Last winter, I attended our orthodontic program’s annual alumni meeting, held at a hotel about 20 minutes away from my house. The weather had been bad all day, despite forecasts for improvement. The ground was icy, and it was raining outside. Although I really wanted to get home after a day of lectures, I held back at the evening reception, knowing that the temperatures were predicted to get warmer and the conditions would improve. Checking my phone regularly, it seemed that the forecasters kept delaying the onset of the warmer temperatures. It was all counterintuitive anyway, since it was dark, and usually that meant that the air would get colder with time. Finally, it just seemed that I had waited long enough, and it was time to go home and feed my hungry dogs, Kingston and Memphis, who were probably impatiently expecting their dinner.
For over 100 years now, orthodontists have been adapting to an ever-changing climate that includes better and more efficient appliances, a growing patient base, technologic advances in diagnostics and planning, and shifting marketing strategies. Every development brings a new “crisis” as practitioners who are caught off guard need to adopt new strategies to cope with the transformation of what was once familiar to them. These types of changes affect every profession and specialty. How the members react and deal with them determines the future of both the individual participants and the field as a whole. As Stephen Hawking said, “Intelligence is the ability to adapt to change.” Those who fail to adjust will be left behind.
Outside, the ground was wet but seemed safe enough. The long-expected thaw must have begun. I drove slowly at first but my confidence built with every turn, and the acceleration of my truck was solid. My pickup had 4-wheel drive and was 16 years old, a true veteran of snow and bad weather. I switched back to 2-wheel drive once I exited the parking lot and joined the street traffic. Cars passed me, I was driving slowly, and the road seemed secure. I turned onto the highway without hesitation, taking the quickest way home, and accelerated as I merged ahead of cars all traveling at highway speeds. The caution I exhibited earlier melted out of my mind as I envisioned my exit coming up just a few minutes ahead. And then, suddenly, I felt the back of my truck slipping off to the left.
A little over 25 years ago, I was getting ready to graduate from my orthodontic residency program. I had learned how to treat patients using preadjusted steel appliances, and it looked as if lingual appliances were a new, growing market for the more esthetically conscious. It was a mechanical challenge that I was eager to tackle. Ceramic brackets had just come out, and only the most forward-thinking orthodontists were using them. Molar distalizing appliances were becoming popular, and it was touted that they would replace headgear. Could you move molars distally without unwanted side effects? Extractions couldn’t really cause temporomandibular joint problems, could they? So many different functional appliances were available, but no one could say whether they really grew mandibles. Do you need to mount cases on an articulator to prevent your patients from developing temporomandibular joint dysfunction? Each new appliance and treatment philosophy challenged practitioners to change their ways of practicing. Maybe I should be looking into Orthotropics. Using implants for anchorage, then onplants, miniscrews, miniplates…the changes kept coming. Lasers became available for in-office use, and orthodontists were exposing partially erupted teeth and recontouring unesthetic gingival margins. Do I need cone-beam computed tomography to diagnose my patients properly? What can we do to make teeth move faster? Should I switch my brackets to a self-ligating system? Corticotomies, microperforations, and vibration, among others, might speed tooth movement. How many of my patients should be treated with aligners?
My hands tensed up and gripped the wheel more tightly, my body shivered a little, and I touched the brake. A fatal error, I realized immediately, as the truck started to spin, clockwise, I think, or maybe the other way. I turned the wheel in different directions in a hopeless attempt to stop the truck from spinning. As I rotated around, I saw the lights of the cars that had once been behind me, and they seemed to be stopped. “That’s good,” I thought. I kept spinning until, finally, I was definitely spinning more slowly. I saw some sort of barrier directly ahead of me, and then I closed my eyes and waited for the impact, but nothing happened.
Beginning an academic career in orthodontics upon graduation was a tough decision for my parents to swallow. My friends were buying fancy cars and big houses, and I was working hard, focused on paying off my loans, and living in a rented apartment. It was fun working with the residents in clinic, and I was doing research and publishing papers. Popular speakers talked about “real-world” orthodontics and contrasted that to what was taught in schools by “ivory-tower” academics. American Board of Orthodontics certification became a requirement for academic advancement, and I witnessed an educator actually throwing a chair at the ABO president as he explained the new, tightened rules for the certification process. Orthodontic education was declared to be in a “crisis” as positions went unfilled at multiple institutions, and there was a shortage of applicants. The American Association of Orthodontists Foundation was born of the specialty’s recognition that the orthodontic educational system needed a boost financially and morally. New orthodontic programs opened with corporate support, and residents were obligated to work in sponsored practices after graduation to pay off their debts. That model failed, but the cost of dental and postgraduate education continued to rise, seemingly unchecked. And new schools and programs continued to open to absorb the students willing to pay higher and higher tuition costs.
Eerie quiet…and then, BAM, my truck hit the concrete barrier wall head-on at a high speed and bounced right back into the middle of the highway in a split second. I was stalled out in the middle of the road but facing forward. I looked back over my shoulder to see that the traffic behind me had stopped to watch the spectacle from a safe distance. I felt okay and did a quick check to make sure. I wanted to get home to feed Kingston and Memphis. I turned the key and was surprised that the truck started right up, and I was able to drive. Turning the wheel to the right was a little rough, since the tire seemed to rub on something if I turned too far. I drove slower than I had ever driven, waiting for the truck to slip away from my control, but I was able to get home.
Twenty five years ago, the controversy in marketing was whether another practitioner’s office sign was too big. There might have been competition from a pediatric dentist or even a general practitioner in town. Orthodontists gave away T-shirts, other logo items, and bicycles to attract patients and build loyalty. Direct mailing, radio, and then television advertising became more popular. Every practice developed a Web site so that patients could find them and hired help to make sure that the search engines would list them first. Now, managing the social media world is essential for keeping a practice prominent in a modern community. Patients used to bring their payments to the office every month; now, we hire third-party collectors to do that for us. Who can keep up with the ever-changing demands of insurance companies and reimbursements? The challenges of managing employees and running a business are often greater than those posed by treating patients.
I saw the puddle of radiator coolant getting bigger in my garage, and I knew the truck was a total loss. But I was okay, and that was the important thing, right? Just a little soreness where the shoulder belt had tightened down on my chest. What happened to the air bag, and why didn’t it open? The dogs didn’t seem to notice any problems as they ate their dinner. It was late, but they seemed happy. The insurance company eventually came and towed my truck away after several calls and several days. The reimbursement check was ready a week later.
Do I embrace change? The answer is “no,” but I accept change. I have been fortunate to be able to work with people who are actually excited and look forward to all the new developments that come along, whether they are new orthodontic appliances, educational tools, or marketing techniques. Bob Isaacson is a good example. He has always been good at envisioning positive potential in what the future can bring. The new residents are an inspiration. They can’t live in the past. They want to try everything that is new. It’s important to listen to what they say, these newcomers to our specialty. I have seen the recently controversial online discussions about the issues we are facing. Some residents and new practitioners (and even some older ones) are scared about what the future will hold for them. We must realize that we can help shape the changes that are inevitable, but we cannot turn back time. We may not know exactly where we are headed, but we should have a vision about where we want things to go.
I have a new truck now. It has more room for Kingston and Memphis to ride with me. They don’t seem to miss the old truck at all. Dogs always have the best attitude.
So, where are we going? We are a specialty that has been here for more than 100 years now. It seems that sometimes we are heading backward or just making circles. But the world eventually moves forward, and we will go forward with it. People often ask what the future will bring. To quote Heracleitus, “The only thing that is constant is change.” The future will be different from what we have now. And we will be there.