January 29, 2016
The common meaning of the word Specialist is “a person who concentrates primarily on a particular subject or activity; a person highly skilled in a specific and restricted field.” In other words a specialist is expected to have expertise in a specific area, and this can be facilitated through training, focus and experience, as well as through individual skills and talents. However, in dentistry, a “Specialist” does not carry its common meaning, – instead it means a Registered Specialist. As such, clinicians who may indeed fall under the common definition of a “specialist” which the public understands, are actually prohibited from advertising themselves as such.
In a recent Federal court case in the USA, the Texas State Board of Dental Examiners (TSBDE), along with the Texas Society of Oral and Maxillofacial Surgeons (TSOMS), were seeking to prohibit 2 dentists from advertising themselves as “specialists” in implant dentistry, alleging that this would mislead the public for three main reasons:
- Oral Implantology is not among the nine officially recognised specialties of the American Dental Association (ADA)
- It would harm those members of the TSBDE and TSOMS who are “specialists”
- Patients would be misled in their understanding of “treatment quality”
All the allegations were dismissed by the court. It found that preventing those dentists from advertising themselves as specialists in oral implantology was in fact a violation of those dentist’s rights to engage in truthful, non-misleading commercial speech. The nature of their practices was such that each could be regarded as a “specialist” by the commonly understood meaning of that word. The ruling noted that the TSBDE and TSOMS “have produced no evidence of actual deception associated with advertising (as a “specialist”) in non-ADA-recognised fields”.
In his ruling the Federal Court Judge stated that “it appears …that the true purpose (of the TSBDE and ADA’s advertising restrictions on dentists) is to protect the entrenched economic interests of organisations and dentists in ADA-recognised specialty areas.” He also raised the question as to whether those ADA-carved specialty areas are actually bona fide.
In Australia we have similar restrictions on advertising, and we also have similar turf wars when it comes to dental implants.
Fact is that whether you are a general dentist or a recognised specialist, each must undertake very similar post-graduate training (which has not been the focus at university), in order to be proficient in oral implantology. It is also a fact that being in a non-implant specialty may actually preclude the clinician from exposure to other areas of practice that are relevant for successful implantology, and to the overall oral health parameters of the patient, and which could otherwise be a distinct advantage for general dentists who undertake further training in this area.
Having practiced in dentistry for the past 20 years, for the most part of my career being completely restricted to dental implants, what puzzles me is the divisions and turf issues that exist between dentists and specialists, the politics of the dental industry. If we look at Medicine, you would not be going to see a specialist Rheumatologist, as one example, if it wasn’t by referral from your GP.
The specialists exist with a focused area of practice that is often not fully understood by the public. It is for GP’s to understand, and it should be the GP’s decision when to refer and who to.
In fact, if you saw a medical specialist without a referral from your GP, you may not receive a Medicare Rebate. The specialists are there to support the GP’s in the overall treatment of the patient by offering expertise within their own niche area of practice, because in their niche they have the training, focus, and expertise. When it comes to dental specialties, the public would expect this to be the same, that is, for the dentist to determine when to refer and who to. There should not be turf issues, rather a teamwork approach. The problem for some specialists, though, is that in dentistry many GP’s during their careers pursue certain interests in certain areas of practice, making them less reliant on specialists. The ultimate question is, does this disadvantage the public? In many cases, for the responsible clinicians, absolutely not, in fact it may be more convenient for patients. However in just as many other cases, for those clinicians who are not as responsible and lack the necessary training and/or insight, this may indeed lead to poorer quality of treatment.
When it comes to dental implants, having been in a practice that is exclusive to dental implants and dento-facial surgery and performing these procedures on a daily basis, I receive referrals from dentists as well as specialists and get to see cases that have gone wrong far more than the average dental practice. Speaking from a position of this slight advantage, I can say without reservations that for every case that has gone wrong when treated by a general dentist, there is a similar case gone wrong treated by a specialist.
Our national board, in its Advertising Guidelines, makes specific references to the use of the word “specialist”. The guidelines state that when a clinician advertises themselves as being a specialist, this must also clearly include “their (specific) area of specialty or endorsement”. The National Law prohibits advertising that “is false, misleading or deceptive or is likely to be so”, and which includes “partial information which could be misleading”. Therefore, whilst our National Law does appear to prevent us from speaking freely by truthfully stating that we specialise in an area like dental implants, it also prohibits specialists advertising that they are specialists when the public cannot discern that their specialty is not actually dedicated to “dental implants”. Thus an Oral and Maxillofacial Surgeon, Periodontist or a Prosthodontist cannot make broad statements like “dental implants by specialist clinicians”, a statement that could very similarly be made by a specialist Orthodontist, and which is highly likely to mislead members of the public into thinking that the clinician is a specialist in the field of dental implants, when they are clearly not not, because within their specialty dental implants are not the exclusive focus.
Advertisements by any registered dental specialist structured in a manner that might imply they are a specialist in dental implants is far more likely to be misleading than a similar advertisement by a dentist who actually “specialises” in this area, by the common definition of that word.
So it would appear that in Australia, at least for now, both dentists and specialists are equally prohibited from advertising themselves as being specialists in the area of dental implants. Whilst this may be fair by creating a level playing field in terms of turf, whether this is unconstitutional by preventing truthful free speech for those clinicians who do actually “specialise” in dental implants, by the common public understanding of the term “specialise”, whether registerable or not, is a matter yet to be tested in our own court system.
I wrote another blog on a similar topic, with the title Dental Specialist Referral, click to check it out.
After posting the above article in a secret Facebook group Dental Product Review, where there was relevant and interesting discussion on the topic.
For the most part there was agreement that both dentists and ANY kind of registered dental specialists are equally prohibited from advertising in a manner that might imply that they are specialists in dental implants. Albeit one member added:
“It would be debatable that an OMFS could not claim some level of specialisation in the area of placement or that a prosthodontist couldnt claim specialisation in the prosthetic side. I suspect the board would have more sympathy for someone with a registerable and relevant specialty claiming this than someone without those qualifications however.”
Thanks for your further thoughts, but whilst the law is sometimes open to interpretation, its certainly not open to debate. I have every faith in our Board and there can not be 2 standards! Since there is no specialty dedicated to dental implants, no one regardless of their other specialisation can imply that they are a “specialist” in dental implants, according to the regulatory definition. By the common definition of the word, if the focus of your practice and training is not exclusive to dental implants, then you are also simply not a specialist in this area.
Therefore registered specialists whose focus is not exclusive to dental implants are in fact far more vulnerable and open to scrutiny because whilst they can use the words “specialist” (provided that it clearly states what it is that they specialise in), the risk of the public being misled by confusing them for being an implant specialist when advertising implant treatment is high. Whereas a dentist (or a specialist) who received adequate training and whose practice is exclusive to dental implants may have a defense on constitutional grounds (freedom of speech) because under the alternative common definition of the word “specialist”, factual truth may in fact deem them as such.
There is no such thing as claiming “some level” of specialisation. You either specialise in something or you do not. Just like a dentist cannot claim to be specialising in periodontics just because he/she performs lots of root planning, an OMFS cannot claim a level of specialisation in dental implants just because they also do implants. OMFS’s in their training (in more recent years) do have some basic exposure to implant placement and grafting techniques. At the very least OMFS’s are seen in the dental community as having the requisite surgical skills and experience to perform advanced surgeries, including implant placement. However the fact of the matter is that, although OMFS’s are highly trained specialists in medicine and oral and maxillofacial surgery, they are relied upon in the industry for treatments such as cancer resections, orthognathic surgeries to correct skeletal jaw deficiencies, repairs of clefts, dento-facial trauma, developmental abnormalities, dealing with oral surgical complications or oral surgery in patients with severely compromised health, etc. For most of today’s registered OMFS’s, dental implants is not a focus. Not in their training, nor in practice. More limiting still, when it comes to considerations of aesthetics, comfort and/or hygiene, is their often limited exposure to the restorative process and practical needs of the patient and dentist. This is not a lack of thoroughness by any means; rather, it is simply a reflection of their other highly important and very much needed roles in the dental community.
- Is specialisation really all about focus?
- Freedom of speech in Australia
In relation to the question is specialisation really all about focus, one member wrote:
“It doesn’t mean anything that The focus of your practice is only implants. A new grad could open a practice tomorrow limited to implants. Is he a specialist? What is considered adequate training.”
The discussion about the public’s natural understanding and definition of the word “specialist” is very hypothetical. In Australia we abide by the regulatory definition, which implies that no one can call themselves an “implant specialist”, whether a dentist or other kind of specialist, and whether a new grad or an experienced clinician. Having said that though, in this hypothetical landscape that we created, the definition of a “specialist” is: “a person who concentrates primarily on a particular subject or activity”. So in fact it does appear to be to a large degree about “focus”. Therefore if a new grad opens a practice that is limited to implants, and risks high financial losses by abandoning other work and dedicating his professional existence to this niche area of practice, which could in fact arm him/her with a quicker trajectory and a gain in experience + knowledge in this area because of his/her “focus”, then provided he/she can prove to also possess the requisite knowledge and skills, by the common dictionary definition (not to be confused with the regulatory and ethical obligations) he/she might certainly be regarded as one who specialises in implants. A specialist endodontist starting out is not less of a specialist than an endodontist who has been in practice for many years.
However, apart from the dictionary definition of the term “specialist”, there is in addition to focus (not instead of), what might be a reasonable expectation of the public in relation to a specialist, that is …expertise! Whilst “expertise” may indeed be facilitated through focus and natural ability, it can only be reliably gained through training and experience. Therefore, in terms of the public’s expectations, for a new graduate with limited exposure to implants or experience to be claiming to be a specialist can be deceptive or misleading in many other ways, even though strictly according to the dictionary he could be regarded as one.
I definitely agree that it would be far less confusing for the public if there was a registerable specialty dedicated to oral implantology, where the training paths are more clearly defined and recognised as being adequate to meet the public’s expectations. But like (our legal friend) implied above, its not a likely scenario and would have opposition from numerous specialist lobby groups.
In relation to freedom of speech another member wrote:
“In Australia we only have implied freedom of speech through the constitution. It covers freedom of speech through your elected representative not as an individual.”
I can’t speak with any sort of authority on constitutional matters, but the suggestion in relation to freedom of speech was an angle that hasn’t really been tested in Australia within the context of this discussion on the use of the word “specialist”. I suspect freedom of speech when it comes to politics, opinion or expression (such as in the article you attached) would be likely to be treated differently to freedom of truthful speech when it comes to factual matters, even in Australia, would it not??
Driven by some guidance from a legal member of the group, there was natural acceptance that US law cannot be applied to Australia when it comes to freedom of speech.