DT News - Canada - Dental specialists in Canada: A true need?

Eli Raviv and Kelvin Ian Afrashtehfar, Canada

Tue. 16 October 2012

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Over the years, dental specialties have emerged in faculties of dentistry due to the advancements within specific areas of treatment, and they have been incorporated if not into each university, at least into virtually every province. In Canada the Commission on Dental Accreditation reviews and accredits the following nine dental specialties programs: dental public health; endodontics; oral and maxillofacial surgery; oral medicine and pathology; oral and maxillofacial radiology; orthodontics and dentofacial orthopedics; pediatric dentistry; periodontics; and prosthodontics.

Dental specialists have exceptional training (or, are highly skilled clinically); but with rights come responsibilities. Specialists also need to lead the way by becoming super-ordinate oral physicians. They must identify hundreds of systemic/genetic disorders that manifest in the oral and craniofacial area supporting the relationship between oral and systemic disease. Yet, conversely, in a survey answered by 200 governmental and professional agencies, more than 90 percent believed that dental health is isolated from general health.

The standard of care required of the health professional increases in correlation to how the practitioner holds himself or herself as a specialist — and the riskiness of the procedure.

The generalist, of course, is not deprived of responsibilities. When accepting a patient, a dentist assumes a duty of care that includes the obligation to refer the patient for further professional advice or treatment if it transpires that the task at hand is beyond the dentist’s own skills. A patient is entitled to a referral for a second opinion at any time, and the dentist is under an obligation to accede to the request and to do so promptly.

In other words, when a generalist performs procedures that are mostly performed by dental specialists because of complexity or difficulty, the law holds all such practitioners to the standard of care expected of specialists providing similar procedures on a regular basis. Agreement on treatment recommendations appears to be somewhat higher among specialists than among general practitioners, indicating that graduate education may influence the decision-making process. Additionally, multidisciplinary treatment continues to produce extraordinary outcomes.

Therefore, referral to an experienced dental specialist — who has the clinical skills, the required equipment and the resources — is in the best interest of the patient and ought to be encouraged when suitable. Certain therapies performed by specialists are significantly more successful than when provided by generalists. For example, root canal treatments have a five-year success rate of 98.1 percentwhen performed by a specialist compared with 89.7 percent when performed by a generalist. For the oral implantology subspecialty, the outcomes of complex procedures diverge predominantly when requiring bone augmentation and management in the aesthetic zone.

When it comes to reviewing numbers, the ratio of growth in the specialties is overwhelmed by growth in general practitioners because some faculties of dentistry limit admission to only two specialists each year; others have only one. Canada has a markedly low ratio of prosthodontists to dentists (1:107) when compared with Nordic countries; but it has a very high number of denturists, or clinical dental technologists. In the United States, with 10 times the population of Canada, there was a projection at one point showing an estimated 294 million hours in unmet prosthodontic services.

A decade ago in Canada, female dentists made up 23 percent of generalists and 14 percent of specialists. The duration of specialty education conflicts with childbearing years and is a potential reason for the specialist gender gap.

Even with this lack of schooling opportunity to fulfill patient needs and meet dentists’ demand for graduate education, some specialties have had to be closed because of financial or political issues — more limitation that ultimately must be addressed. To mention an example, a prestigious McGill prosthodontic program had to be closed more than 20 years ago, leaving the University of Montreal as the only option in Quebec to enter the specialty. Unfortunately, this last program, too, is being shut down for the next coming year. Quebec dental graduate education is left without any option to back up its prosthodontics backbone.

To cover the shortage of specialists in Canada, guidelines for the evaluation, education and registration of dental specialists trained from non-accredited institutions were developed, without sacrificing public protection or weakening self-regulation.

The fact that spending-power limits dental specialty care is true. We are in the presence of difficult financial times that limit patient access to needed treatment. Among patients making a first-time appointment with a specialist, countless numbers will drop out of treatment or go untreated altogether because of high costs, often connected to the expense of new technologies. Most of these treatments are not totally covered by the health insurance.

In response to these challenges, faculties of dentistry created one-year hospital- or university-based training residency programs — and the “advanced general dentist” was born. Results of these programs show that such dentists on average achieve a superior set of skills compared with general dentists and have shown a reduced need to make outside referrals.

Other answers need to be formulated by the individual institutions most influencing the careers of the specialty professionals being accredited. As oral health professionals we must do what is in the patient’s best interest. We owe patients for the opportunity they give us to serve them. As a final commentary: The need for dental specialists in our country will not be diminished, but the challenges that limit patient access to their services must be addressed.

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