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Volume 28 , Issue 3
May/June 2013

Pages 651–652

EDITORIAL: Does Anyone Really Benefit from Turf Wars?

Steven E. Eckert, DDS, MS

PMID: 23748294

My understanding is that most countries throughout the world control the practice of dentistry through governmental agencies that grant licenses to (or provide registration of) dentists. This means that dental practitioners must demonstrate professional training prior to their receipt of a license. That license then identifies and controls the procedures that may be performed by the dentist. In essence, the granting of a license does not compel the clinician to perform every procedure known to the profession; instead the clinician decides what procedures are within their own skill set. Ultimately there is an expectation that clinicians “self-regulate” and that this will limit the procedures offered by individual dentists to those for which they feel most competent.

Indeed, dentists have traditionally recognized the need for this limitation of procedures to those for which they have adequate training, knowledge, and skill. Hence, the profession mandates continuing education to maintain skills and has created dental specialties that have strict guidelines that limit procedural offerings.

Once specialties are created it is not unusual to see the procedures offered by them undergo gradual modification and generalized expansion. In some instances, the expansion is quite logical, while in others, the expansion may mimic uncontrolled metastasis.

When clinical offerings are established through an educational system that objectively trains individuals to critical levels of knowledge and skill, a specialty is defined. Conversely, when specialties expand their treatment offerings simply by claiming new areas of skill or knowledge without additional didactic and clinical training, a disconnection with traditional education occurs. Simply claiming new areas of knowledge or skill without expansion of training time can demonstrate that the previous training time was excessive, that the new knowledge demands no additional training, or that new areas of knowledge and skill are being claimed without appropriate training.

Realistic assessment of educational program length must be routinely undertaken. Should program length be identified as excessive, a specialty must either shorten the program length or consider logical expansion of its program offerings. Of course, such a situation is unlikely since we are witnessing a burgeoning expansion of the knowledge base, which inevitably argues against reductions of educational program time.

What is happening in dental specialty training today? Most specialties have expanded their educational offerings, creating a situation where they expand into the turf of other specialties. Periodontists are required to receive experience in the provision of dental prostheses, while prosthodontists, endodontists, and orthodontists are required to provide surgical implant procedures. Likewise, oral and maxillofacial surgery, pediatric dentistry, and dental radiology have also expanded their procedural base. Indeed, exposure to the full scope of training regarding a specific topic leads to a better informed clinician, but proficiency in each step of the process cannot be ensured without appropriate training that generally occurs over time. Since none of the aforementioned dental specialties have increased their program time to incorporate these new skills, it would appear that the clinical procedures provided by specialists remain relatively unchanged while their knowledge base has surely expanded.

Looking at this situation, one wonders if we are entering the realm of turf wars. The definition that my computer dictionary provides for the term “turf war” is “an acrimonious dispute between rival groups over territory or a particular sphere of influence.” If exposure to new procedures results in an expansion of clinical offerings from specialists, I fear that the acrimony among specialties will increase while the quality of patient care, our ultimate goal, will not be favorably impacted.

I find it interesting that dentistry has taken a completely different path than medicine. In medical specialties there is a consistent narrowing of the scope of practice. One may suggest that the basic guidelines of surgery are related to appropriate anatomic identification, hemostasis, and careful wound repair. This is true for a neurosurgeon or for a general surgeon, and yet the surgical resection of an adenoma of the pituitary gland would certainly be handled by a different surgeon than would the resection of an adenoma of the thyroid gland. I experienced this firsthand when an orthopedic surgeon who only treats knees performed my anterior cruciate ligament repair. Had I needed a joint replacement, a completely different orthopedic surgeon would have performed this procedure. Ultimately the turf wars in medicine have resulted in narrower definition of a clinician’s “turf,” a situation that has resulted in improved patient care.

Returning to dentistry, almost all of the new specialty offerings are already within the purview of the general dental license. This means that the specialist could provide treatment within the dental practice act guidelines even though the specific procedures may not be part of the traditional description of that specialty. Said another way, the general dental license allows the specialist to perform some procedures that are not part of the definition of that specialty. In such a situation, an individual clinician may exhibit exquisite skills but these skills simply may not be part and parcel of the specialty itself.

In the United States today there are nine recognized dental specialties. The American Dental Association is considering the establishment of special areas of interest within the field of general dentistry. It is not unrealistic to think that a decade from now there could be 20 or more descriptors related to how dentists limit their practice. There is no doubt that there are disciplines within dentistry where additional training could provide a more knowledgeable and skillful clinician. It should be recognized, however, that some of these interest areas will encroach upon the turf of existing specialties.

Special areas of interest would require at least 1 year of training after which the clinician could challenge an examining board associated with that area of interest. The methods that need to be followed to create this board have yet to be established, although one might anticipate a ‘grandfathering’ process in which clinicians who are recognized as ‘expert’ in the field become the examiners who will ultimately decide who has achieved the standards of knowledge and skill requisite for a given topic.

Quite obviously the landscape is changing. The previously defined borders among specialties are blurring and this is occurring while the general dental community creates new areas of special interest. Rather than assembling pieces of a puzzle, with different disciplines and specialties contributing their own pieces, we are now witnessing overlapping of turf. If we assume that patients should be the ultimate beneficiaries of any changes in treatment models, one might ask if this will truly be the case as their ability to distinguish levels of expertise among the myriad of turf war combatants becomes more difficult.

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