Orthodontists and State Boards

To most orthodontists, a letter from the State Board of Dentistry is about as welcome as a letter from the IRS. Although it is possible for either letter to bring good news, the possibility of bad news is always on your mind. Why is this and what are the appropriate roles of the state board and the practice of orthodontics?

All states require qualified dental professionals to have a license to practice dentistry in their state. The purpose of this license is to protect the people by controlling the quality of dentistry offered to the citizens of that state.

State boards grant licenses to practice dentistry on the basis of an applicant successfully completing a series of written and clinical examinations. Today, all states recognize the results of the written National Dental Board examination as a benchmark for licensure.1 States also give an examination on local matters such as that state's dental practice act. The results of a clinical examination given by a regional dental board are accepted in most states, but 10 states still provide the clinical examination themselves.1

Keeping in mind that the primary purpose of a dental licensure is to ensure the level of quality of care offered to the citizens of that state, how does this system ensure quality orthodontic care to these same citizens? Well, in the majority of states an orthodontist is licensed exactly the same as all dentists are licensed. In other words, the presumption is that passing a licensing examination for general dentistry assures the public of good quality orthodontic care.

In practice, this means that in most states the public is assured of quality orthodontic care by the fact that an orthodontist has demonstrated proficiency in executing dental restorations and assorted general dentistry tasks. I do not know of any evidence-based arguments in support of this presumption.

In many other states (22 or 23 is the last information I saw), persons applying to limit their practice to orthodontics must pass some form of additional orthodontic examination. This practice is consistent with the position that special knowledge and skills are necessary to announce oneself as in a limited practice.

Inasmuch as states protect the public by licensing dentists and, inasmuch as practitioners in a limited practice are allowed to present themselves to the public as possessing special expertise, is it appropriate for states that do only a general dental examination to presume that a general dental examination guarantees the public adequate quality orthodontic care?

The licensing issue has many ramifications and the debate has gone on for decades. The qualifications for a license are important in this debate. One school of thought argues that the entrance examination for licensure is necessary to provide quality services in the state. If this position is correct, it seems important that this entrance examination properly assess the orthodontic capabilities of orthodontists entering that state.

The alternative school of thought argues that entrance level license examinations do not protect the public and are not valid in measuring the quality of care to be delivered by an applicant. If this view were correct, then all licenses would be granted on the basis of some criteria other than entrance level examinations.

Although the existing positions are long standing and strongly held, other scenarios are possible. Both the state boards and The American Board of Orthodontics (ABO) have quality orthodontics for the public as their goal. Imagine what it would be like if

1. ABO certification was awarded in some form at the same time a person completes an accredited orthodontic program, which includes some form of ABO evaluations (this does not preclude approval requiring on-going performance evaluations) and

2. States moved to a position of requiring ABO certification as a measure of competency for persons who wish to announce a practice limited to orthodontics in their state.

The result would be win–win–win. States would win with an assurance of a valid entrance examination directed at orthodontic competency. The ABO would win by becoming the gold standard for defining quality in orthodontics. And, perhaps most important, the public would win because all practices limited to orthodontics would mean fully prepared and competent orthodontists.

I urge consideration of these ideas. They hold great potential to help states make their licensing procedures more valid. They raise the ABO's stature as the body that sets minimum standards for acceptable orthodontic care and make the ABO represent virtually 100% of the orthodontists. Perhaps, most importantly, the ABO's most important role becomes providing the public with a way of knowing where to find quality orthodontic care. All it requires is for the state to accept the ABO certificate as qualification for announcing a limited practice and for the ABO to modify their goals and objectives for certification.

My interest in this subject grows out of my experiences consulting in cases of orthodontic patient dissatisfaction, serving as a member of a state board and serving as an examiner on a regional board. It was clear to me that even in the most egregious cases, boards were often uncertain about how to judge the merits of complaints involving orthodontic care. It was also clear to me that boards welcomed consultants or reference groups from organized orthodontics for advice in these cases.

A proactive posture calls for us to offer our expertise to fill this need. The alternative could well come from outside of organized orthodontics and we are the best judges of orthodontic care. Can we afford to do anything less?