted. Uprighting is typically done in full fixed appliances and usually requires extensive time-consuming treatment.
The correction of maxillary incisor spacing can lead to occlusal disharmony, resulting in TMJ discomfort if not done properly. If the teeth are periodontally involved, bone loss is a consideration in addition to the posterior bite collapse and tongue posture, as well as habits typically related to these problems.
My suggestion to Dr. Christensen is that he should try to limit his dental insights into those areas in which he is fully trained and knowledgeable.
