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  • Dr. David Alfaro

Them's the breaks

I do not know if it is the increasing number of candles on my cake each year, or if my friends have had a recent bout of bad dental luck, but lately, I have been getting this call a lot:

" dentist says my tooth is broken and I need an implant. They have a specialist that can do it for me. Do you mind taking a look?"

This makes me both very sad and very happy. Of course it upsets me to see that my friend has a busted tooth, but what I find great is that they had the foresight and willingness to go a specialist for a second opinion.

But are people being referred to specialists for consultations for complex dental care?

Let us talk "second opinions".

There was an era in Vancouver when general dentists referred to prosthodontists for their complex occlusal rehabilitations, dental implant restorations, difficult crown and bridge cases, and of course, dentures. The golden era had big names who were local pioneers in dental implantology, and were instrumental in developing the interdisciplinary study club culture that is so prominent in Greater Vancouver today.

But things have changed.

Everyone has become a specialist.

Who exactly are dental specialists?

The College of Dental Surgeons of BC has recently implemented a very big change in advertising regulations: we dentists can no longer list credentials on any of our promotional materials or professional communications.

Those changes mean that even though I have a Masters in Craniofacial Sciences, a Diploma in Prosthodontics and have succesfully completed board exams that allow me to hold a Fellowship in the College of Dental Surgeons of Canada (making me an actual specialist).........I cannot put them on my business cards anymore. My name now has to read:

Dr. David P. Alfaro, Certified Specialist in Prosthodontics

I am allowed, however, to list my creditials on my website, or in a text paragraph on my promotional materials, with strict formatting guidelines.

The intention of this change makes sense, because things are really clear; either you are licensed as a general dentist, or as a specialist. No more confusing acronyms.

What dental specialties are truly specialties?

One of the reasons these new regulations came about was because people were advertising themselves as specialists in specific treatments that are not officially recognized as specialties in BC.

There is no such thing as an "implant specialist". The same goes for a "TMJ Specialist"....and there certainly is no specialty of "cosmetic dentistry".

But if you read bios, and look at the names of dental offices, you will see that people often state that they are "specialists" or "experts" in something......then you look up the registration of the dentist, and they are licensed as general dentists; these people are violiating college regulations and are decieving the public.

This is not a problem limited to general dentists either; specialists have been just as guilty of calling themselves things that we are not allowed to call ourselves, such as implant specialists. Yes, we may be very experienced and trained in dental implants, but the rules state that we must call ourselves specialists in our specialty.

Can my general dentist do this treatment?

Many of my general dental classmates from Columbia often get in this debate with their specialist friends.

The real answer is: of course, a general dentist can do whatever he or she feels comfortable treating.

But it comes down to training. Unfortunately, my Columbia classmates are a bit blinded to the reality that we went to a top tier program and that other dentists from other programs may not have had the exposure to advanced dentistry that we did. So they are quick to step to the defense of the general dentists in this oft heated argument of who should be performing complex dentistry.

At Columbia, from day one we were volunteering and shadowing in the full spectrum of specialty clinics, we were encouraged to do externships, we had mandatory hospital based oral surgery rotations, we spent one day a week in fourth year rotating in hospital based general dentistry residencies, oh..... and were taught by some of the top specialists in the country.

To top it off, 95% of graduates end up completing a minimum 1 year of residency. So yes....we Columbia grads can feel pretty comfortable tackling complex dentistry. don't know what you don't know.

We assumed that every program was like that, but, it wasn't until I spoke to graduates from other schools, and was validated when I taught in a dental program myself, that I realized how far ahead I was right out of Columbia. I mean, I did not do more crowns, or bridges or fillings than graduates from other programs, but from day one I was observing and assisting in IV sedation sinus lifts, implant surgeries, lateral ridge augmentations, complex endodontics, connective tissue grafts....tough stuff. It was ingrained in us that dental school teaches you the basics, and that you go to residency to prepare you for clinical practice.

That opportunity is just not offered at every dental school. But we didn't realize it at the time, and we sure complained about our experiences then! Man was I a spoiled brat.

The reality of most dental programs is that general dentists finish school having spent perhaps a fragmented 2 years actually doing clinical dentistry, and they may never have assisted in an implant surgery, or even worked with implant dentures, crowns and bridges. Forget sinus lifts. You would be lucky to get some classic perio surgeries completed, but lateral ridge augmentation? Nope. Ortho? Maybe.

When I was in residency, and in the time I spent teaching at the local dental school, I encouraged students to come and shadow me, and definitely suggested that they complete a residency of some sort. But at the local program where I was, historically there were only a handful of students that would actually go on to advanced training. Unfortunately, the students think that the experience required to tackle advanced cases will come in private practice and in study clubs and lectures.

Dental continuing education, however, is not the same as a residency. Period. Only those who have completed a residency will understand. don't know what you don't know.

Why does this matter?

I agree with the college on is about protecting the public.

If someone is calling themselves a specialist in something, they better truly be a licensed specialist in that field. Too many times do I have patients coming to my office for a second opinion from the "implant clinic in the mall", or telling me that their general dentist was going to bring in a "specialist" to do their implant.... and then I do the research......and the person is licensed as a general dentist.....

What am I supposed to do? Talk about an ethical dilemma. I started off my career by treading lightly, but the problem is so ubiquitous that I stopped keeping my mouth shut.

The patient needs to know: that doctor is not licensed as a specialist. They may be VERY good at what they do, and may be very capable of taking on challenging cases....but that does not make them a specialist, nor should they be advertising themselves as one. You have to be licensed as a specialist to truly be one.

When someone is licensed as a specialist, you know that they have completed at least 2 or 3 years, and thousands of hours of advanced university level training beyond their dental degree, and have passed a rigorous set of written and oral examinations to be able to be registered as a specialist.

For general dentists who are tackling complex dentistry such as dental implants, bone grafting or orthodontics, there is no way to confirm their training. A mini-course on dental implants is way different than a 3-year residency and masters, and having to pass a structured, ridiculously difficult licensing exam for specialists. Providing Invisalign or Six-month Smiles is not the same as being an orthodontist.

There is a broad range of training available to general dentists via continuing education. There are programs as simple as taking a weekend cruise and popping some implants in a pig jaw, but hopefully people enroll themselves in one of the more structured programs that are available. These programs can range from 10 days to 30 days of training, and cost the dentist tens of thousands of dollars to take. These programs can get "accreditation" from continuing education societies, but are not equivilent to an accredited dental residency, and certainly do not qualify people for licensing as dental specialists.

So yes, there are some very well trained dentists out there that have pursued advanced education in a responsible manner. But no matter how you look at it, even if you take a 30 day implant course, and frequently place dental implants, that amount of training does not compare to a 3 year residency, completing a board exam, and then running a speciality practice where you deal with complications every day.

Why am I being so cranky pants about this?

Unfortunately, my specialty has become a graveyard for failing dentistry. I do recognize that I am getting the outliers and that a majority of dental work completed in Vancouver is well thought out and performed by competent individuals, but, as a specialist in prosthodontics, I have nightmare problems walking in to my office every day.

I get it, sometimes things just go the wrong way. But....more often it is tourism dentistry or someone trying to save a buck somewhere, and sometimes, the dentist was taking on a case without realizing the hidden challenges.

If you ever hear someone say that dental implants are easy, or that invisalign is easy, do not believe them. There is no such thing as a "slam dunk" case. If you think that, you simply have not seen the failures that I have seen, even in those cases that should have been dunks.

People don't know what they don't know.

I blame the market pressures of today. Vancouver is supersaturated with dentists. There is so much competition in this city that some people would rather take on a case that is beyond their skill set, just to ensure that the patient does not go somewhere else. If they can't do it, they will bring someone in to help them, often a rep from an implant company, a lab tech, or another general dentist, but rarely an actual specialist, because for some reason, there is this huge disconnect between specialty and general dentistry right now.

So what can the public do?

First of all, never jump into a treatment without fully looking at all of the options.

Second, if you are told that you are being sent to a specialist, make sure that they are a specialist! If you are being sent to another general dentist, that has to be made clear to you. It is not to say that the general dentist is not skilled, but it is about the actual licensing status. Specialists are specialists and general dentists are general dentists. We need to clear up any confusion.

Look up your dentist's registration status here: Registration Status

(They didn't make it easy, you have to go to +more search options to find a specialist)

Lastly, go for a second opinion. I know people who spend hours rearching and pondering a gadget or a pair or running shoes, but when their dentist says, oh, you need braces, have you considered Invisalign? They do it without checking with anyone else. How does that make sense?

Go ask a specialist. Go back to your general dentist. A good general dentist and a good specialist will work as a team. It is worth the consulatation fee to get a specialist's opinion on complex dentistry, and believe me, implant dentistry and orthodontics both qualify as advanced dentistry. And if you go somewhere that does free consults, great! Then go for a third and pay for it.

Take your time before you decide to make a permanent change to your face.

Being informed is paramount!

If you don't you know!

Thanks for reading!

Please like and share!

Dr. Dave

Certified Specialist in Prosthodontics

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