I listened to the talk “A Call for Professionalism” by Dr. Peter Greco and Dr. Eladio DeLeon, Jr. on the AAO member website (their talk starts about 1:34:00) and it was interesting to say the least. I won’t bore you with the details as you can watch the talk for yourself but the thing that really grabbed my attention was what Dr. Greco said at 1:40:30 while quoting a physician born in the 1800s –

“We must combine the new economy with the old morality…”

When it comes to orthodontists and the AAO, their obsession with the past never ceases to amaze me. Dr. Greco recited the 7 wonders of the ancient world, referred to Hippocrates and then took his central theme on morality from a man whose parents were likely alive when it was considered legal and even moral by some to own another human being. A man who lived during a time when women were not allowed to vote, when segregation was normal, when it was perfectly acceptable to judge someone based on their religion, race language, preferences or anything else that was not considered Anglo-Saxon-Protestant-White…

So exactly which part of “old morality” is Dr. Greco suggesting we revise? We can look at photos of the men in the AAO leadership over the years and it won’t be hard to figure out. Sure there have been a few dashes of diversity added in recent years but, again, Dr. Greco is calling for “old morality” so this makes me wonder what he and his old morality colleagues think of the slightly changing face of AAO leadership.

We can garner clues as to the point of this call to professionalism from listening to Dr. DeLeon’s words in which he seems to yearn for the days when it was illegal to advertise, regret that state dental boards no longer have unlimited power with no restraint on their propensity to crush competition or immunity from consequences and Dr. DeLeon decries the fact that the AAO can’t block new dental schools being built. He further seems to suggest that he and his fellow SOE members should impress upon CODA the need to change the rules for accreditation in an attempt to accomplish through CODA paperwork what is forbidden by the law of the land. I’m sure these same kinds of suggestions for opposition to the new were made by elder statesmen when women and non-whites first tried to enter the sacred halls of dental schools. Though these may seem disparate motives and circumstances, one only need look at both scenarios from the point of view that the dental establishment will always fight to protect itself from anything it sees as a threat to the status quo. Anything. Be that females, “other” races, people of different beliefs or, in the last week, anyone or anything who wants to compete with established doctors for the right to service the public. Even the public that the orthodontic establishment refuses to treat!

Here’s the funny part. Even after the dental establishment is forced to incorporate the changes they vehemently opposed and it becomes obvious that there was never any “danger to the public”, we still refuse to admit we were wrong and go ahead like nothing ever happened. It’s amazing to look back at the history of orthodontics and dentistry in general to watch this scenario repeat itself over and over and over… Will we ever learn?

To his credit, Dr. DeLeon did put up a slide “showing” that “more dental schools will not solve the access problem” but one doesn’t need to be an expert in psychology to see how little time he spends on this “study” or that he chose his words carefully when talking about the results. It was like watching a doctor saying to a patient that a prescribed medicine would not solve the disease so they shouldn’t take it… while knowing that the medicine would certainly alleviate the symptoms and put the patient on the road to recovery over time.

How is it possible that such a large group of very smart people can not only think this way but never even consider the possibility that the party line is flawed? Are we so caught up in our echo chamber that we don’t realize that by only considering our point of view and the point of view of those who agree with us that we are multiplying our innate confirmation bias to our detriment? It boggles the mind and saddens me greatly to watch. How can we refuse to recognize that the world has changed, patients have changed and that we only service a tiny fraction of our fellow Americans? How can we be so arrogant to believe that everything done in a “traditional office” turns out roses and anything other than that consistently renders rotten results and is dangerous? Our emotions rule us and have blinded us to the assumptions we’ve held so long that we don’t even recognize as such any longer.

I truly hope the profession and our member organization come to their senses but I am far from optimistic that reality will be able to break through. Oh well, we are consistent if nothing else.

9 thoughts on “A Call for Professionalism

  1. So what’s your answer? Why even have any standards, or a speciality, or even a profession? Seems like a lot of bitching and moaning with no real solutions. All this talk about “disruption”, “access” etc are code words for lowering the quality of care and enriching their venture capitalist puppet masters. Seems comical…the manufactured outrage and hyperbole.

  2. Thanks so much for taking the time to comment. I have a few questions if you don’t mind. Can you show me the definition of quality and proof that you can get more than a few dozen orthodontists to agree to it in practice? If so I’ll go with that. Though the AAO did finally adopted standards there is a huge caveat saying that an orthodontist’s clinical judgment may allow them to deviate from the “standards” so this makes the standards problematic at best. Quality seems to be the the word almost every orthodontist uses to defend what we do while talking about how everyone else is not doing quality… If an orthodontist’s clinical judgment is sacrosanct (as the standards make it clear they are) then how can one or any orthodontist make the blanket statement that another who disagrees with them is bad or low quality or anything else for that matter? Seeing as how I have a DDS, an MDS and a tremendous amount of experience, what makes your opinion (or any other orthodontist’s opinion for that matter) of what is appropriate and what is not superior to mine? Remember that I’m not saying anything about the “quality” of orthodontics done in a traditional setting other than the obvious but denied fact that every doctor has cases that don’t finish perfectly. Along the same lines, how is no treatment superior to “limited treatment” or any treatment that addresses esthetic or functional issues – especially in simple cases or cases where we can get someone out of a “traumatic bite”? How can orthodontists claim with a straight face that wearing some clear aligners cannot effectively move teeth just because of their mode of delivery? Do you consider an orthodontist who works with a DSO one of the puppets you mention above? What about one who has a bank loan on their practice that they must pay monthly? Can you share with me, in your opinion, who is and who is not a puppet specifically and why? Seems to me that by your implications here anyone who are not financially free is likely to have strings attached? Does that mean that only those orthodontists who no longer have to work, are debt free and financially independent are the only ones who can be trusted to have a “quality” opinion? How many of them are there? How can this be evaluated and a standard set for “puppet freeness” and who will decide the guidelines? The majority? That sounds fun and takes us back to the “old morality” argument. And finally, where is the outrage and hyperbole to which you refer? In this piece I quoted from a recorded video that you can watch yourself, pointed out that words have meaning and noted the cyclical nature of dentists defending the establishment against perceived threats over the years. There was no heat in what I wrote so I’m interested to hear your take as perhaps I’ve missed something.
    As to “the answer” that’s simple (in my opinion). The AAO and orthodontists in general (since not every orthodontist is an AAO member – far from it) should seek to provide our services to the maximum number of people possible. This is good for our businesses and good for patients and potential patients. Having an inclusive instead of an exclusive mindset would go a long way towards this solution!
    Thanks for you time. I look forward to an interesting discussion.

  3. Sure I can. The ABO, for one, has established guidelines on what to shoot for in terms of quality. Now, of course, others may choose to disagree, as is their prerogative. I’m familiar with the AAO’s standards as well. Unfortunately, too many people conflate the “clinical judgement” clause to imply a laissez faire “anything goes, nothing matters” perspective. The AAO standards never said that an orthodontist’s clinical judgement is sacrosanct in all situations – hence the standards as the rule and clinical judgment as an exception. As to your experience/training etc., that is the exact reason to have standards and inject some objectivity into what can otherwise be a hopelessly subjective evaluation. Just because practitioners may have a few cases that do not finish ideally…do we discard any attempt at a good finish, and make sloppy results the de facto standard ? That’s akin to never running a marathon if you didn’t finish a few times!
    Getting someone out of traumatic occlusion is indeed a worthwhile goal of limited treatment, but in reality, what outcomes are made worse in the attempt to attain some degree of alignment? Wearing direct to consumer clear aligners is a recipe for disaster not because of the mode of delivery, but more due to the lack of an idea of existing status (no clinical exam, x-rays, TMJ status) intended position, supervision, titration and monitoring. The line begins to blur between “doing some good” and “doing some not so good”. The DSO model is not inherently good or evil…but, it does lend itself to some interesting conundrums when profit is the sole motive. When the same crowd also attempts to tear down standards, decries diagnostic records/retention/stability and touts access to care, is it that far-fetched or cynical to wonder if there is a conflict of interest? Is the solution to the status quo worse than the status quo?
    Let me ask you a few questions – Is orthodontics or should it be an alignment-only speciality or a speciality at all? If all else we do doesn’t matter, why fight against 3-month smiles or even 3-day smiles. Would it be wrong to slap on a few brackets for say a fortnight and then call it done? Shouldn’t we be encouraging GPs, chiropractors, even nail salons to place some brackets and wires? Do they even need any dental training? If so, how much? After all that would maximize our reach. What could go wrong? Why only have SDC or another aligner company provide orthodontic services instead of anyone with a pair of hands?
    The point re: being inclusive vs. exclusive is certainly something to think about and worth pursuing, but does it have to be at the cost of quality? Most orthodontists already attempt to maximize their patient load, so I would concur with that. But, are we making a want into a need…?

  4. Interesting points. A couple more questions. What percentage of the orthodontists in the US are ABO certified – even if you include all the people who get certified while still in residency? The fact that the ABO hands out ABO certification to residents who have only treated one or two dozen cases start to finish under the supervision of instructors is a joke and proof positive as to their desperation to increase membership – maybe one day more than 1/3 of orthodontists will join their little club. I just love seeing newbys still wet behind the ears claiming they are better than experienced orthodontists because of a piece of paper – what a joke! Furthermore, do “traditional” orthodontists or ABO certified orthodontists tell their patients that they failed and refund their money and refer the case to the state dental board if they have a less than ideal outcome? Shouldn’t they if there is an agreed to standard of care that you all hold so dearly? We all know everyone has bad cases and some more than others when judged by those standards but I know they don’t say a word to patients when things don’t work out if they can get away with it.
    Why does it have to be all or nothing? How can you assume that people who agree with you do good work or at least the best they can and that people who do not agree don’t care and are only in it for the money? How can you say that DSO employees and those doing tele dentistry are all about the money but pretend that those who own their own practice care not a feather or a fig about their cashflow? I’ve been in a few closed Facebook groups and visited a few offices and I’ve seen the posts about NEEDING to start patients earlier than necessary in Phase I to keep them from going elsewhere and about orthodontists who keep the braces on after the case is done to make sure they get paid… And ONLY practice owners would say or do such things – employees don’t care. I didn’t see any outrage against these comments or actions or hear anyone agree when I suggested we shouldn’t do that! Finally, how can you say that people should be punished for what might go wrong and damn an entire delivery channel instead of holding each provider accountable for their results as all Dental Practice Acts demand? If an orthodontist or dentist treats a case – in person or via teledentitry – and does harm then the patient has the right to complain to the state board or take civil action and the provider will have to account for that. Can you try and convict a practitioner for what might happen before it does as you and the AAO suggest?
    I love your thoughts on clinical judgement being the exception to the rule as it sounds very good but the pragmatic orthodontist knows that every case is different as every human being is different. Furthermore, as you well know, if you present an orthodontic case to a group of 10 orthodontists you will get 20 ways the case could be treated! We have all seen this since entering residency and on Facebook and any time orthodontists get together. No one can legitimately pretend that there is any standard way of doing what we do. Most things work most of the time.
    Are you going to say next that there is a set amount of time between office visits and a set, maximum number of aligners that can be given to a patient? For that matter where does it say in any of the DPAs that radiographs or an in person exam is required before rendering orthodontic treatment?
    If you are so convinced teledentiry is bad and will yield bad results and that patients won’t like it once they know more about how bad it is and how awesome ABO/AAO members are then why not let it just play out? The state boards will handle it and you’ll be proven right and it will all end quietly without orthodontists and the ABO having to come off as protectionists. I suspect I know and I believe it has a bit to do with concern on the part of traditional orthodontists for their profit margins.
    I used to think just like you and the majority of orthodontists – my professors sold me the same line of BS as the rest of you and I believed it. I used to think I had the market for quality cornered, that my time was valuable, that most people don’t deserve access to care and if people couldn’t afford my fees they were better off without care. Over time and with experience I learned that I was wrong and I’m very happy to have broken free of the groupthink that our profession so staunchly defends.
    PS If you want a group to go after for rending bad and irreversible treatment to patients then go after the Tweed boys… They take out all 4s and upper 6s like it’s nothing. If you want to see what that looks like after a few years go to UT Memphis and pull some cases.

  5. What percentage are ABO certified? Not enough. But does lack of certification preclude adoption of the standards? Just because someone has treated a dozen or so cases only, are the outcomes doomed from the start? As for experienced orthodontists, does the mere fact that they have existed longer and treated more cases automatically confer on them the mantle of “better”? Treatment guidelines/standards exist as an ongoing process to accomplish better treatment quality and patient outcomes. They are clearly not a “refund” mechanism. However, they are used for just that when cases end up in litigation and/or peer review. Just because some “traditional orthodontists” do not offer to pony up money (for whatever reason) when a case is less than ideal, does not make for a compelling argument to do away with standards. Agreeing with you or me is really not the point. The folks pushing SDC have a financial interest in its’ success and this is often in direct contravention to what is best for the patient. Most practitioners absolutely care about income (like they should), but it is not (and should not be) at the expense of patient care. There are of course uncritical/unethical actors, but again why do we persist in using the lowest common denominator as a yardstick? That seems very self-serving. The point you make re: practitioners being aggressively unethical is a very important one, and I completely agree with that, but two wrongs don’t make a right. I never said people should be punished or convicted for what might go wrong…I just happen to completely disagree with the existing limitations on the mode of delivery and can’t see how things could go right. Lack of consensus regarding treatment modalities in some cases doesn’t mean ambiguity in what is considered negative sequelae of treatment. For example :
    1. CC not satisfied
    2. Poorly aligned teeth
    3. Poor or unimproved occlusal function
    4. Poor or unimproved dental and facial esthetics
    5. Excessive root resorption
    6. Loss of periodontal support
    7. Instability of the treatment results
    While these can certainly occur in practice, with this mode of delivery, it almost seems guaranteed!! Just because x-rays may not be mentioned in the DPA, does that obviate their need? Letting it play out is perfectly fine if it was perfectly harmless, which unfortunately it is not since there is a person at the business end of that aligner. Damage to personal profit is certainly a motive for some opponents of SDC, but that certainly doesn’t change the complexion of the other criticisms. After all, aren’t SDC and its proponents concerned about profit margins too? They are certainly not an NPO serving an underserved populace. Millions of people cannot afford to pay 1,500$ for SDC aligners. Is this steep fee fair to them? If altruism reigned so paramount with these access to care advocates, why not charge 100$ or less and treat the case to a lower standard yet. After all, some straight is better than no straight. Why this 1,500 $ cutoff? Just because you used to think something in the past, and have now changed your mind doesn’t necessarily obviate the validity of your former perspective. After all, who is to say that you might not ever adopt a different perspective more in line with your former views? Groupthink doesn’t mean it is the wrong thought. As for irreversible damage with orthodontics, I have seen it range from compromised facial esthetics to teeth pushed out of the alveolus with this all or none extractionist/expansionist debacle. A treatment modality is not attributable to the damage wrought by inaccurate diagnosis, improper treatment goals and shoddy mechanics. We don’t eschew driving just because someone we know had a car crash. Or in your example, eschew premolar extractions because somewhere in Memphis, someone/s rendered what was arguably bad/irreversible treatment involving extractions. That outcome is hardly an inevitability…like you said, it doesn’t have to be “all or nothing”.

  6. Agreed. You make some goood points and a well thought out argument. Thanks so much. You also make the argument for teledentistry well though I know that’s not your intent. As to free treatment I’ve done more than anyone I know of. Millions of dollars worth and I’ll continue doing so. Thanks for your time. Stay true to what you believe and I’ll do the same. It would be great if you’d consider the fact that you’re speaking theoretically about the “dangers of teledentistry” since it’s obvious you’ve never done any. Also you might want to look at patient complaints per 1000 cases treated in traditional offices vs teledentistry before being too sure you’re right as I’m afraid you’ll be shocked by what you find. Either way we can agree to disagree and see what the future holds. Have a great Sunday.

  7. Likewise. I really enjoyed the debate and hope that tele-dentistry does indeed work out to have a positive impact on patient care and treatment outcomes. it would be fantastic to elevate standards and access. Cheers and enjoy the rest of your weekend!

  8. Hello – I’m just a doc from the country where much goes right over my head. Would you care to elaborate the meaning behind the photo of brazil nuts with the #LysleJohnston used in several of the recent posts? Thanks in advance

  9. Great question. It’s not my story to tell however. I’m sure it will be told in time though. All in good time.

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