Practice Management

Examination of Current Interface Between General Practitioners and Certified Specialists


Ron Weintraub


September 21, 2016

September 21, 2016

The focus of dental practice and public expectations is shifting to a more holistic and biological base centering on pathological, general health issues. Ironically, our most qualified experts often express the feeling that they are less included in the treatment of some challenging issues in dental treatment. It would seem logical that as the scope of treatment for many patients enlarges, the importance of use of experts in various fields would be more sought after than previously. Actually, the converse in some areas seems to be prevalent.As oral health providers, we should realize that as knowledge expands and treatment modalities and equipment become more complex, Certified Specialists should be more important in our everyday practice. Examining the current interface between general practitioners and certified specialists shows existence of an overlap of General Practitioners (GP) and Certified Specialists (CS).

Recognized Certified Specialists

The Royal College of Dental Surgeons of Ontario lists the following as recognized specialists in Ontario:1. Dental Anesthesiologists2. Endodontics3. Oral and Maxillofacial Radiology4. Oral and Maxillofacial Surgeons5. Oral Medicine Specialists6. Oral Pathology7. Orthodontics and Dental Facial Orthopedics8. Pediatric Dentistry9. Periodontics10. Prosthodontics11 .Public Health Dentistry

Potential for Overlap of Specialists with General Practices

The possibility exists of an overlap of specialists with general practices in the following areas:Dental Anesthesia, Endodontics, Oral and Maxillofacial Surgery, Orthodontics and Dental Facial Orthopedics, Pediatric Dentistry, Periodontics, Prosthodontics.

As oral health providers, we should realize that as knowledge expands and treatment modalities and equipment become more complex, Certified Specialists should be more important in our everyday practice.

Historical Relationship VS Current Trends

Why is there an apparent disconnect between the historical relationship and current trends vis-a-vis crossreferring? Although the established parameters for GPs to perform almost all aspects of dentistry legally, provided they have adequate training and expertise, it is left to GPs’ judgment whether to refer or treat in-house. Some of the active drivers to promote in-house treatment include the following:a. The availability of extra-curricular hands-on courses (mostly offered by CSs) add some postgraduate training components to GPs’ skillset;b. The degree of diminished busyness of some GP offices in larger urban areas opens up time to expand the level of offering in the office;c. The expansion of many multi-provider group practices allows clinicians the option to focus on areas of dentistry of their interest and gain knowledge and proficiency to offer to their patient base.

From Patients’ Perspective

  • Patients appreciate not having to relocate for treatment to a non-familiar office that does not offer the relationship component the family practice affords.
  • Patients automatically assume their GP office is sufficiently trained to provide all services.
  • Areas of procedures that easily fall within the scope of the GP office are no longer routinely referred out (e.g. Periodontics, Orthodontics, Surgical and Prosthodontics) because offices used to be so busy with routine treatment that they did not have to extend their mandate.
  • Current patients benefit from more treatment offered at the GP fee guide level, therefore, making access to care more attainable financially.

Some Issues Regarding Referral

  • Dental Anesthesia – There are two choices: (1) in house and (2) at a specialized facility. The decision whether to bring in a certified anaesthetist (dental or medical) should take into account the ability to provide trained staff (beyond Registered Nurse and clinical assistant) to support both in preparation and recovery versus the ability of the trained anesthetic/clinical dental treatment provider to produce more results in a shorter period of time under general anesthesia.
  • Endodontics – We should avoid taking on extra challenging root configurations with the idea that we can satisfactorily negotiate and seal the canals with the thought we can always send it off to an Endodontist. This scenario is a loss to the GP, a loss to the Endodontist, and a loss to the patient often leading to the patient leaving the practice.
  • Oral and Maxillofacial Surgery – Similarly, we should avoid the concept of “I will try, and if I am not successful, I can always refer out to an oral surgeon”. Even though routine surgical placement of implants is part of many everyday general practices, case selection is of primary importance. When some doubt of good results in our hands exists, wisdom prevails to refer out to another level of expertise. The same criteria exist for seemingly complex Exodontia.
  • Orthodontics – Many courses on in-house management of Orthodontic intervention as well as Invisaline are available. Moreover, a beneficial role for a well-trained generalist to offer in-house service after a complete evaluation and diagnosis has been done. The decision whether to refer is always based on patients’ best interest.
  • Periodontist – Periodontists are often referred to for complex implant placement as well as periodontal surgery and hygiene maintenance. It is a good opportunity to share periodontal maintenance between the Periodontist and the generalist.
  • Prosthodontist – In the area of full mouth rehabilitation, a generalist should consider the benefit to the case when it does not have to be prepared segmentally in their environment. Therefore, the management of re-establishing an ideal occlusal relationship to the full arch reconstruction is optimally achieved in a prosthodontic environment.

The proper supportive interaction between the generalist and the certified specialist is beneficial for all stakeholders of our profession, particularly the wellbeing of the patient as well as the professional relationship between CS and GP. The mutually supportive interaction between GP and CS bodes well for the continuing ethical professional growth of our practices.PA

Ron Weintraub is a founding partner with the Bayview Village & Downtown Dental Associates and brings over thirty-five years of knowledge and experience in the practice of general dentistry to The Professional Advisory. Large companies such as Patterson Dental, Ash Temple Ltd, Henry Schein Arcona, & the former Canadian Dental Co. have benefited from his insight. As owner of Innovative Practice Solutions, Ron advises dentists on practice enhancement, practice purchases, sales, location evaluations, associate buy-ins, and business mergers. Dr. Weintraub can be contacted at (905) 470-6222 Ext. 221 or