Orthodontic News

The following article is reprinted with permission from the author Orhan C. Tuncay, Editor-in-Chief, Clinical Orthodontics and Research, and was first published in Clinical Orthodontics and Research, Vol. 4, issue 1.

The American Perspective:

ORTHODONTICS -  The First Specialty of Dentistry is at risk to be the first to disappear.

By Orhan C. Tuncay

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Despite the good economic times and impressive advances made over the past twenty years in our field, we may not have orthodontics as a specialty much longer. There are several reasons for this, but the most imminent one is the potential for the disappearance of the orthodontic department.

Why would an orthodontic department disappear? This question has a simple answer: There cannot be a department without faculty. The current lack of full-time faculty is the most significant crisis we had to face since the inception of our specialty. Much of the current full-time orthodontic faculty have gray hair, and some no hair. Once this fifty or sixty something crowd retires they will not be replaced. There are only a handful full-time faculty who have the interest, enthusiasm and skills necessary for a career in academics. Unfortunately, many of this already small group will give up the academic life to put bread on the table and pay their children's school tuition. Whether senior or junior, the income of a typical orthodontic faculty member is many fold less than what a practicing orthodontist can earn. All the studies conducted to understand the core of full-time faculty dissatisfaction, come up with the same conclusion: the full-time faculty salary is not an incentive to do the work. The other and intangible element is that the full-time faculty is not really "accepted." They may even be the subject of ridicule when the young doctors (to borrow a phrase from LE Johnston, Jr.) get together for a quick beer.

Clearly, this is disgraceful. The full time faculty have accepted that they will indeed get paid a little less, and they will put up with the politics of their institution. Not to mention they will put in endless hours of work - but why? It is because they understood the importance of education, advancing the field and giving back. Above all, however, to ensure the sustenance of the specialty. They have chosen to make sacrifices for the greater good, the future of orthodontics. They believe looking after their fellow persons is important. But how big must that sacrifice be? Moreover, are they the chosen ones to pay for the attitude (if not the sins) of the rest?

Unless steps are taken to prevent it, we will lose our specialty. Imagine a scenario in a dental school far away, where time has come for all the orthodontic faculty to retire or to resign. There are no full-time orthodontists to lecture, conduct the precilinical laboratory sessions, assign patients, grade exam papers, report the final grades, etc. at the predoctoral level. In order to stay accredited, the dental school curriculum must contain orthodontic courses. How will the administrators handle this problem? Certainly it will be no sweat off their back to ask the pedodontic department to teach orthodontics. As bizarre as it may sound, this is a trivial event compared to the bigger issue. The bigger issue is that this dental school will no longer have a graduate program in orthodontics either. As this trend spreads to other schools around the nation, the graduate orthodontic program, as we know it will disappear.

The specialty status is granted by the American Dental Association. To be a specialty, the field must be special, have an organization, a board certification process, a journal, and an educational system. In the absence of any one of these elements, the field is not special to be recognized as a specialty. If orthodontics can be taught by pedodontists or other specialists, how can anyone claim it to be special? The orthodontist will no longer be a specialist.

Imagine the orthodontist is not a specialist!

A small group of wise men realized this could happen and founded the AAO Foundation. The purpose of AAOF is to support the orthodontic education. The support is in many forms, but mostly the foundation funds the orthodontic research that would not be funded by other means, and the young faculty with salary support. The money to do all this comes from the interest accrued. But who cares if the orthodontist is recognized as a specialist? only less than 23% of the membership. Sadly, a good number of those sponsors are the current residents. Many of the practitioners who contribute do so at the minimum level.

For example, the regent level sponsorship requires a pledge of $25,000. It can be paid over a ten-year period. Simple arithmetic reveals that this is a $208 a month contribution. Where else do we spend $208 a month? An orthodontist who goes out to eat say, three times a week, will leave more than $208 in tips for the waiter. If the orthodontic community's self-respect in being a specialist is less than the tip left for the waiter, then not much could be said. Obviously, the orthodontist is neither special, nor he/she deserves to a specialist. Perhaps, the non-contributing 76% of our members fall into this category. Chances are they have not given to their departments either. Yet, they preach to others the importance of tithe.

It is hard to imagine there exists an orthodontic practice that does not give away free treatment. For a dentist's kid, a family member, a friend, etc. At the end of the fiscal year, when the income and overhead figures are assessed how can anyone tell that they gave a treatment or two away? Clearly, the few freebies would have no impact. Could those free treatments not be given to the department or to the specialty? and most importantly, to the AAO Foundation in return for self-respect?

There can be no excuses for not supporting one's practice, principles and pride. The issue is the survival of our species. Not to contribute $208 a month is a vote for extinction. Often we hear "someone ought to do something." Who might that someone be? If read carefully, the O of the AAO spells orthodontists. It is the organization of the orthodontist, not orthodontics. The orthodontist is that someone who ought to be doing the something. Dear colleagues, time has come for all orthodontists to put their money where their mouth is. Being a specialist, in particular and orthodontist, is worth more than the tip left on the restaurant table. Don't give away your specialty. Don't let it be the first to disappear.

The following article is reprinted with permission from the author Orhan C. Tuncay, Editor-in-Chief, Clinical Orthodontics and Research, and was first published in Clinical Orthodontics and Research, Vol. 4, issue 2.

The American Perspective - Part II:

Strategies for the survival of the species

By Orhan C. Tuncay

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Today's orthodontist faces two options. The first option is to do nothing and eventually become a general practitioner dentist, and the other is to be proactive in preserving the specialty. In the face of serious shortage of educators there isn't a third option. It is safe to assume that given a choice no orthodontist would like to relinquish his/her specialty status. What then are the preservation measures?

The answer is simple: academia must be made attractive either for the residents of the United States or for potential immigrants, or both. People are happiest in an environment where they make a comfortable living, achieve the things they think are important and be recognized for those achievements. Who will make all these happen? The dental school? Dental schools have neither a good track record of such deeds, nor any willingness to change that one can recognize. They have their own set of problems. The salvation therefore, must come from within - obviously, in the form of an organization. The American Association of Orthodontists (AAO) along with its Foundation (AAOF) is in a position to make a difference. These two organizations can lobby to change the way an academic earns a living and to have the opportunity to advance the field.

Medical schools faced the faculty shortage problem long ago and were able to quickly institute an effective solution. For all intents and purposes, the medical school clinics today are faculty practices and the attendings earn commensurately per their busyness. At the same time, money for their activities of scholarship comes from those same clinics or from the associated foundations of various specialties. In contrast, the current fiscal model of a dental school is for the administration to claim the money generated in the orthodontic clinic, and in turn give a meager budget or handouts or favors to the department. A perhaps politically correct version of this model in some schools is where the administration has taken away the department's budget entirely, but the department keeps a portion of the clinical income. In either scenario, the sum of money is small, and there are no funds for investment. No funds to pay the faculty satisfactory salaries, for investing in new faculty lines, or for investing in scholarly activities. In many schools alumni contributions have kept the departments afloat, but in some other schools, administration takes even those funds away from the department. Generally speaking, the orthodontic department is the cash cow that supports the inactivity of other departments. Clearly, there would be no attraction for this arrangement in academia for any sane person where the pay is low and the obligation to carry the school's financial burden is high. How can the AAO and AAOF help?

The system must change. Dental schools must be run by administrators with entrepreneurial skills, and the fiscal power decentralized. It would be naïve to expect any existing administration to make this change on its own volition. The change must come from the office of the President of the University and the Board of Trustees. The AAO must put significant effort and money into lobbying these bodies. Perhaps, such lobbying is needed even at the Congressional level. Lobbying is expensive, but no more expensive than not being a specialist. In the short term, AAOF funds are better spent for lobbying activities to preserve the specialty.

During the period while this new order is taking place the orthodontic department could be augmented by imported academic personnel from abroad. Unfortunately, there is no such mechanism. At best in some states, the imported faculty member can teach in the clinic and have an intramural practice one day per week. The State Board of Dentistry must be lobbied to allow these faculty to practice on a daily basis as long as they stay in academia full-time. Additionally, AAOF could provide matching funds for their retirement plans as well as portfolio management advice and services. There is ample expertise among the AAO to provide such support to the young academic, citizen or permanent resident.

Investment of funds in these areas is what will ensure our survival as specialists. Not as a criticism, but rather as a statement of fact, it can be said the AAO has been preoccupied to address the needs of the current membership at the expense of investments for the future of the specialty. The exceptionally well put together "Practice Alternatives" program, for example, is in place really to help the selling of current members' practices. Similarly, the Council on Scientific Affairs while trying to decide whom to award among the candidates oftentimes finds itself trying to choose between advancement of science and practical issues of today. Meanwhile, the Council on Informatics spends more time trying to help the current membership, rather than planning for the future, and there are identical stories told for the Council on Communications or Education, or the rest. Obviously, the needs and interests of the current membership can never and must never be overlooked. Yet at the same time, room must be made for the future of the specialty.

It will behoove all of us to support the AAOF to make these changes happen at the AAO level, Board of Trustees level and at the State Board of Dentistry level. Extinction is not an exciting practice alternative.

The following article, written by Dr. Larry White, is reprinted with permission from the Orthodontic Cyberjournal, and was first published as a guest editorial in Orthodontic Cyberjournal, June 2001 edition.

Dr. White's background as a clinician, Editor of the JCO and former Chair of an Orthodontic Department gives him a unique perspective on the current state of orthodontic education in the U.S. Though some may find this essay controversial, it is intended to make us think about the current state of education in our profession and of the pending problems of supply and demand for orthodontists. (Editor, Orthodontic Cyberjournal)

An Historical Time Line

By Dr. Larry White

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The April 2001 issue of the American Journal of Orthodontics carried an historical time line that highlighted some of the notable achievements of the American Association of Orthodontists over the past century. Time tends to erase some memories and one forgets that the profession hasn't always had among other things air turbine handpieces, the American Board of Orthodontists or an executive secretary of the AAO.

Another development that occurred in 1970 was the dissolution of the orthodontic preceptorship program, which the AAO formally endorsed in 1940s. This orthodontic training program allowed dentists to apprentice with an established AAO member for three years and then establish their own specialty credentials by passing an examination. By 1970, pressure from the AAO to consolidate and balance orthodontic training placed all sanctioned training in university programs.

On the surface, this change seemed as innocuous as it was well meaning, but nothing altered orthodontics quite like this one change because it essentially turned over the future of orthodontics to the universities of the United States. From this point on, they would essentially determine the direction of the profession. Universities and their faculties would decide who was admitted, how many were admitted, the curricula taught, the hours devoted to research, the amount of clinical experience, the time spent in the programs and so forth. The AAO, through its House of Delegates, has some input, but it is minimal at best so as not to interfere with the autonomy and discretion of the individual institutions that manage these programs.

How has this assignment of duty worked? For the most part reasonably well, but recently the custodians of this charge have been telling the AAO that a crisis in orthodontic education now exists. Currently, at least 10 chairs of orthodontic programs lie vacant. Approximately 100 full-time positions remain unfilled in orthodontic departments. Were it not for the unselfishness of part-time faculty in our universities, many of the orthodontic programs would undoubtedly have to close. With this much dilution of faculty, it is hard to see how the current orthodontic education scheme can remain healthy and viable. The crisis as I briefly experienced it has three aspects: personnel, purses, and product.

Most universities complain that they cannot compete for personnel because of low salaries, which their institutions dictate; but this is only partly true. The schools do have salary caps that cannot be easily violated. Yet many of the schools severely limit what their faculties are able to earn outside of their university employment. Some insist that the faculty engage in an inefficient and highly limited intramural practice as the only supplement to their salary. They forbid any independent outside practice.

Also more and more schools are insisting that Chairs come with Ph.D. degrees. And not just the degrees but also the obligatory NIH research grants that they are supposed to collect with those degrees. In fact, the pursuit of federal grants has become such a priority for full-time faculty that it has relegated the teaching of orthodontics to a secondary status.

Another barrier that has arisen even for people who do get their advanced doctorates has been the recent tendency of schools to give tenure only to those who publish in highly ranked journals. Not one of the orthodontic journals worldwide is ranked in the upper 1st or 2nd tiers of publications, which universities recognize. This means that orthodontic Ph.D.s will need to publish in fields completely outside of orthodontics, which dictates that their stay in academia will be prescribed by disciplines that hold no esteem for orthodontics. I have a friend who is a first-rate orthodontic researcher, teacher, clinician and frequent publisher whose tenure was denied in this senseless way.

A Ph.D. may better prepare people for a research career, but it can hardly confer extended clinical knowledge. But deans of dental schools increasingly endorse this personnel approach. In some instances, we now have the scandal of even non-dentists being made chairs of orthodontic departments, which de-emphasizes clinical features even more. Additionally, only a little over 50% of all the orthodontic chairs in American schools are members of the American Board of Orthodontics. While the ABO is not necessarily the sine qua non of orthodontics, it does indicate at least a minimum of interest in clinical skills and knowledge. Such decisions are almost always left up to the deans of the institutions, so if there is a personnel crisis in orthodontic education, it is self-inflicted, and we have to look no further than to the leadership of our schools.

Deans who have taken a pragmatic approach to this problem have little or no problem in faculty recruitment. The University of Pacific comes to mind as an institution that allows faculty to have independent practices, so their teachers are able to do about as well financially with their part-time practices and full-time professorships as they would do in a full-time orthodontic practice.

Those who wish to teach full-time should not be financially punished because of their appetite for academia. Yet, that is exactly what happens for the most part in many orthodontic departments right now. Many potential professors simply decide that they can't afford to teach full-time with all of the institutional restrictions on their earning power. Who can blame them? One's family should not suffer because of an inclination to instruct. Nevertheless, if these people could supplement inadequate organizational salaries with outside work, many more would be willing to make that tradeoff and the so-called personnel crisis in orthodontic education would abate.

A second feature of this crisis in orthodontic education that is closely related to the personnel issue concerns the purse or the economics of running orthodontic departments. Traditionally, orthodontic departments have been substantial profit-centers for dental schools - so much so that incomes from their enterprises are often diverted to shore up the less profitable departments. Whatever the merits of such administrative decisions, and they are often compelling, the net effect has been to dilute and limit the resources of orthodontic faculties and to place their programs in jeopardy.

It is no accident that the most successful and well-regarded orthodontic departments are those whose chairs have proven worthy of keeping and employing major amounts of their departments' incomes.

I am not sure how all of this school-wide dependence on orthodontic departments developed, but right now it is almost universal. Without the income generated by orthodontic departments, many schools' entire curricula would be endangered. My suspicion is that as the sponsors of schools such as state legislatures continued to squeeze budgets, deans began to scramble to find funds wherever they existed.

Nevertheless, this is an unsustainable economic situation. Institutions must decide if they really want graduate departments of orthodontics and properly fund them or they need to shut them down.

The final feature of this crisis is the product of our schools or the graduates. Of the 300 orthodontic residents who graduate each year, 100 of them are foreign-born, and they return to their homelands. That leaves only 200 to replace the 300 - 500 orthodontists who now retire each year. This is occurring while the demand for orthodontic services continues to grow. Although orthodontists may feel that a shortage of competition is a good thing, they should not expect the public, the federal and state governments to feel the same way. They have a history of intervening and regulating professions and industries in ways that are not always beneficial to all of the parties.

One solution might be to limit the number of foreign admissions and thereby increase the volume of orthodontists who will stay and practice in the U. S. There is certainly no lack of qualified American candidates for those 100 positions that are now taken by foreign students. At one time there were no alternative training centers for people from other countries, but at this point practically every nation in the free world has some first-rate programs. The presence of foreign orthodontists has certainly enriched orthodontic departments and has extended the influence of America throughout the profession worldwide, but ultimately, the first priority of American universities is to serve its own citizens, and right now we are in danger of not doing that.

Almost all of the early university orthodontic programs were two-year events, and the ADA approved curriculum is still designed for two years. But within the past decade, more universities have extended their orthodontic curricula to three years. The justification for this lengthening has been to allow residents to complete meaningful research, gather master degrees and defend their theses. There are several pros and cons regarding this lengthening of orthodontic training. Nevertheless, one indisputable effect has been to retard the provision of orthodontists to the public.

Until recently no one had even studied, much less discovered, if this extra year of training actually benefits residents. For instance, do three-year residents become ABO Diplomates more often than two-year residents do? Do they make more faithful alumni and/or society members? Do they engage in study clubs more frequently? Do they publish more professional papers? Do they finish treatments more thoroughly? A study now completed at LSU shows that there are no measurable differences in two-year graduates and those of three years. So we may be doing the residents and the public a disservice by insisting on a third year.

All of the proceeding has been said to preface the flashback, which the AJO historical time line encouraged in my own mind. Many of the best and most contributive orthodontists I have known during my professional life have been those trained in preceptor programs, e.g., Reed Holdaway, Charles Tweed, Tom Creekmore, Homer Phillips, Tom Matthews, Jim Reynolds, Birte Melsen, Giorgi Fiorelli, etc. I don't think anyone would ever question the competency, contributions or dedication of these people. Could we possibly create these kinds of people again with preceptor programs? Maybe it is time to take another look at the preceptor program as a way of supplementing our university programs to relieve the current orthodontist shortage, which will only grow in the near future.

I feel confidant that the AAO and ADA methods of accrediting university programs could be easily adapted for orthodontic preceptor training programs. The unevenness of education in the previous program was due to a poor-vetting technique for the participating doctors. Accreditation groups could solve this problem by approving only doctors who meet specially developed criteria for preceptor training and enforcing that standard much as they now do for institutions. Orthodontists who wished to retire could qualify to accept and train a preceptor within this program.

The lesson from all of this is that the profession cannot afford to continue down the same path that has led us to this crisis. Somewhere we need to get back on a track that will allow us serve our members, residents and the public at large in an exemplary manner.


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