This is a guest post by Dr. Jonathan Nicozisis. Enjoy!
Is there moral confusion about the future of the orthodontic specialty? Are you a Chicken Little Orthodontist or are you cut from the cloth of the Ozymandias (ref.1) Orthodontists who think they will endure the test of time and continued to be showered with accolades doing what has always been done? It might be considered that the Chicken-Little Orthodontists among us and those that follow the Ozymandias perspective on their orthodontic world order are polar opposite of each other; yet, what they have in common is that each perception will not withstand Darwin’s natural selection process.
We individual orthodontists chose our profession because we liked the idea of having our own autonomy. We like being able to make our own choices and being in control of our own destiny and how we treat our patients. We like being able to carve out a week of work however it is we so desire. That has been, is and will continue to be, but the playing field is and will continue to be different going forward. It is subject to different weathering conditions that they did not speak of during our residencies. There are external forces at work putting pressure on how we practice. Forces that are beyond our control causing us to peak outside the comfort zone of our self-construction fiefdoms where everything feels just fine.
To be succinct, the bracket market is collapsing. And with it, it’s pulling many things along towards it peril, including how we educate our soon to be graduates.
Why is it collapsing? It might be because we orthodontists have finally had enough of being gouged all these years for expensive designer brackets promising this, that and the other thing. Perhaps it is because of the public’s demand to straighten their teeth without using decades old analog technology of wires and brackets; it truly is analogous to making phone calls using a rotatory telephone. Even more so, perhaps we are finally realizing that the continued increasing salary and health care costs of employing labor to tie and untie cassette-tape-technology-braces is the blubber of the overhead whale that needs to be trimmed in order to truly shift overhead to a lab fee which generates more revenue for the same unit of cost as labor. (ref. 2)
As this collapse of the bracket market is occurring, where are you positioned for this transition of our profession? Is your annual percentage of cases in aligners in line with their market penetration? How adept are you at imparting forces on teeth to get them to their desired final positions with customized plastic regardless who makes it? Do you have different options other than only comprehensive treatment to serve the desires of prospective customers….I mean patients? Are you crying foul/fowl and crying out like Chicken Little or is your Ozymandias pride getting in the way? As mentioned, either approach will be succumb to Darwin. He always wins.
What is the moral confusion about the future? Is advancement though technology really good for us? Is this shift from analog to digital really what we should wish for? The Chicken Little mentality claims ‘this isn’t fair and my sky is falling’ because we will be replaced as a result of this technology. This a natural knee jerk reaction leading to practice paralysis and eventual decay. The Ozymandias moral confusion about the future is the misguided belief that aligner therapy cannot provide the same level of care and results as traditional fixed appliances because they tried it a few times and it didn’t work; hence it remains inferior. They don’t trust patients to be compliant. It’s just down right heresy to attempt it in teens or younger patients.
I find it amusing that often these same Ozymandias-minded nay-sayers are using bulky removable appliances for early treatment that are akin to wearing a hockey puck with clasps on it.
Nevertheless, another aspect that concerns me regarding the moral confusion about the future of our profession is how many residency programs still refuse to teach and adopt aligner orthodontic therapy as a part of their curriculum. As I travel around the country lecturing, I am disheartened to meet many recent graduates telling me their program ‘didn’t believe in aligner therapy’ and as a result had zero instruction or exposure to it. What a disservice this Ozymandias perspective does to our profession. It is this pride and arrogance that ultimately made Ozymandias irrelevant against the test of time. Without a change of perspective, residency programs will follow the same destiny. Why would one go into debt and attend a residency program that does not teach them how to move teeth with an approach that is currently well above twenty percent penetration in the market place and only growing? That is morally a bankrupt mindset causing young graduates to wither on the vine.
Getting back to the notion of autonomy, we orthodontist can choose to still have it, but we must adapt and evolve to stay relevant. What has been uncomfortable for us is that we feel that the market forces being imposed upon us are like the proverbial tail wagging the dog. Well, I might suggest that you become the hand that is holding the tail that is wagging the dog. Get adept to moving teeth with plastic. Own it! Make it your own. Make it a part of your office culture so that it reflects your personality in your own way. Rather than swimming against the current and complaining like Chicken Little or being too proud like Ozymandias, go with it! Ride it! Get to the over ground! Don’t let your paralysis or pride make you irrelevant.
This will be a fad. By that I mean the ‘novelty’ of moving teeth with aligners will take a solid generation or so (maybe less) to become common place; much like the change-over from banding each tooth to direct bonding. After that, it will be simply no big deal to move teeth without braces. Braces will be the rotatory phone of yester-year in orthodontics and we will be back to where we were before the advent of aligners. By that I mean we will be in the rugby scrum of practice differentiation hawking the latest Apple product as a prize for those patients who refer the most friends. As Yogi Berra said, it will be déjà vu all over again.
As my mentor and chairman Dr. Orhan Tuncay recently so eloquently elucidated in Seminars in Orthodontics (ref.3), it is the hope that our genotypic and phenotypic diagnostic tools and skills will evolve to allow us to differentiate ourselves as specialists once again. We can then truly evolve from being a fancy analog car mechanic moving teeth with cassette tape technology to specialists best adept at truly understanding our patients’ genotype, phenotype and induvial biology and what their tissue response will be to ‘cure’ them of their orthodontic ills and address their cosmetic concerns.
I have shed my Ozymandias clothing and opted not listen to the Chicken Little’s among us. My future is clear. I am here now. Making it my own riding the wave of market demand while trying to share my alleged knowledge and experiences. As a first among equals, that is my obligation. It is your obligation too; to share whatever it is you are ‘first’ at with your orthodontics colleagues who are equals. This is how we will survive this collapse and transition. We’re not done yet. Waiting for the rest of you to make it your own like I did. Put flowers in the mud baby and dream out loud!
Jonathan Nicozisis, DMD, MS
‘And I have no compass and I have no map. And I have no reasons to get back. And I have no religion. And I don’t know what’s what. And I don’t know the limit of what we got. Don’t worry. It will be alright. You got the right shoes to get your thought the night. It’s cold outside, but brightly lit. Skip the subway, let’s go to the over ground. Get your head out of the mud baby! Put flowers in the mud baby! Over ground!… I’ve been hiding. What am I hiding from? Don’t worry baby, it’s gonna be alright. Uncertainty can be the guiding light. I hear voices. Ridiculous voices. Let’s go over ground and take your head out of the mud baby! Dream out loud!
–Zooropa -Paul Hewson
- Ozymandias: Percy Bysshe Shelley
- The Plastic Employee: J. Nicozisis, The Progressive Orthodontist, Q1: 2017
- Seminars in Orthodontics, Vol. 23, No1, March 2017