Quatity assurance in orthodontics Robert E. Moyers, DDS, PhD* Ann Arbor, Mich.
O r t h o d o n t i s t s define quality orthodontics by cephalometric measures, the patient by the shortness of the treatment time, and the parent by the size of the bill, but goodness or quality is not subject to measurement or statistical analysis. However defined, quality orthodontics interests others besides dentists--laymen, public health agencies, and insurance companies, for example. Quality assurance is a public health term that does not define the level of quality assured or say to whom it is assured--presumably a quality satisfying the patient. We rarely buy a car, an appliance, or certain services without an implied or written warranty, since warranties are a part of our everyday life that is subject to some legal definition and control. This article examines quality assurances, the warranties for orthodontic services. It addresses such questions as who is responsible for meeting the patient's expectations and whether orthodontic patients are protected in the same way that purchasers of lawn mowers, hair dryers, or a window-cleaning service are. QUALITY OF ORTHODONTIC SERVICES: CURRENT ASSURANCES
Donabedian ~notes that the quality of technical care, of general health care, is positively related to the quantity and quality of the training of the clinician, to the degree of specialization of the field, and to the amount of clinical experience of the practitioner regardless of age. He finds the quality of inpatient treatment highly related to the control of staff privileges, the responsibilities assigned clinicians, the size of the institution, and whether it has teaching and research functions. The quality of ambulatory care patients receive is significantly related to the equipment and office facilities, the ability to control the case load, and whether the clinician is associated with colleagues who are qualified and equally or better trained. There is a great variability of general health care quality with respect to the geo-
From the University of Michigan. The Salzmann Memorial Lecture for 1989. *Professor of Dentistry (Orthodontics); Fellow, Center for Human Growth and Development. 8/1/15355
graphic location, the institution where it is provided, the characteristics of individual practitioners, and the fields in which they practice. In an epidemiologic sense, the quality of health care varies widely within the populations of both consumers (patients) and providers (doctors). Despite a vast literature of the quality of medical care, we find only superficial attempts to define quality orthodontics. Nevertheless, let us see if we can extrapolate these general principles of quality assurance to the specifics of orthodontic services. Orthodontics differs from the other areas of dentistry in several particular ways that are important in assuring quality of treatments: 1. Orthodontics is not in the mainstream of the dental school curriculum since the amount of time dedicated to it is a small fraction of that assigned to restorative dentistry, prosthodontics, oral surgery, periodontics, or even endodontics. Dentists entering practice have less background and competency in orthodontics than in other clinical fields. 2. The number of teaching hoursrequired to achieve even minimal clinical competence is higher than for other fields in dentistry. 3. Correction of a malocclusion requires more time and appointments than the single-treatment procedures of most of dentistry. 4. Malocclusion is a variation of normal morphology and growth rather than a disease process; thus it is not amenable to the logic of Koch's postulates. 5. There usually are no acute symptoms as found in trauma or disease. 6. Severe malocclusions may be associated with general developmental disorders, and less severe conditions display oral dysfunction and undesired facial esthetics. 7. The patient's chief complaint often reflects psychological, esthetic, or dysfunctional concems. 8. State and regional boards do not emphasize testing of orthodontic theory and never test orthodontic clinical or technical prowess. Dentistry attempts quality control at three levels. The first level is dental education by the accreditation of dental schools and by the examination of the national 3
4 Moyers and state boards of dentistry. The second level is specialty training, which is similarly supervised by accreditation review and by the specialty boards, which offer an extra level of advanced certification (e.g., the American Board of Orthodontics). The third level is the general level of practice performance throughout the profession, which provides an especially difficult problem and only recently has been approached by such efforts as periodic renewal of credentials of practitioners and mandatory continuing education. Several agencies and organizations are generally assumed to be responsible for quality assurance of orthodontic treatments. Let us examine each with respect to orthodontic treatment in orthodontic specialty practice, pediatric dentistry, and general practice.
Quality assurance in orthodontic specialty practice • Medical specialties originated because of a natural grouping of diseases or syndromes within one body system. To name the medical fields (i.e., urology, dermatology, otolaryngology, thoracic surgery) is to define their scope and responsibilities. Most dental specialties have been defined by the techniques employed for a specific clinical problem, since dentistry's work is confined to the oromasticatory system. Most of the special fields in dentistry are separated only by the techniques used to deal with the ravages of two diseases, caries and periodontal disease. On the other hand, orthodontics defined like most medical specialties, has its focus on aberrant growth and morphology of the face, jaws, and occlusion and thus is more analogous to pediatrics than is pedodontics. 1. All programs leading to specialty practice must meet the requirements of the American Dental Association's Commission on Accreditation of Dental and Auxiliary Educational Programs, which, with the Council on Dental Education, defines the various areas of specialty practice, prepares guidelines for specialty training programs, and accredits them. 2. Through its section on orthodontics, the American Association of Dental Schools provides programatic support to help orthodontic departments meet the requirements of the American Dental Association. 3. The Council on Orthodontic Education of the American Association of Orthodontists is charged with promoting the highest standards of orthodontic education. 4. The American Board of Orthodontics provides an examination and the highest level of certification available in orthodontics. 5. All states with specialty licenses recognize orthodontics. The regional and national boards do not provide specialty examinations and licenses. 6. The legal profession has recently taken an in-
Am. J. Orthod. Dentofac. Orthop. January 1990
creasing interest in treatment of malocclusion and temporomandibularjoint disorders that have many common features: (a) each is a variation of normal growth, development, and function; (b) signs and symptoms that are meaningless in some patients are highly significant in others; and (c) few controlled clinical studies are available to validate particular treatments. Diagnostic medical tests are usually more specific, more standardized, and more commonly used. In medical cases, specific drugs or methods with scientific studies attesting to their validity are available to establish a provable standard of care, but that is rarely the case in orthodontics. The absence of scientific clinical studies or standard approved clinical teaching makes the role of the expert witness important in such cases, since the jury alone decides whether or not the treatment rendered was below the standard of care. Quality assurance in this system is set by a series of precedents, each of which is determined by a jury of laymen rather than by informed professionals or clinical scientific research. It would be difficult to get a consensus among orthodontists about orthodontic methods of treatment (treatment tactics), but it is possible to find consensus about strategies (treatment goals). Furthermore, it is possible to define treatments that are below the standard of practice (e.g., treatments that have been abandoned or that studies have shown to be unsatisfactory). Aggrieved patients must have a chance to be represented in court, but the peculiarities of today's tort system make it a most inefficient way to protect the public. Quality assurance in orthodontic specialty practice can best be guaranteed by scientific clinical research defining appropriate standards of care that could then be adopted as a required part of the curriculum in all graduate programs.
Orthodontic quality assurance in pediatric dentistry specialty practice There are three reasons that the pedodontist is interested in orthodontics. First, strong undergraduate training programs in pedodontics now produce general dentists who serve children well, creating a diminishing number of family dentist referrals of patients to pedodontists, Second, fluoridated communal water supplies and topical fluoride treatments have dramatically diminished caries in young children. Third, pedodontists often become disenchanted because pedodontic practice has become insufficiently challenging and the economic base of their practice has decreased. Frustrated, pedodontists rationalize claiming that "pedodontics serves all the needs of the child; therefore the treatment of malocclusions is our responsibility." Let us examine pediatric dentistry's training pro-
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grams and organizations to ascertain what quality assurances there are for orthodontic treatments rendered by pedodontics. 1. There is much variation in the amount and the nature of orthodontics taught to graduate students in pediatric dentistry. Some programs require formal courses in cephalometrie diagnosis, occlusal development, craniofacial growth and development, and elementary orthodontic techniques; most offer some of these courses, and some offer none. There is even greater variation in the clinical orthodontic training, which is usually supervised by a member of the orthodontic faculty and consists of the management of a few mixed-dentition cases of mild to moderate severity. 2. The orthodontic requirements for pediatric dentistry are not clearly described in the guidelines of the American Dental Association. The requirements for orthodontics and growth theory are minimal and those for orthodontic techniques and clincial practice are trivial. There certainly is no assurance that pediatric dentists are well prepared in orthodntics. 3. An examination of the Journal of the American Association of Dental Schools and the programs provided by the pedodontic section of the AADS show no recent strong effort to seriously address the matter of orthodontic teaching in graduate pedodontic programs. 4. A careful reading of all the issues of the American pedodontic journals for the last I0 years reveals little space has been given to craniofacial or occlusal development, orthodontic diagnosis, or the treatment of malocclusion. The formal programs of pedodontic societies and the continuing education offerings of pedodontie departments have shown a significantly increased interest in orthodontics. 5. Candidates for the American Board of Pediatric Dentistry are examined on various aspects of growth and development and are required to present the records of a few treated clinical cases, one of which is usually a minor orthodontic problem. Pedodontists are in the strange position of having obliterated much of the need for the services for which the specialty was founded and for which they were trained. Pediatric dentistry seems to be seeking and needing a new role for itself; however, that desire alone does not qualify pedodontists as orthodontic clinicians. Their ambitions alone do not assure quality treatment of malocclusion; nor is there any indication of major formal efforts to train or retrain pedodontists to qualify as orthodontic clinicians. Orthodontic quality assurance in general practice Current data suggest that more than 50% of all malocclusions are treated by dentists with little formal train-
ing in orthodontics. Although ethically these dentists cannot hold themselves to be orthodontists, legally they can attempt the treatment of any malocclusion. Who assures the public of the quality of treatments rendered by well-meaning dentists who have little training in orthodontics, have never been well tested by licensing bodies for their orthodontic competency, and are rarely subjected to a review of their clinical abilities? This is a problem without parallel bt medichre or dentistry because there is no other field bz which one half of all treatments are provided by clblicians with little trainblg and no testing of competence. 1. General dentists in recent years have often enroiled in proprietary courses in orthodontics outside the mainstream of dental education. An increasing number of orthodontic short courses are sponsored by dental societies, orthodontic supply houses, general dentists, and orthodontists. To the cynic, sometimes these courses seem to exploit the dentist's desire to learn for the promoter's profit. Some are offered with such excessive zeal for a single idea or technique that objective educational perspective is lost. Others are weak because of the incompetence or lack of training of the teachers. No other field in dentistry has as many courses offered by outside "experts" as orthodontics. Within the past few months, I have received announcements of orthodontic courses taught by general practitioners, dental hygienists, chiropractors, physical therapists, financial planners, dental technicians, pedodontists, periodontists, hypnotists, and child psychologists. How can an uninformed dentist know which course is worthy of his time and money? 2. The Academy of General Dentistry lists "approved" courses that its members may take for credit toward a "master's" in orthodontics. One hour of instruction equals one point. The member accumulating 2000 points qualifies for a "master's in orthodontics" and on payment of a fee of a few hundred dollars, may participate in a graduation ceremony, replete with cap and gown, and receive a certificate attesting to qualifications in orthodontics. The "master's" of the Academy of General Dentistry is not recognized by any other dental group or education accreditation agency. 3. Four organizations of general dentists interested in orthodontics have joined together to form the Federation of Orthodontic Associations, which sponsors programs, short courses, and the hlternational Journal of Orthodontics. 4. Restorative and prosthetic dentistry continues to dominate the testing given by state and regional boards. There is nothing in the dental law of any of the 50 states that prevents any dentist from undertaking the treatment of any malocclusion, no matter how severe the problem
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or how ill-trained the dentist. Yet there is no testing of orthodontic competence by state or regional boards. One of the major problems in dental quality assurance now is the protection of the public from the effects of inadequate predoctoral orthodontic training and the many current inappropriate and poor orthodontic short course offerings. The control mechanisms, such as hospitals, that prevent physicians in general practice from overextending themselves do not exist in dentistry. The profession is frustrated and the public suffers. The American Dental Association, which spends many dollars each year certifying toothpastes, denture powders, amalgam filling materials, and accrediting undergraduate and graduate dental programs, assumes no similar responsibilities in the field of continuing education. Nor does the American Association of Dental Schools have any means of monitoring the quality of courses presented outside their authority. General dentists will continue to treat many matocclusions; therefore they will continue to seek training, but I am pessimistic about our ability to help general practitioners as much as they sometimes believe we can. It is difficult to imagine a practical format for a program with enough discipline and intensity to give the general practitioners orthodontic ability comparable to the clinical skills that can be achieved much more easily in other areas of dentistry. The public will be better served when well-trained orthodontists accept their primary responsibility for all orthodontic education, including that of the dentist in general practice. Unless proper accreditation is established for all orthodontic education and orthodontists provide training in reputable surroundings, shoddy courses will remain. The role of health insurance companies
Dentistry has escaped, for the most part, the kind of intensive scrutiny of cost and quality that purchasers of health care have applied to medical and mental health services. Cost-control measures in dentistry have taken the form of pretreatment review for all cases exceeding a certain dollar cost, usually about $150. About 80% of all dental claims fall below the dollar threshold for review. Of those subject to review, the vast majority are processed by lay analysts on the basis of claim forms alone or radiographs. Only 5% of all claims are referred to a dental consultant for evaluation, less than 0.01% for another oral examination, and less than 0.001% to a peer review committee. Because of a lack of sufficient data and variations in review from one carrier to the other, it is difficult to make meaningful comments about the quality of dental care currently being provided under any insurance plan. While improved quality is the intended outcome of review, cost-saving capability is the yardstick most carriers use to evaluate the pretreatment review systems. Therefore there is a tendency to con-
Am. ,I, Orthod. Dentofac. Orthop. January 1990
centrate any review on high-cost services such as orthodontics but that is minimal and dependent on the subjective evaluation of the orthodontic consultant in the absence of well-established national or local standards of care. The vice-president of a large insurance company recently said that educational and licensing agencies had failed to establish orthodontic standards of care, peer review had proved inadequate, and thus it might be left by default to the insurance carriers to set standards of care. He noted that the safety of the seas is guaranteed by Lloyds of London, whose ship inspections attest to the worthiness of each vessel. It is possible that insurance companies will have to define the standards of orthodontic practice, since no one else has yet done so. TRENDS IN CLINICAL QUALITY CONTROL
There are many reasons that quality control is more advanced in medicine than in orthodontics. Medicine has specific diagnostic tests, well-defined, tested, and commonly taught treatment protocols, and the specialty board examinations in medicine and surgery are highly integrated with residency training programs. More than 90% of physicians who complete medical residency training become board certified, usually as a part of the training itself. Hospitals maintain strict standards for granting hospital staff privileges and rigorously review the results of new surgical procedures, drugs, and other treatment methods. Insurance companies have controlled excesses in surgery (e.g., by the use of second opinions). The preparation of "Guidelines for Quality Assessment of Orthodontic Care" is a significant step forward in orthodontics. The preamble to these guidelines contains this significant sentence: "These guidelines do not establish a standard of care endorsed by the American Association of Orthodontists." This disclaimer is important because such standards cannot be adopted until there are definitive studies on the efficacy of routine treatment procedures for typical malocclusions and such standard treatment procedures have been required and included in all orthodontic graduate and/or predoctoral programs. Some dental societies now prohibit specialists from serving on peer review committees that hear complaints from aggrieved patients, arguing that a specialist is not a "peer" of a general practitioner. Their exclusion greatly diminishes the profession's responsibility to protect the public and reenforces two quality levels of orthodontic treatment. It will be difficult to reverse this trend to less protection of the public's interest, but the trend must be reversed if the dental profession is to be responsible for quality assurance in orthodontics. The National Institutes of Health recently funded
Volume 97 Number I
several extensive studies to assess orthodontic efficacy. I am skeptical of their practicality because most of the approved studies are based on populations of patients treated by faculty members or graduate students in dental schools. Realistic standards of practice can be established only by analyzing the level of treatments in a wide variety of actual practice settings by a large number of practitioners. What is being done in the real world by all dentists treating all kinds of malocclusions on a day-by-day basis would be far more relevant to current problems than studies carded out within the special environment of the dental school. SOME IMPENDING PROBLEMS IN ORTHODONTIC QUALITY CONTROL
Today luxuries have become necessities. Health service is thought of as a utility. Orthodontics is no longer a status item but a need. The emphasis on prevention has changed the public's image of the dentist and the dentist's image of himself. Consumerism has not only become faddish but is a strong social force, putting some dentists in a bind since they are rendering services for which they have not been adequately trained. It puts all dentists on the spot if there are important areas of public need that the profession is not meeting. Dentistry is an unusual aberration in our capitalistic democracy since it is a licensed monopoly granted special privileges. The monopoly that dentistry and medicine have is not like a Kentucky Fried Chicken franchise, which grants an exclusive territory without competition; rather, the government has said: "We think that the professions can best determine what is good for the public and we charge it exclusively to regulate health services for the public's good." We have special privileges because we are burdened with these special responsibilites, but, in the case of orthodontic treatment, dentistry has not met its mandate to protect the public's health. Thus far we have dealt with the mechanisms of quality assurance in orthodontic treatments. I want now to address three troublesome trends that demonstrate how dentistry has failed to confront the matter of quality assurance in orthodontic treatment. These trends are (1) the loss of professionalism in dentistry, (2) new patterns of delivery of orthodontic services, and (3) the loss of some control of dental education by dental schools and the American Dental Association. The loss of professionalism in dentistry
It is easy to explain the degeneration of professional behavior in the professions as a sign of the times or to blame it on the U.S. Trade Commission for their unusual restraint-of-trade action against dentistry. Whatever the reasons, there is less formal constraint of dentists' behavior in the practice setting, in our dealings
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with the public, and in our toleration of shoddy and cheap advertising of our services. Colleagues we once thought to be ethical professionals now use the most blatant devices to promote themselves and their practices. Luring others to attend short courses has become, for some, a bigger money-maker than dental practice itself. Why do we tolerate, collectively, such behavior when it destroys the public's image of us, demeans our many years of effort to promote quality services, and destroys the very rationale for the establishment of professions in this country? What we choose to do about this trend as individuals is our own personal, ethical decision, but what we must do in concert is more significant and effective because it concerns the whole profession of dentistry. New patterns of delivery of orthodontic services
Changes are taking place in the way that orthodontic services are delivered to the public. We are in an age of experimentation and we do not yet know which, if any, of these new schemes will survive. Nor are there data on their quality control. The examples here may be matched in any state. I chose three recently observed in Michigan. Example 1. A general practitioner who attended a proprietary dental school, which offered weekend orthodontic courses, obtained a contract from a union to operate as an orthodontic PPO (preferred provider organization), which made it possible for general practitioners with similar contracts for family practice to refer their orthodontic cases to him. There is a specialty practice law in Michigan that he apparently is not contravening unless he calls himself an orthodontist, but he seems to be, in fact, operating against the spirit of the law. Example2. A Michigan-licensed orthodontist living in another state flies to Michigan 2 days each month, spending 2 half-days in each of two towns, where he does initial examinations and treatment plans for orthodontic patients, whose treatments are carded out by general practitioners during his absence. It is not clear who is legally responsible for the quality of treatment of these cases--perhaps the orthodontist since he reviews and supervises the cases, perhaps the general practitioners since they are doing most of the work. All treatments are carded out in an HMO clinic, sponsored by a reputable health insurance carrier. Example 3. An HMO orthodontic clinic is run by a dental carder corporation. An orthodontist, who holds American Board certification, is associated with this clinic. Since he practices there 2 days a week, he does not do all the treatment plans or supervise all the treatments that are carded out by general practitioners and assistants, whether the orthodontist is present or not. There is no question about the abilities of the ortho-
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Moyers
dontist, but we may worry about quality assurance when untrained practitioners each see 100 orthodontic patients a day and there is a 6-week interval between visits. We will have to learn to extend orthodontic services to the largest number of people. One of these three schemes may be a significant step forward in reaching that goal, but we have absolutely no data about the quality of the service. The loss of control of dental education by dental schools and the profession There have been some intereting experiments in educating the general practitioner and the pedodontist beyond the level of that possible in short courses alone. The way that one experienced orthodontic teacher has attempted to meet the problem of continuity of clinical supervision during learning, always absent in short courses, is to establish a proprietary school where course work is especially designed for pedodontists and advanced general practitioners. Instruction is in a private office 2 days a week for 10 weeks. A student who completes the first 10-week course may arrange for the orthodontist-teacher to visit the student's practice 1 day a month for several months at an additional fee. I am troubled by two facts: (1) There are now no testing mechanisms in place to tell how well these dentists are trained and (2) the more successful the teacher is, the more imitators there will be. There are not many orthodontic teachers as good as this man, and we already have far too many amateur pedagogues offering courses in orthodontics. A brochure describes another innovative method. A competent, well-trained orthodontist opens his home and practice on extended weekends over a period of time. The advantages of group learning are provided, but there can hardly be an adequate library, other clinical opinions, or the time necessary to contemplate and read widely. Furthermore, treatment of cases when students return home are unsupervised. Cynics may say that such efforts are always prompted by greed and these innovations are but new ways to make money. Others may contend that such efforts cannot possibly succeed at a decent level of quality. How much money a colleague makes by ethical, efficient teaching should not interest us. However, the quality of work his students perform concerns us all. SUGGESTIONS FOR IMPROVED ORTHODONTIC QUALITY ASSURANCE Quality assurance is so multifactorial that no single solution can be a total solution. It is so complicated we
Am. J. Orthod. Dentofac. Orthop. January 1990
are often tempted to avoid the problem, claiming either (1) that it is not our responsibility or (2) that nothing can be done. The energies of us all are required in the search for a series of solutions that will help restore the integrity of the specialty and the good name of dentistry. Someone in dentistry has to lead the way. Surely it should be the orthodontists. The following suggestions reflect one man's opinion about what needs to be done at this time. 1. If the public is to be protected, there must be one standard of practice used in the review and assessment of all treatments, regardless of the qualification or experience of the clinician. Some believe there can be a high road and a low road in orthodontics, the high road taken by the specialist and the low road by all others in the profession. I do not. 2. We must work to define practical standards of treatment for every routine orthodontic problem. Note that I say standards of treatment, not methods of treatment. 3. In order to meet such acceptable standards of practice in general dentistry, well-defined standards for predoctoral orthodontic training must be established, for some malocclusions at least, and implemented in all dental schools in this country. 4. We must insist on rigorous orthodontic requirements and testing in state board and national and regional board examinations. 5. The American Dental Association Commission on Accreditation, in conjunction with the American Association of Orthodontics, should move to provide evaluations of the content and utility of all continuing education courses in orthodontics being offered by dental schools and dental associations. Courses that meet established standards should bear the imprimatur of the ADA and the AAO to protect the enrollees and the patients whom they may treat. 6. There should be formal testing of theory and clinical competency in orthodontics for every graduate program in pediatric dentistry. If that is not done, the specialty of pediatric dentistry will be greatly diminished and the Commission of Accreditation of the American Dental Association should be asked to define the differences, if any, between the specialties of pediatric dentistry and orthodontics. There are significant differences in the training of orthodontists and pedodontists and in their clinical capabilities. Those differences must be made clear to all, especially the public. 7. I have used Dr. O. B. Vaugh's presidential address to the American Board of Orthodontics as the basis for these suggestions about the role of the ABO in quality assurance. Less than one fourth of all members of the American
Volume 97 Number 1
Association of Orthodontists are now certified by the American Board o f Orthodontics, a ratio significantly less than seen in the medical specialties. The American Board of Orthodontics, in conjunction with the Council on Orthodontic Education, should take the following steps: a. Develop a plan to synchronize all graduate residency programs toward completion o f a part o f the Board's didactic and clinical requirements by the end of the training period. b. Grant provisional Board certification for a period o f a few years to those who pass this initial examination. Rigorous clinical case presentations could be completed when sufficient cases are accumulated in practice. c. For a limited period, make an all-out effort to increase dramatically the number of practicing orthodontists taking the examination each year. Such a program would require much sacrifice, the recall to duty of former Board members, the recruitment o f orthodontic educators, and the determination on the part of many members to "bite the bullet" and take the Board examination at last. The result will be a far greater gap between certified orthodontists and all other dentists, for the majority of us would have then met the highest standards of competency testing. It is routine in medicine; it should be so in dentistry too. The time has come! The time has come for our profession to stand up for high standards in all aspects of clinical dental education. The time has come for someone to protect the public. The time has come for someone to act to guarantee the high quality of all orthodontic treatments. That someone should be the orthodontist, for we are the ones who are best trained,
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and we are those most experienced in this area of dental health. Action on the reforms I have mentioned is needed now! Some implementations could begin at once, within the agencies o f the American Association of Orthodontists. The changes will be difficult, but they will be made more difficult by further neglect. No matter before the specialty o f orthodontics today is more important than our obligation to help obtain quality assurance for all patients receiving orthodontic treatment. We cannot dedicate ourselves to more; we dare not do less. REFERENCE
I. Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press, 1980.
Reprint requests to: Dr. Robert E. Moyers Center for Human Growth and Development University of Michigan 300 N. Ingalls St. Ann Arbor, M1 48109 •
a
•
Many of you know Jack Salzmann for his textbook, for his years of service as REVIEWSAND ABSTRACTSeditor of our JOURNAL, and for his service in almost every office of the American Association of Orthodontists. It is easy to recite his many accomplishments in a typical panegyric; I wish to be more personal. It was my luck to be given important responsibilities in orthodontics at a young age. Some wait and watch to see the young make mistakes; Jack helped by giving candid, honest advice and warm support. He arranged for my placement on important committees. Few tasks have given me more pleasure than this one, because it is a way to say thanks to Jack for all he has done for all of us.
O r t h o d o n t i s t s define quality orthodontics by cephalometric measures, the patient by the shortness of the treatment time, and the parent by the size of the bill, but goodness or quality is not subject to measurement or statistical analysis. However defined, quality orthodontics interests others besides dentists--laymen, public health agencies, and insurance companies, for example. Quality assurance is a public health term that does not define the level of quality assured or say to whom it is assured--presumably a quality satisfying the patient. We rarely buy a car, an appliance, or certain services without an implied or written warranty, since warranties are a part of our everyday life that is subject to some legal definition and control. This article examines quality assurances, the warranties for orthodontic services. It addresses such questions as who is responsible for meeting the patient's expectations and whether orthodontic patients are protected in the same way that purchasers of lawn mowers, hair dryers, or a window-cleaning service are. QUALITY OF ORTHODONTIC SERVICES: CURRENT ASSURANCES
Donabedian ~notes that the quality of technical care, of general health care, is positively related to the quantity and quality of the training of the clinician, to the degree of specialization of the field, and to the amount of clinical experience of the practitioner regardless of age. He finds the quality of inpatient treatment highly related to the control of staff privileges, the responsibilities assigned clinicians, the size of the institution, and whether it has teaching and research functions. The quality of ambulatory care patients receive is significantly related to the equipment and office facilities, the ability to control the case load, and whether the clinician is associated with colleagues who are qualified and equally or better trained. There is a great variability of general health care quality with respect to the geo-
From the University of Michigan. The Salzmann Memorial Lecture for 1989. *Professor of Dentistry (Orthodontics); Fellow, Center for Human Growth and Development. 8/1/15355
graphic location, the institution where it is provided, the characteristics of individual practitioners, and the fields in which they practice. In an epidemiologic sense, the quality of health care varies widely within the populations of both consumers (patients) and providers (doctors). Despite a vast literature of the quality of medical care, we find only superficial attempts to define quality orthodontics. Nevertheless, let us see if we can extrapolate these general principles of quality assurance to the specifics of orthodontic services. Orthodontics differs from the other areas of dentistry in several particular ways that are important in assuring quality of treatments: 1. Orthodontics is not in the mainstream of the dental school curriculum since the amount of time dedicated to it is a small fraction of that assigned to restorative dentistry, prosthodontics, oral surgery, periodontics, or even endodontics. Dentists entering practice have less background and competency in orthodontics than in other clinical fields. 2. The number of teaching hoursrequired to achieve even minimal clinical competence is higher than for other fields in dentistry. 3. Correction of a malocclusion requires more time and appointments than the single-treatment procedures of most of dentistry. 4. Malocclusion is a variation of normal morphology and growth rather than a disease process; thus it is not amenable to the logic of Koch's postulates. 5. There usually are no acute symptoms as found in trauma or disease. 6. Severe malocclusions may be associated with general developmental disorders, and less severe conditions display oral dysfunction and undesired facial esthetics. 7. The patient's chief complaint often reflects psychological, esthetic, or dysfunctional concems. 8. State and regional boards do not emphasize testing of orthodontic theory and never test orthodontic clinical or technical prowess. Dentistry attempts quality control at three levels. The first level is dental education by the accreditation of dental schools and by the examination of the national 3
4 Moyers and state boards of dentistry. The second level is specialty training, which is similarly supervised by accreditation review and by the specialty boards, which offer an extra level of advanced certification (e.g., the American Board of Orthodontics). The third level is the general level of practice performance throughout the profession, which provides an especially difficult problem and only recently has been approached by such efforts as periodic renewal of credentials of practitioners and mandatory continuing education. Several agencies and organizations are generally assumed to be responsible for quality assurance of orthodontic treatments. Let us examine each with respect to orthodontic treatment in orthodontic specialty practice, pediatric dentistry, and general practice.
Quality assurance in orthodontic specialty practice • Medical specialties originated because of a natural grouping of diseases or syndromes within one body system. To name the medical fields (i.e., urology, dermatology, otolaryngology, thoracic surgery) is to define their scope and responsibilities. Most dental specialties have been defined by the techniques employed for a specific clinical problem, since dentistry's work is confined to the oromasticatory system. Most of the special fields in dentistry are separated only by the techniques used to deal with the ravages of two diseases, caries and periodontal disease. On the other hand, orthodontics defined like most medical specialties, has its focus on aberrant growth and morphology of the face, jaws, and occlusion and thus is more analogous to pediatrics than is pedodontics. 1. All programs leading to specialty practice must meet the requirements of the American Dental Association's Commission on Accreditation of Dental and Auxiliary Educational Programs, which, with the Council on Dental Education, defines the various areas of specialty practice, prepares guidelines for specialty training programs, and accredits them. 2. Through its section on orthodontics, the American Association of Dental Schools provides programatic support to help orthodontic departments meet the requirements of the American Dental Association. 3. The Council on Orthodontic Education of the American Association of Orthodontists is charged with promoting the highest standards of orthodontic education. 4. The American Board of Orthodontics provides an examination and the highest level of certification available in orthodontics. 5. All states with specialty licenses recognize orthodontics. The regional and national boards do not provide specialty examinations and licenses. 6. The legal profession has recently taken an in-
Am. J. Orthod. Dentofac. Orthop. January 1990
creasing interest in treatment of malocclusion and temporomandibularjoint disorders that have many common features: (a) each is a variation of normal growth, development, and function; (b) signs and symptoms that are meaningless in some patients are highly significant in others; and (c) few controlled clinical studies are available to validate particular treatments. Diagnostic medical tests are usually more specific, more standardized, and more commonly used. In medical cases, specific drugs or methods with scientific studies attesting to their validity are available to establish a provable standard of care, but that is rarely the case in orthodontics. The absence of scientific clinical studies or standard approved clinical teaching makes the role of the expert witness important in such cases, since the jury alone decides whether or not the treatment rendered was below the standard of care. Quality assurance in this system is set by a series of precedents, each of which is determined by a jury of laymen rather than by informed professionals or clinical scientific research. It would be difficult to get a consensus among orthodontists about orthodontic methods of treatment (treatment tactics), but it is possible to find consensus about strategies (treatment goals). Furthermore, it is possible to define treatments that are below the standard of practice (e.g., treatments that have been abandoned or that studies have shown to be unsatisfactory). Aggrieved patients must have a chance to be represented in court, but the peculiarities of today's tort system make it a most inefficient way to protect the public. Quality assurance in orthodontic specialty practice can best be guaranteed by scientific clinical research defining appropriate standards of care that could then be adopted as a required part of the curriculum in all graduate programs.
Orthodontic quality assurance in pediatric dentistry specialty practice There are three reasons that the pedodontist is interested in orthodontics. First, strong undergraduate training programs in pedodontics now produce general dentists who serve children well, creating a diminishing number of family dentist referrals of patients to pedodontists, Second, fluoridated communal water supplies and topical fluoride treatments have dramatically diminished caries in young children. Third, pedodontists often become disenchanted because pedodontic practice has become insufficiently challenging and the economic base of their practice has decreased. Frustrated, pedodontists rationalize claiming that "pedodontics serves all the needs of the child; therefore the treatment of malocclusions is our responsibility." Let us examine pediatric dentistry's training pro-
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grams and organizations to ascertain what quality assurances there are for orthodontic treatments rendered by pedodontics. 1. There is much variation in the amount and the nature of orthodontics taught to graduate students in pediatric dentistry. Some programs require formal courses in cephalometrie diagnosis, occlusal development, craniofacial growth and development, and elementary orthodontic techniques; most offer some of these courses, and some offer none. There is even greater variation in the clinical orthodontic training, which is usually supervised by a member of the orthodontic faculty and consists of the management of a few mixed-dentition cases of mild to moderate severity. 2. The orthodontic requirements for pediatric dentistry are not clearly described in the guidelines of the American Dental Association. The requirements for orthodontics and growth theory are minimal and those for orthodontic techniques and clincial practice are trivial. There certainly is no assurance that pediatric dentists are well prepared in orthodntics. 3. An examination of the Journal of the American Association of Dental Schools and the programs provided by the pedodontic section of the AADS show no recent strong effort to seriously address the matter of orthodontic teaching in graduate pedodontic programs. 4. A careful reading of all the issues of the American pedodontic journals for the last I0 years reveals little space has been given to craniofacial or occlusal development, orthodontic diagnosis, or the treatment of malocclusion. The formal programs of pedodontic societies and the continuing education offerings of pedodontie departments have shown a significantly increased interest in orthodontics. 5. Candidates for the American Board of Pediatric Dentistry are examined on various aspects of growth and development and are required to present the records of a few treated clinical cases, one of which is usually a minor orthodontic problem. Pedodontists are in the strange position of having obliterated much of the need for the services for which the specialty was founded and for which they were trained. Pediatric dentistry seems to be seeking and needing a new role for itself; however, that desire alone does not qualify pedodontists as orthodontic clinicians. Their ambitions alone do not assure quality treatment of malocclusion; nor is there any indication of major formal efforts to train or retrain pedodontists to qualify as orthodontic clinicians. Orthodontic quality assurance in general practice Current data suggest that more than 50% of all malocclusions are treated by dentists with little formal train-
ing in orthodontics. Although ethically these dentists cannot hold themselves to be orthodontists, legally they can attempt the treatment of any malocclusion. Who assures the public of the quality of treatments rendered by well-meaning dentists who have little training in orthodontics, have never been well tested by licensing bodies for their orthodontic competency, and are rarely subjected to a review of their clinical abilities? This is a problem without parallel bt medichre or dentistry because there is no other field bz which one half of all treatments are provided by clblicians with little trainblg and no testing of competence. 1. General dentists in recent years have often enroiled in proprietary courses in orthodontics outside the mainstream of dental education. An increasing number of orthodontic short courses are sponsored by dental societies, orthodontic supply houses, general dentists, and orthodontists. To the cynic, sometimes these courses seem to exploit the dentist's desire to learn for the promoter's profit. Some are offered with such excessive zeal for a single idea or technique that objective educational perspective is lost. Others are weak because of the incompetence or lack of training of the teachers. No other field in dentistry has as many courses offered by outside "experts" as orthodontics. Within the past few months, I have received announcements of orthodontic courses taught by general practitioners, dental hygienists, chiropractors, physical therapists, financial planners, dental technicians, pedodontists, periodontists, hypnotists, and child psychologists. How can an uninformed dentist know which course is worthy of his time and money? 2. The Academy of General Dentistry lists "approved" courses that its members may take for credit toward a "master's" in orthodontics. One hour of instruction equals one point. The member accumulating 2000 points qualifies for a "master's in orthodontics" and on payment of a fee of a few hundred dollars, may participate in a graduation ceremony, replete with cap and gown, and receive a certificate attesting to qualifications in orthodontics. The "master's" of the Academy of General Dentistry is not recognized by any other dental group or education accreditation agency. 3. Four organizations of general dentists interested in orthodontics have joined together to form the Federation of Orthodontic Associations, which sponsors programs, short courses, and the hlternational Journal of Orthodontics. 4. Restorative and prosthetic dentistry continues to dominate the testing given by state and regional boards. There is nothing in the dental law of any of the 50 states that prevents any dentist from undertaking the treatment of any malocclusion, no matter how severe the problem
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or how ill-trained the dentist. Yet there is no testing of orthodontic competence by state or regional boards. One of the major problems in dental quality assurance now is the protection of the public from the effects of inadequate predoctoral orthodontic training and the many current inappropriate and poor orthodontic short course offerings. The control mechanisms, such as hospitals, that prevent physicians in general practice from overextending themselves do not exist in dentistry. The profession is frustrated and the public suffers. The American Dental Association, which spends many dollars each year certifying toothpastes, denture powders, amalgam filling materials, and accrediting undergraduate and graduate dental programs, assumes no similar responsibilities in the field of continuing education. Nor does the American Association of Dental Schools have any means of monitoring the quality of courses presented outside their authority. General dentists will continue to treat many matocclusions; therefore they will continue to seek training, but I am pessimistic about our ability to help general practitioners as much as they sometimes believe we can. It is difficult to imagine a practical format for a program with enough discipline and intensity to give the general practitioners orthodontic ability comparable to the clinical skills that can be achieved much more easily in other areas of dentistry. The public will be better served when well-trained orthodontists accept their primary responsibility for all orthodontic education, including that of the dentist in general practice. Unless proper accreditation is established for all orthodontic education and orthodontists provide training in reputable surroundings, shoddy courses will remain. The role of health insurance companies
Dentistry has escaped, for the most part, the kind of intensive scrutiny of cost and quality that purchasers of health care have applied to medical and mental health services. Cost-control measures in dentistry have taken the form of pretreatment review for all cases exceeding a certain dollar cost, usually about $150. About 80% of all dental claims fall below the dollar threshold for review. Of those subject to review, the vast majority are processed by lay analysts on the basis of claim forms alone or radiographs. Only 5% of all claims are referred to a dental consultant for evaluation, less than 0.01% for another oral examination, and less than 0.001% to a peer review committee. Because of a lack of sufficient data and variations in review from one carrier to the other, it is difficult to make meaningful comments about the quality of dental care currently being provided under any insurance plan. While improved quality is the intended outcome of review, cost-saving capability is the yardstick most carriers use to evaluate the pretreatment review systems. Therefore there is a tendency to con-
Am. ,I, Orthod. Dentofac. Orthop. January 1990
centrate any review on high-cost services such as orthodontics but that is minimal and dependent on the subjective evaluation of the orthodontic consultant in the absence of well-established national or local standards of care. The vice-president of a large insurance company recently said that educational and licensing agencies had failed to establish orthodontic standards of care, peer review had proved inadequate, and thus it might be left by default to the insurance carriers to set standards of care. He noted that the safety of the seas is guaranteed by Lloyds of London, whose ship inspections attest to the worthiness of each vessel. It is possible that insurance companies will have to define the standards of orthodontic practice, since no one else has yet done so. TRENDS IN CLINICAL QUALITY CONTROL
There are many reasons that quality control is more advanced in medicine than in orthodontics. Medicine has specific diagnostic tests, well-defined, tested, and commonly taught treatment protocols, and the specialty board examinations in medicine and surgery are highly integrated with residency training programs. More than 90% of physicians who complete medical residency training become board certified, usually as a part of the training itself. Hospitals maintain strict standards for granting hospital staff privileges and rigorously review the results of new surgical procedures, drugs, and other treatment methods. Insurance companies have controlled excesses in surgery (e.g., by the use of second opinions). The preparation of "Guidelines for Quality Assessment of Orthodontic Care" is a significant step forward in orthodontics. The preamble to these guidelines contains this significant sentence: "These guidelines do not establish a standard of care endorsed by the American Association of Orthodontists." This disclaimer is important because such standards cannot be adopted until there are definitive studies on the efficacy of routine treatment procedures for typical malocclusions and such standard treatment procedures have been required and included in all orthodontic graduate and/or predoctoral programs. Some dental societies now prohibit specialists from serving on peer review committees that hear complaints from aggrieved patients, arguing that a specialist is not a "peer" of a general practitioner. Their exclusion greatly diminishes the profession's responsibility to protect the public and reenforces two quality levels of orthodontic treatment. It will be difficult to reverse this trend to less protection of the public's interest, but the trend must be reversed if the dental profession is to be responsible for quality assurance in orthodontics. The National Institutes of Health recently funded
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several extensive studies to assess orthodontic efficacy. I am skeptical of their practicality because most of the approved studies are based on populations of patients treated by faculty members or graduate students in dental schools. Realistic standards of practice can be established only by analyzing the level of treatments in a wide variety of actual practice settings by a large number of practitioners. What is being done in the real world by all dentists treating all kinds of malocclusions on a day-by-day basis would be far more relevant to current problems than studies carded out within the special environment of the dental school. SOME IMPENDING PROBLEMS IN ORTHODONTIC QUALITY CONTROL
Today luxuries have become necessities. Health service is thought of as a utility. Orthodontics is no longer a status item but a need. The emphasis on prevention has changed the public's image of the dentist and the dentist's image of himself. Consumerism has not only become faddish but is a strong social force, putting some dentists in a bind since they are rendering services for which they have not been adequately trained. It puts all dentists on the spot if there are important areas of public need that the profession is not meeting. Dentistry is an unusual aberration in our capitalistic democracy since it is a licensed monopoly granted special privileges. The monopoly that dentistry and medicine have is not like a Kentucky Fried Chicken franchise, which grants an exclusive territory without competition; rather, the government has said: "We think that the professions can best determine what is good for the public and we charge it exclusively to regulate health services for the public's good." We have special privileges because we are burdened with these special responsibilites, but, in the case of orthodontic treatment, dentistry has not met its mandate to protect the public's health. Thus far we have dealt with the mechanisms of quality assurance in orthodontic treatments. I want now to address three troublesome trends that demonstrate how dentistry has failed to confront the matter of quality assurance in orthodontic treatment. These trends are (1) the loss of professionalism in dentistry, (2) new patterns of delivery of orthodontic services, and (3) the loss of some control of dental education by dental schools and the American Dental Association. The loss of professionalism in dentistry
It is easy to explain the degeneration of professional behavior in the professions as a sign of the times or to blame it on the U.S. Trade Commission for their unusual restraint-of-trade action against dentistry. Whatever the reasons, there is less formal constraint of dentists' behavior in the practice setting, in our dealings
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with the public, and in our toleration of shoddy and cheap advertising of our services. Colleagues we once thought to be ethical professionals now use the most blatant devices to promote themselves and their practices. Luring others to attend short courses has become, for some, a bigger money-maker than dental practice itself. Why do we tolerate, collectively, such behavior when it destroys the public's image of us, demeans our many years of effort to promote quality services, and destroys the very rationale for the establishment of professions in this country? What we choose to do about this trend as individuals is our own personal, ethical decision, but what we must do in concert is more significant and effective because it concerns the whole profession of dentistry. New patterns of delivery of orthodontic services
Changes are taking place in the way that orthodontic services are delivered to the public. We are in an age of experimentation and we do not yet know which, if any, of these new schemes will survive. Nor are there data on their quality control. The examples here may be matched in any state. I chose three recently observed in Michigan. Example 1. A general practitioner who attended a proprietary dental school, which offered weekend orthodontic courses, obtained a contract from a union to operate as an orthodontic PPO (preferred provider organization), which made it possible for general practitioners with similar contracts for family practice to refer their orthodontic cases to him. There is a specialty practice law in Michigan that he apparently is not contravening unless he calls himself an orthodontist, but he seems to be, in fact, operating against the spirit of the law. Example2. A Michigan-licensed orthodontist living in another state flies to Michigan 2 days each month, spending 2 half-days in each of two towns, where he does initial examinations and treatment plans for orthodontic patients, whose treatments are carded out by general practitioners during his absence. It is not clear who is legally responsible for the quality of treatment of these cases--perhaps the orthodontist since he reviews and supervises the cases, perhaps the general practitioners since they are doing most of the work. All treatments are carded out in an HMO clinic, sponsored by a reputable health insurance carrier. Example 3. An HMO orthodontic clinic is run by a dental carder corporation. An orthodontist, who holds American Board certification, is associated with this clinic. Since he practices there 2 days a week, he does not do all the treatment plans or supervise all the treatments that are carded out by general practitioners and assistants, whether the orthodontist is present or not. There is no question about the abilities of the ortho-
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dontist, but we may worry about quality assurance when untrained practitioners each see 100 orthodontic patients a day and there is a 6-week interval between visits. We will have to learn to extend orthodontic services to the largest number of people. One of these three schemes may be a significant step forward in reaching that goal, but we have absolutely no data about the quality of the service. The loss of control of dental education by dental schools and the profession There have been some intereting experiments in educating the general practitioner and the pedodontist beyond the level of that possible in short courses alone. The way that one experienced orthodontic teacher has attempted to meet the problem of continuity of clinical supervision during learning, always absent in short courses, is to establish a proprietary school where course work is especially designed for pedodontists and advanced general practitioners. Instruction is in a private office 2 days a week for 10 weeks. A student who completes the first 10-week course may arrange for the orthodontist-teacher to visit the student's practice 1 day a month for several months at an additional fee. I am troubled by two facts: (1) There are now no testing mechanisms in place to tell how well these dentists are trained and (2) the more successful the teacher is, the more imitators there will be. There are not many orthodontic teachers as good as this man, and we already have far too many amateur pedagogues offering courses in orthodontics. A brochure describes another innovative method. A competent, well-trained orthodontist opens his home and practice on extended weekends over a period of time. The advantages of group learning are provided, but there can hardly be an adequate library, other clinical opinions, or the time necessary to contemplate and read widely. Furthermore, treatment of cases when students return home are unsupervised. Cynics may say that such efforts are always prompted by greed and these innovations are but new ways to make money. Others may contend that such efforts cannot possibly succeed at a decent level of quality. How much money a colleague makes by ethical, efficient teaching should not interest us. However, the quality of work his students perform concerns us all. SUGGESTIONS FOR IMPROVED ORTHODONTIC QUALITY ASSURANCE Quality assurance is so multifactorial that no single solution can be a total solution. It is so complicated we
Am. J. Orthod. Dentofac. Orthop. January 1990
are often tempted to avoid the problem, claiming either (1) that it is not our responsibility or (2) that nothing can be done. The energies of us all are required in the search for a series of solutions that will help restore the integrity of the specialty and the good name of dentistry. Someone in dentistry has to lead the way. Surely it should be the orthodontists. The following suggestions reflect one man's opinion about what needs to be done at this time. 1. If the public is to be protected, there must be one standard of practice used in the review and assessment of all treatments, regardless of the qualification or experience of the clinician. Some believe there can be a high road and a low road in orthodontics, the high road taken by the specialist and the low road by all others in the profession. I do not. 2. We must work to define practical standards of treatment for every routine orthodontic problem. Note that I say standards of treatment, not methods of treatment. 3. In order to meet such acceptable standards of practice in general dentistry, well-defined standards for predoctoral orthodontic training must be established, for some malocclusions at least, and implemented in all dental schools in this country. 4. We must insist on rigorous orthodontic requirements and testing in state board and national and regional board examinations. 5. The American Dental Association Commission on Accreditation, in conjunction with the American Association of Orthodontics, should move to provide evaluations of the content and utility of all continuing education courses in orthodontics being offered by dental schools and dental associations. Courses that meet established standards should bear the imprimatur of the ADA and the AAO to protect the enrollees and the patients whom they may treat. 6. There should be formal testing of theory and clinical competency in orthodontics for every graduate program in pediatric dentistry. If that is not done, the specialty of pediatric dentistry will be greatly diminished and the Commission of Accreditation of the American Dental Association should be asked to define the differences, if any, between the specialties of pediatric dentistry and orthodontics. There are significant differences in the training of orthodontists and pedodontists and in their clinical capabilities. Those differences must be made clear to all, especially the public. 7. I have used Dr. O. B. Vaugh's presidential address to the American Board of Orthodontics as the basis for these suggestions about the role of the ABO in quality assurance. Less than one fourth of all members of the American
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Association of Orthodontists are now certified by the American Board o f Orthodontics, a ratio significantly less than seen in the medical specialties. The American Board of Orthodontics, in conjunction with the Council on Orthodontic Education, should take the following steps: a. Develop a plan to synchronize all graduate residency programs toward completion o f a part o f the Board's didactic and clinical requirements by the end of the training period. b. Grant provisional Board certification for a period o f a few years to those who pass this initial examination. Rigorous clinical case presentations could be completed when sufficient cases are accumulated in practice. c. For a limited period, make an all-out effort to increase dramatically the number of practicing orthodontists taking the examination each year. Such a program would require much sacrifice, the recall to duty of former Board members, the recruitment o f orthodontic educators, and the determination on the part of many members to "bite the bullet" and take the Board examination at last. The result will be a far greater gap between certified orthodontists and all other dentists, for the majority of us would have then met the highest standards of competency testing. It is routine in medicine; it should be so in dentistry too. The time has come! The time has come for our profession to stand up for high standards in all aspects of clinical dental education. The time has come for someone to protect the public. The time has come for someone to act to guarantee the high quality of all orthodontic treatments. That someone should be the orthodontist, for we are the ones who are best trained,
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and we are those most experienced in this area of dental health. Action on the reforms I have mentioned is needed now! Some implementations could begin at once, within the agencies o f the American Association of Orthodontists. The changes will be difficult, but they will be made more difficult by further neglect. No matter before the specialty o f orthodontics today is more important than our obligation to help obtain quality assurance for all patients receiving orthodontic treatment. We cannot dedicate ourselves to more; we dare not do less. REFERENCE
I. Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor, Michigan: Health Administration Press, 1980.
Reprint requests to: Dr. Robert E. Moyers Center for Human Growth and Development University of Michigan 300 N. Ingalls St. Ann Arbor, M1 48109 •
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Many of you know Jack Salzmann for his textbook, for his years of service as REVIEWSAND ABSTRACTSeditor of our JOURNAL, and for his service in almost every office of the American Association of Orthodontists. It is easy to recite his many accomplishments in a typical panegyric; I wish to be more personal. It was my luck to be given important responsibilities in orthodontics at a young age. Some wait and watch to see the young make mistakes; Jack helped by giving candid, honest advice and warm support. He arranged for my placement on important committees. Few tasks have given me more pleasure than this one, because it is a way to say thanks to Jack for all he has done for all of us.
