Orthodontic and future Alton

W. Moore,

education: Past, present,

D.D.S.,

M.S.*

Seattle, Wash.

T

o understand the dilemma that the orthodontic specialty finds itself in today, one must review the history of orthodontics and orthodontic education. Without this perspective, it is impossible to comprehend the frequent hostility and biting criticisms leveled at orthodontists by some within the dental profession and the resulting reactions of the orthodontic specialists. Charges of secrecy, aloofness, separateness, exclusiveness, and so on are harsh and bitter criticisms, difficult to bear by the members of any group. One could rationalize such charges as being based upon jealousy, envy, or other irrational reactions to any successful group or individual. We know that individual examples of secrecy, aloofness, etc. can be cited for any of the various branches of medicine and dentistry. Why, then, has orthodontics as a group been singled out to be the “Peck’s bad boy” of dentistry? As a result of this situation, orthodontists have been in recent years getting more and more “up tight” and defensive and now are on the verge of developing a real case of paranoia. This has led to overreaction, hysteria, and sometimes irrational statements or actions on the part of some orthodontists and, in several instances, of small orthodontic groups. How did this situation develop and what should be done now to ameliorate or correct the serious problem that is injurious not only to the total dental profession but, more important, to the patients and the public whom it is our privilege to serve? A partial answer to these questions can be found in interpreting historic events with the benefit of hindsight and a little retrospective analysis. The current situation began when the first formal educational program for dentistry was established in 1840 in Baltimore, Maryland. Prior to that time Mershon Association *Professor Dentistry.

42

Memorial Lecture, of Orthodontists of

Orthodontics,

presented at the annual meeting in Las Vegas, Nev., April 20-23, 1975. Associate

Dean,

University

of

of

Washington,

the

American School

of

Orthodolltic

educntiox

43

knowledge of dentistry was for the most part transmitted by the time-honored custom of preceptorship training. Dentistry began as a “how-to-do-it” profession. Hence, the formalizing of dental education primarily involved the teaching of surgical techniques and restorative procedures. The development of organized dental education was preceded by that of medicine. Most of the early dental educators and leaders had already qualified for medicine prior to their interest in dentistry. Thus dentistry might be considered one of the first specialties of medicine. Dentistry’s

break

from

medicine

The break or separation from medicine was based probably on the high incidence of dental disease and the rapid development of restorative and surgical procedures and techniques for their implementation. The body of such specialized knowledge and techniques became increasingly more voluminous and complex and thus required more and more time for transmission. The major emphasis was placed on learning to execute the exacting procedures being developed and this set the tone of dental education for years to come. Concomitantly, the medical profession, more generally physical disease oriented, began to develop and utilize the body of knowledge that we now call the “basic biologic sciences.” Through the study, development, and application of these sciences, the cures for many of the diseases that had always plagued mankind began to be revealed. Some dental educators, with previous medical background, recognized that the rapid advances being made in medicine through the study of the biologic sciences portended equally important breakthroughs for dentistry. These educators still tended to regard dentistry as a specialty of medicine. Their numbers, however, were small in relationship to the growing number of dentists who were trained following the initiation of formal dental education. Unfortunately, the will of the technically oriented dentists and dental teachers prevailed in determining the path that dental education was to follow for the next century. A few, to whom we owe the scientific basis for modern dental practice, continued to strive to broaden the base of our knowledge and increase dental horizons. CT.V. Black, Angle, and Case are examples of such men, and all were physicians as well as dentists. It was only natural that they viewed dentistry in a different light from their dent&y onZy trained colleagues, who were more technically oriented. Black provided a scientific, theoretical basis for the development of the art of restorative procedures, and Angle and Case did much the same for orthodontics. Orthodontics interested a limited number of dentists between 1840 and 1890, and the vast majority of these were also physicians. It was regarded as a very incidental part of dentistry by the newly developing dental schools and of more interest to the physician-trained dentist than to those whom they were training for dental practice. The early orthodontic pioneers produced a substantial body of literature during this period, but it did not find its way into the curriculum of the dental schools. Around 1890 Angle presented a rational approach to the study of ortho-

dontics with the development of a classification system for malocclusion. A system of orthodontic treatment procedures based upon the classification logically followed. Thus, the first major step was taken to develop a pore of knowledge that was soon to provide the basis upon which formal orthodontit~ &l~ciltioll was to be built. Except for the subjects of’ ora. anatomy and oc~luaion little if any of the formal dent,al knowledge of that day was applicable to ortbodontics and its study. Concepts of heredity, bone growth, and comparative anatomy, however, which were being studied by workers in the basic biologic sciences in medicine, obviously were related directly t,o the developing field of orthodontics. With their medical backgrounds, Angle and Case drew upon the related developing biologic sciences for background information and possible answers to the many clinical problems of orthodontics. At this same time dental education per se was not appreciative or cognizant of the need for biologic training in the background of its graduates. Late in the 1800’s Edward H. Angle and Calvin S. Case separately announced themselves as being in the exclusive practice of orthodontics and thus became the first orthodontic specialists. Orthodontics-a

specialty

or a profession

Angle, founder of “scientific orthodontia,” probably did more than any one man in dentistry to foster this branch of dental science, causing its separation from general practice and thus bringing about its specialization and advancing it to a recognized science. He proposed that orthodontics and general dentistry were radically different and constituted in reality separate specialties of medicine-dentistry being the study of the disease of the mouth and orthodontics the study of the relationship of the teeth to the development of the face. To him, orthodontics was not a part of dentistry but a sister profession. Angle described the situation which led to the establishment of the Angle School in words which are quoted by Weinberger’ as follows : In 1880 I had become very much interested in orthodontia, and I came to believe that some time, perhaps after a long time, orthodontia would be practiced as a specialty, for it seemed to me that its importance entitled it to a closer study and application in practice and that only would enable anyone to become sufficiently familiar with its principles and master its technique, to overcome its difficulties and be successful in its practice. This conviction has constantly grown upon me in the years that have followed. In 1896 I advocated its teaching and practice as a specialty in a paper read before the Western Pennsylvania Dental Association, which was published in the Dental Review. My experience in teaching orthodontia in four different dental colleges covering a period of thirteen years convinced me that it was impossible ever to successfully teach it to dental students. This is abundantly proved, I think, by the fact that although orthodontia has been a part of the curriculum of all the dental colleges from Harris’ time down, not one dental student in all that time has gained sufficient knowledge of the subiect in the dental college to enable him to practice it with sufficient success to make it his sole means of gaining livelihood, in spite of the immense number of these deformities in every community.

VoZww

Number1

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Orthodox tic education.

69

I then tried Northwestern

hard to impress University and

the the

management University

of

of the dental Pennsylvania

45

departments of with the desira-

bility of their forming special departments devoted exclusively to the study and practice of orthodontia. I proposed that orthodontia in these institutions should be made optional; those having an aptitude and liking for the work giving, after the second year, their entire time to its study and practice. The answer was, always, “This is too Utopian,” or “It is too early.” Having become entirely discouraged with my experiences in dental colleges, I became filled with the belief that if orthodontia was to make any material progress, a separate school, formed, which would amply liking for the subject to study and where it would be relieved which are necessarily thrown the Angle School of Orthodontia.

entirely independent of dental schools, must be provide opportunity for those with aptitude and in a broad, thorough, and comprehensive manner, from all the blighting, handicapping influences around it in dental colleges. Hence was founded

It is evident from the above description that Angle found through his experience in teaching in four different dental schools, that orthodontics held little interest for the students he was instructing and that the curriculum time necessary to develop his teaching program was not available. Nor was there much interest in the emerging related biologic sciences which he recognized as basic to the understanding and practice of orthodontics. As a result, he left dental education and formed his own school of orthodontics where he had complete control of the curriculum. This set the pattern for orthodontic education for many years to come. As Angle said, although orthodontia had been a part of the curriculum of all the dental colleges from the very first, not one dental student in all that time had gained sufficient knowledge of the subject in the dental college to enable him to practice. What he did not say, however, was that orthodontic training in the curriculum was not of sufficient significance to dental educators to be set up as a division or department within the school; rather, the responsibility for its teaching was assigned to the department of prosthodontics. Den’tal

educators’

early

reaction

to

orthodontics

It is obvious that the dental educators of that day viewed orthodontics as primarily the construction of appliances and had little if any appreciation for the complexity of the science as it was being developed by those who were devoting their life’s work to its study. Thus, the die was cast, with orthodontic education developing primarily outside the formal dental education institutions. Unfortunately, the so-called orthodontic teaching programs that were developed in the undergraduate dental schools up until 1920 were technically oriented like the rest of the curriculum without the presentation of the basic biologic principles essential to an understanding of orthodontic diagnosis and treatment planning. These inadequate efforts created chaos in the dental school clinics, where failure of orthodontic treatment was the rule rather than the exception. The few specialists who were adequately educated in orthodontics

were not numerous enough to man the orthodontic teaching programs ~lcvcloped by the undergraduate tlcntal schools ; thus, the tcaehing was c7~rric~tl out by persons who had an interest in the subject but were ill pt~cparctl to teach it. Even if an adequate number of potential orthodontic* teachers had existed, evidence indicates t,hat the schools would not ha.vc btcn willing to devote a sufficient amount of time to do an adequate job of orthodontic education. The art and techniques of restorative dentistr,v were expanding rapidly and dental education devoted its major efforts to its enhancement. Endodontics, periodontics, and pedodontics were beginning to he recognized as an integral part of the general dental curriculum, so we began to see a lengthening of the course work necessary to become a dentist, culminating in the 4 y-car curriculum. Patterned after medicine, watered-down versions of the basic biologic sciences were also added to the course of study, with the teaching of the possible clinical application left to clinicians with little background in the subjects. Restorative dentistry, endodontics, periodontics, and pedodontics continued to demand more time as these disciplines increased in complcxit!, and sophistication, to the point where going to dental school meant an g-hour day and a s-day week for 4 years. A large number of the dental sc*hools were privately owned and were required to operate at a profit to the owners; hence “quantity” production was the guiding rule for the dental clinics. The subject of orthodontics, except for a few lectures, was virtually dropped by most of the undergraduate dental schools in the early 1920’s. It emerged as a postgraduate program in several of the better established schools at that time. Because of the small number of available student places and schools, however, preceptorship training for ort,hodontic specialization b(~~anl(~ the pattern. Orthodontics

placed

back

in dental

curriculum

It was not until 1935, when the curriculum survey report2 of the American Association of Dental Schools was published, that a formal recommendation was made to place orthodontics back in the dental curriculum. Implementation of this recommendation was another matter. The 4 years of dental education were already crammed with the subject matter that had developed within the formal framework of dental education. Where then, was orthodonticas, which had developed outside the dental school setting, to be plac*cd in an already overcrowded curriculum? Lip service was given by dental educators to the need for orthodontics to be taught in the undergraduate curriculum, but they had no idea what this entailed nor how such a program should bc developed. In addition, no one was willing to assume the necessary expense or add a fifth year to the dental curriculum t,o accommodate the teaching of orthodontics or, conversely, willing to delete anything from the current course of study that existed. Hence, token lectures were added to comply with the recommendation of the curriculum survey. Only one exception can be cited for advanced thinking on thr part of a dental

Volume Number

Orthodontic

69

1

educatio9i

47

educator. Guy S. Millberry recognized the dilemma facing dental education of how to crowd more into an already full dental curriculum without increasing the time necessary to negotiate it. In 192’73 he began to talk about devising a pathway curriculum in dentistry. He proposed two pathways-restorative dentistry and children’s dentistry. In 1930 4p5 he initiated this dual curriculum at the University of California College of Dentistry. After his retirement in 1937, it was continued by Deans Willard Fleming61 ’ and Wendell Wylie8-*0 and operated successfully for 37 years until 1967, when it was scuttled by the Council on Dental Education of the American Dental Association. Millberry’s plan became known as Curricula I and II. Curriculum I was restorative dentistry oriented, with only the basic fundamentals in children’s dentistry and lectures in orthodontics included. Curriculum II was designed to produce a child specialist with the basic preparation of a specialist in orthodontics. In order to create the necessary time in Curriculum II the students received only special lectures in prosthodontics and fixed partial dentures, with very limited laboratory instruction in prosthetics and fixed partial denture techniques, and no clinical experiences in these areas. The time thus freed was approximately one third of the total hours of the former dental curriculum and was devoted entirely to orthodontic education. The program content and time were comparable to the postgraduate programs of the time. It was Millberry’s initial goal to produce a pediatric dentist capable of managing all of the dental problems of childhood, including orthodontics. The men so educated qualified well as orthodontic specialists, however, and, largely because of the requirement of the orthodontic specialty organizations for exclusive practice, the majority abandoned Millberry’s concept of the pediatric dentist and became orthodontic specialists. Prior to 1945, the very limited number of available student places in orthodontic postgraduate educational programs led to the wide utilization of preceptorship training for those desiring to become specialists. Many of these individual training programs were little more than “slave labor,” but they were a practical necessity if the aspiring specialist wanted to become recognized as an orthodontist and to qualify for membership in the orthodontic specialty organizations. The end of World War II saw many dentists returning home from the military service with educational benefits available to them and the desire to become specialists. The demand for postgraduate orthodontic education was extremely high. The schools responded by establishing many new postgraduate programs in orthodontics but still were not able to meet the demand. The individually arranged preceptorships still took up the slack. Supervised

preceptorship

with

peer

review

In 1957 the American Association of Orthodontists, as a result of a move by a large number of formally trained orthodontists to abolish preceptorship training, established formal requirements for preceptorships with required peer review and supervision. They also developed formal requirements for

4%

Moore

postgraduate orthodontic education. In addition, they set the year 1967 as the final year in which a preceptorship program would be recognized as meeting the requirements for membership in the American Association of Orthodontists. The American Board of Orthodontics adopted the same educational requirements for candidates seeking eligibility status leading to eventual certification. Due to the fact that the advanced program of orthodontic education that had been conducted successfully at the University of California for 37 years was taught at the undergraduate instead of the postgraduate level, it had been classified with preceptorship status and its graduates required to serve an additional 2 years of semisupervised guidance under the supervision of a member of the American Association of Orthodontists. This requirement consisted of an American Association of Orthodontists’ member certifying that he had visited or consulted periodically with the Curriculum II graduate in the graduate’s own ofice. The 1967 demise of the American Association of Orthodontists’ formal preceptorship program threw a cloud over the status of Curriculum II. The Council on Dental Education of the American Dental Association, using the American Association of Orthodontists’ and the American Board of Orthodontics’ discontinuance of recognition of preceptorship training as a basis, applied the coup de grace by discontinuing formal accreditation of Curriculum II. Thus, ended a 37-year-old successful experiment in dental education. When a program operates successfully for 37 years and its graduates have one of finest records of candidates examined by the American Board of Orthodontics from any of the formal educational programs, is it still an experiment? Undergraduate

orthodontics

Since 1945, and up until the present time, dental administrators continue to discuss and press for orthodontics to be taught at the undergraduate level but they still refused to answer the question by providing the necessary time in the curriculum. These discussions, with no time allotment or real commitment on the part of the dental schools, have led to charges that orthodontics was tell students who hoarding its “secrets.” Dental educators and administrators ask “Why no orthodontics?” that orthodontists are not willing to teach in the schools and give up their “tricks of the trade.” Many educators, because of their lack of knowledge of orthodontics, still regard it from a “how-to-do-it” point of view. The few orthodontic educators who have tried to create orthodontic educational programs at the undergraduate level have attempted in vain to secure adequate curriculum time. Some attempt, in the minimal time available, to instill dental biology into their teaching program as an essential basis for understanding the science of orthodontic diagnosis and treatment planning. This approach is looked upon by many of their fellow dental teachers and students as a diversionary practice to avoid divulging the true secrets of orthodontics. Most students conditioned by the traditional approach to dental education are only interested in how to do it, not in wh.v or whether it should be done at all. Thus we see that formal orthodontic education, for the most part, developed outside of dental education primarily because it was never really recognized as

VoZunze69 Number1

Orfhodo?ltic

education

49

part of the undergraduate curriculum in dentistry. Orthodontics might well have developed as a specialty of medicine rather than dentistry if the early workers in the field had so chosen. A dental degree was required by Angle of the early students who sought specialty training in orthodontics in his first school of orthodontics. The pattern of orthodontic education being laid down outside of the dental schools’ jurisdiction caused orthodontics to develop its own curriculum, basic sciences, and technical skills. Little of this basic knowledge found its way into the dental curriculum in spite of numerous attempts by dedicated orthodontic teachers. Orthodontics’

dilemma

today

So, after 70 years of separateness, is it any wonder that dentists and dental educators without orthodontic backgrounds seem to cast a jaundiced eye toward the orthodontist B Never having been exposed to orthodontics, except in a cursory manner, they lack the background to understand and look at the specialty or its area of knowledge in an objective way. All they can visually see is the applicances used by the orthodontist so it appears that all the answers to the “real secrets” must be mechanical. When the orthodontist says that the mechanics involved are incidental, and that you must first master certain basic biologic principles, he is interpreted as being evasive and protecting his secrets. This is the dilemma orthodontics finds itself in today. The preceding historical discussion gives some insight into some of the major factors that have contributed to the lack of communication between dentistry and the specialty of orthodontics. Lack of communication leads to misunderstanding and then to charges of secrecy and aloofness. To understand the reasons behind the unwarranted attitude of many in the dental profession is, however, of little solace to the orthodontic specialist. Orthodontics’

secrets

All the knowledge that is basic to the specialty of orthodontics is in the area of public domain. There are no secrets and no part of the knowledge necessary to the successful practice of orthodontics is reserved for the exclusive use of the orthodontist alone. How to transmit this information to the dental profession is one of the most frustrating problems facing orthodontics and orthodontic educators toda.y. The incorporation of such material into the dental curriculum requires a commitment of time and faculty on the part of dental schools and educators that so far they have not been willing to make. As pointed out previously, only one school in the history of formal dental education has made the attempt, the University of California at San Francisco. They were forced by outside pressure to discontinue their program after 37 years of successful operation. Guy S. Millberry obviously lived 50 years before his time. The only real answer to orthodontics’ present dilemma is education. It is time for orthodontics to take the offensive and abandon the defensive posture that it has been forced into through lack of understanding. Orthodontics was the first and continues to be a t.rue specialty of dentistry and should continue to be recognized as such. Much of the foundation knowledge

50

Moore

upon which the science of orthodontics is based should bc as importailt to the practice of all phases of dentistry as it, is to orthodontics. An understanding of normal occlusion and its variations in all stages of its growth and development is essential to being able to recognize a malocclusion in its incipiency. Such an understanding requires a basic knowledge of craniofa.cial morphology, cephalometrics, normal and abnormal growth and development of the fact and jaws, the anatomy and physiology of muscle and bone tissue, a working knowledge of genetic principles, and other information too detailed to spell out here. To impart this information in a meaningful way to students in dentistry would require hours numbered in the hundreds rather than in the tens which are now devoted to undergraduate orthodontic instruction. Once a student has this background he is then in a position to study orthodontic diagnosis and treatment planning, which will require several hundreds of additional hours of study and application. Obviously, no undergraduate dental school is at present committed to this required expenditure of time. In face of the twenty to as many as 200 hours of instruction time now being assigned to undergraduate orthodontics in the dental schools of the TJnited States, most orthodontic educators have given as much of the necessary background material as time permitted, but rightly have refused to have students engage in clinical treatment without knowing the basic principles of diagnosis and treatment planning. The primary role of dental education should be to produce a knowledgeable intelligent dentist first, not an uneducated technician trained to perform manual tasks by rote. The orthodontic educator’s reluctance to teach techniques prior to a basic understanding of the subject has caused unhappiness upon the part of students, general dental practitioners, and dental school administrators. Too frequently we hear from dental school administrators, “just show them how, and let them move a tooth to keep them happy.” This is tokenism in its worst form and a potential serious threat to the public’s welfare to which the dental administrators, at the same time, so nobly give lip service. Dental

education

responsibilities

If dental school educators are serious in their expressed desire to include some orthodontic clinical practice in the armamentarium of the general dental practitioner, they will have to provide the necessary curriculum time and faculty to achieve this goal. They could add two academic years to the dental curriculum, which is the time proved to be required to produce a safe beginner in the practice of specialty orthodontics, but this is obviously an impractical and generally unacceptable solution. What, then, are the alternatives? The answer is simple. T)ental educators should recognize the fact that the scope of dentistry has expanded well beyond the point where it can all be taught and mastered in a 4 year time frame. Medicine recognized this fact years ago and extended its minimum time requirements to 5 and more years with required residencies and the institution of specialty training programs. Dentistry followed suit with postdoctoral specialty programs, but still clung to the traditional 4 year predoctoral program where it is expected unrealistically that all possible phases of dentistry should be basically mastered.

In the past 10 years medicine has moved on to predoctoral pathway education for the M.D. degree. They recognize that gradua.tes will have varying backgrounds and skills according to their aptitudes and interests, with the only commonality being their M.D. degree. Interestingly enough, the first pathway system of professional educat,ion was introduced by Millberry in 1927 and was tried and proved successful for 37 years. The obvious answer to the dilemma in dental education today is to restudy and reinstitute the pathway approach in dental education. Like all sciences, dentistry’s knowledge and sophistication has grown exponentially during the past 40 years, yet we attempt to teach it all in the same 4 year framework that existed 40 years ago. We should recognize that the time of the “cradle-to-the-grave” dentist is now past. The practice of dentistry is rapidly changing due to advances in prevention knowledge and techniques, public awareness of the need for dental service, changing patient needs, and social pressures from consumer groups a,nd politicians. The gradual demise of solo practice and the advent of trained auxiliaries, to mention just two influences, require redefining the roles of the dentist and his relation to the dental specialties. Such modified definitions of dental professionals will then determine the most suitable curriculum to achieve their education. Millberry showed a way almost 50 years ago with two curriculum pathways, one in restorative dentistry and the other in children’s dentistry. Today, in view of the many changes and advances made in dentistry over the past 40 years and in the changing philosophy concerning the methods of delivering dental health care, the pathway approach would require some modification from Millberry’s original concept. For example, three basic pathways could produce several end products in a 4 year period that would handle the majority of the public’s dental problems and needs. The remainder of the dental needs still would require attention from the various specialty areas. The suggested pathway options at the predoctoral level are general practice with emphasis on adult dentistry, general practice with emphasis on dentistry for children, and preventive dentistry. Two of these pa.thways would produce professionals basically equipped to provide for the most common dental needs of our population by age grouping and the third proposed pathway would produce a public health oriented person whose general need is recognized but whose finite role in the dental care delivery system is yet to be established firmly. The

“core

curriculum”

and

“pathway

system”

The following is offered to illustrate how a curriculum might be constructed in a pathway system of dental education (Fig. 1). First, there is a core of knowledge essential to the intelligent practice of dentistry, regardless of the particular areas to be emphasized in any pathway curriculum. This core portion of the curriculum should be carried on throughout the 4 years of dental education. No part of dentistry as it is now constituted should be totally eliminated from any curriculum that is developed; thus, a portion of the knowledge of all areas will constitute the core curriculum. It is essential for all dentists to be conversant with and aware of the therapeutic possibilities and benefits for any oral con-

52

Moore

SPECIALITY AREA

1

2

3

4

5

6

YEARS W

Fig. 1. Possible

-

~4

PREDOCTORAL ,DDI, construction

of curriculum

in pathway

POSTDOCTORAL MS, system

of

dental

education.

dition that a patient might present that requires some form of dental treatment. The core curriculum should be developed with this in mind. It is suggested that the first year of the dental curriculum be composed entirely of core teaching, with the jnt,roduction of a survey course that would enable the students to intelligently select the pathway that more nearly matches their aptitudes and interests. The remaining time left in the curriculum, after accounting for the core portion, would then be devoted to subjects and clinical activities in the individual pathways. The first step in developing a. pathway curriculum design would be to define the core curriculum. We have already indicated that no recognized clinical discipline should be eliminated, so how do we determine what constitutes the core of any clinical area ? Knowledge in any of the clinical divisions of dentistry can be viewed as a continuum of the total body of knowledge which comprises that area and can be expressed in percentage or in the number of hours required for mastery of that particular discipline (Fig. 2). The required level of learning of the discipline will vary with the needs of the particular health professional being educated. For example, of the 100 per cent total knowledge of a given clinical area, a person may need 15 per cent to understand the area and to he able to intelligently refer for treatment and 75 per cent to diagnose and render treatment for, say, 60 per cent of the population, and 100 per cent to qualify as a true specialist in the area. The percentage of knowledge input, then, for each of the clinical disciplines would vary according to the type of dentist being trained. In the example illustrated in F’ig. 2 the initial 15 per cent of the knowledge of orthodontics would constitute the core portion of the curriculum for all pathways. The end objective would be for the individual to understand t,he discipline and to be able to intelligently refer patients for treatment. It should be recognized that the time required to master a given segment of curriculum would vary according to the complexity of the subject matter being taught within a discipline, as well as among the various clinical disciplines.

Volume 69 Num her 1

education

Orthodontic

53

--POSTDOCTORAL-

PREDOCTORAL

UNDERSTAND -AND INTELLIGENTLY REFER DIAGNOSE AND RENDER TREATMENT FOR60% OF THE POPULATION

WDEQUATE

SPECIALIST Fig.

2.

Expression

of

percentage

of

time

required

for

mastery

of

a particular

discipline.

Following up on this approach, the curriculum for each of the proposed pathways might resemble the illustrated distribution of per cent of curricular time for the various components that now comprise an average dental curriculum (Table I). Column 1 of the table contains the per cent of curricular time now devoted to each of the listed broad subject matter headings in at least one general dental curriculum. Column 2A contains the projected hypothetical per cent of time necessary to basically understand and intelligently refer a patient for necessa.ry treatment. Column 2B shows the additional per cent of time necessary to learn initial treatment procedures. The per cent of time indicated in Columns 2A and 2B, therefore, would constitute the core curriculum common to all pathways and comprises 63 per cent of the total available curricular time. The next three columns illustrate the remaining hypothetical per cent time distribution for each of the proposed pathways, i.e., pediatric dentistry, adult dentistry, and preventive dentistry. It should be noted that basic science instruction, oral diagnosis, and elective time are common in time allotment for each of the pathways. Decreased curricular coverage in subjects peripheral to the main pathway creates the curriculum time necessary to produce health professionals well equipped to deal with the dental problems of the age group in which their studies have been concentrated. Estoblishing

educational

objectives

and

time

requirements

In order to define the best balance of time distribution between curricular subjects for each pathway, each area or discipline would have to establish educational objectives and time requirements for each of the proposed health professional types. In lieu of this it is possible to make a tentative approximation based on previous experiences and knowledge of general dental curricula. If 4,000 is the “magic” number of hours in a S-year dental curriculum, then Table II illustrates the hour distribution among the various subject areas based upon the previously suggested hypothetical percentage distribution. It may be

54

Moore

Table

I.

conventional

Suggested and

percentage various

pathway

of

time

in

subject

matter

in

a

4

year

curriculum-

options Pathway

curricula

Core Conventional curriculum f%)(l)

13 32 10 10 10 5 5 3 2 2 2 6 Total 100

Subjects or clinical areas

Basic sciences Restorative dentistry Oral diagnosis Periodontics Prosthodontics Endodontics Pedo-ortho Oral surgery Community dentistry Hospital dentistry Auxiliary utilization Electives

Understand and refer (%I (2AJ

13 10 2 2 2 I 2 1 2 2 2 0 39

Basic treatment knowledge f%) PB)

7 8 5 I 1 1 1

24

Pediatric dentistry

(%I (3)

Adult dentistry

VW (4)

Preventive dentistry

(%I (5)

15 3 7 3 31

I 3

6

6

37

37

16 5 3 6 37

noted that in this example, the pediatric dentistry pathway would have a total of 1,240 hours, plus an additional 240 hours of elective time, for a grand total of 1,480 hours. It is interesting bo note that the American Association of Orthodontists in 1957 suggested a minimum of 1,500 hours of instruction for recognition of a formal postdoctoral orthodontic education program. Since that time the requirement has been changed to two academic years of full-time residency. In the adult dentistry and preventive dentistry pathways the time distribution between the various subjects could be altered according to the student’s interests and aptitudes to better prepare himself for other specialization, if that is his goal. Any three of the pathways with an additional year’s study could lead to the creation of a new specialist for dentistry, whose counterpart has already been created in medicine, the family practitioner, The fifth year of study would be in those subjects not emphasized in the initial pathway program. The family practitioner would be equipped to take care of the common dental needs of the entire family but would still call on the specialist in t,hr more difficult cases. It may be asked what effect the pathway system of dental education would have on the current specialties of dentistry. The answer is, little, other than to redefine in some instances what constitutes certain specialties’ spheres of practice. Students graduating from the adult dentistry pathway would be well equipped to begin study in the specialties of prosthodontics, endodontics, periodontics, and oral surgery. Graduates of the preventive dentistry program would be well on their way to graduate work in public health. All three pathways could lead into advanced study in the specialty of oral pathology. The graduate of the pediatric dentistry pathway would be comparable in education and training to our present-day pedodontist. He would be ideally

vo1unae Number

69

Orthodox tic educntio9k

1

Table II. Suggested hours of time in subject conventional and various pathway options

in a 4,000 hour

matter

Pathway

55

curriculum-

curricula

Core Conventional curriculum (1)

520 1,280 400 400 400 200 200 120 80 80 80 240 Total 4.000

Subjects or clinical areas

Basic sciences Restorative dentistry Oral diagnosis Periodontics Prosthodontics Endodontics Pedo-Ortho Oral surgery Community dentistry Hospital dentistry Auxiliary utilization Electives

Understand and refer

654) 520 400 80 80 80 40 80 40 80 80 80 0 1.560

Basic treatment knowledge

(2BJ 280 320 200 40 40 40 40

960

Pediatric dentistry

Adult dentistry

(31

(4)

Preventive dentistry

(5)

600 120 280 120 1,240

280 120

240 1.480

240 1.480

640 200 120 240 1.480

equipped to enter into postdoctoral educational specialty programs in orthodontics or pedodontics. This would require, however, redefining the role and education of the present-day pedodontic specialist. A logical redefinition would be an individual equipped to deal primarily with the dental problems of severely handicapped pediatric and adolescent individuals, with care being administered, for the most part, in specialized surroundings, i.e., hospital environment or like facilities. The definition of the orthodontic specialist would remain much as it is today, but his postdoctoral education would emphasize adult orthodontics, surgical orthodontics, and the orthodontic management of more complex problems than it is possible to cover in today’s curriculum because of time limitations. The pediatric dentistry pathway graduate would be ideally suited for true graduate study in orthodontics. A graduate of any of the pathways determining at a later date he would like to pursue postdoctoral education in one of the specialties his initial education de-emphasized could take the additional year to become a family practitioner and then enter into his specialized postdoctoral field. The old argument will be raised against the pathway approach to dental education : “DO the students know so early in their educational careers which pathway to choose?” The answer can be stated, simply, “Do they relate best to children or adults?” Only a few will be preventive dentistry oriented but they will be aware of it and so choose. A balance will have to be established in the number to be admitted to each of the pathway programs that is related to the over-all population needs. With dentists more selectively educated for their chosen area of practice, dentistry can be prepared to enter the twenty-first century.

Specialties

not

threatened

This proposed approach to dental curriculum planning does not de-emphasize the need for specialty training but in fact could conceivably materially shorten the time necessary for such training by developing t,he basic foundation f’or specialty training at the predoctoral level. The new general practitioners would be ‘capable of handling a larger percentage of the public’s needs and more capable of intelligently diagnosing and referring the more involved problems. Specialists could concentrate on the more involved or complex dental problems and the needs of the dental public would be better met. What effect would the adoption of such a spstem of curriculum design have on our present-day mode of dental practice? Initially none. If the proposed system of dental education was instituted tomorrow, it would take 4 years to produce the first graduate and 20 years before there was a sufficient number of them to gradually change the orientation of dental care delivery. Initially, an additional several years would be necessary for dental schools and faculties to “tool up” to begin such an undertaking. Thus, we are talking about an appreciable effect being attained at the earliest in the twenty-first century which poses no threat to our present generation of dentists. The specialty of orthodontics has nothing to lose by taking leadership in bringing about these changes. Many individual orthodontists have played leadership roles in organized dentistry and dental education t,hroughout the history of dentistry. It is now time for aggressive collective action bp the orthodontic specialty itself. Orthodontics, because of its unique heritage and potential contributions to the predoctoral dental curriculum, can lead t,he way to better dental health for all and further help elevate dentistry from the mechanistic rut it has been in since formal dental education was established. REFERENCES

An historical review of its origin and evolution, 1. Weinberger, B. F.: Orthodontics: St,. Louis, 1926, The C. V. Mosby Company, vol. 2, pp. 676-677. of the Curriculum Survey Committee, American 2. A course of study in dentistry: Report Association of Dental Schools, Chicago, Ill., 1935. basic training for the practice of medical specialties, 3. Millberry, G. S.: The minimum including dentistry, J. Am. Dent. Assoc. 14: 1648-1653, 1927 course of instruction in orthodontia, Dent. Cosmos 72: 4. Millberry, G. S.: An adequate 491-506, 1930. 5. Millberry, G. S.: A redefinition of the principles of orthodontic education, Angle Orthod. 6: 184-197, 1936. 6. Fleming, W. C.: University of California curriculums, J. Dent. Educ. 5: 221-227, 1941. 7. Fleming, W. C.: Should undergraduate orthodontic education be revised? Angle Orthod. 12: 173-176, 1942. Orthodontic education, certification, and licensure, Ana. J. ORTHOD. 37: 8. Wylie, W. L.: 376-386, 1951. 9. Wylie, W. L.: The undergraduate orthodontic program at the University of California, J. Am. Dent. Assoc. 57: 128-135, 1958. 10. Wylie, W. L.: A reappraisal of the orthodontist as specialist, J. Can. Dent. Assoc. 27: Nov. 1961.