BDJ In Practice spoke to Claire Nightingale, Dentex partner at Queens Gate Orthodontics and NHS Consultant at Watford General Hospital and Jamie Morley, Leadership Coach and Author, about the problems facing orthodontists, the future of the specialty - and one solution available to improve their patients' experience

What are the main problems orthodontists face as we head into 2023?

CN I think all sectors within which orthodontics is provided have their unique challenges. NHS orthodontists are dealing with the backlog caused by COVID-19, poor UOA values and difficulties in finding specialist orthodontists, particularly outside of London. Recruitment and workforce issues are rife across dentistry, and we're no exception. Specialist orthodontists are highly trained but the value the NHS places on remunerating that skill set is low. I was recently told that specialist orthodontists are like 'gold dust', but at the same time, young orthodontists seem to have to work in multiple sites to fill a month of employment - how those two things can be equally true is a conundrum to me. Additionally, orthodontists, and their teams, have lost their jobs within practices that have lost their NHS contract. This is a cruel evolution in healthcare provision.

In the private sector, I've observed a significant change in referral patterns as general dental practices either employ in-house orthodontists or prefer to provide the treatment themselves, often with clear aligners. An estimated 70% of Invisalign providers nationally are GDPs which reduces referrals to specialist orthodontists. Consequently, I worry that patients may not be getting the benefit of a comprehensive discussion of treatment options, including referrals to NHS hospitals for orthognathic treatment.

Finally, I have concerns that we're not training orthodontists to work with modern technology that's being used in private practice, where digital scanners have replaced impressions and increasingly, I'm managing complex malocclusions with Invisalign. On the NHS, I can still only train orthodontists to use traditional techniques, such as metal fixed braces and functional appliances.

What are the current trends within the profession?

CN Treatment opportunities are very much moving towards clear aligners, as well as the integration of artificial intelligence within orthodontics. Technology enables us to take better care of our patients and lighten our work loads. Dental Monitoring is one such advancement and has revolutionised my practice.

I need to reiterate the problem of investment - with a widening discrepancy between what can be achieved in private practice and on the NHS. Take imaging technology, for example. Are there enough consultant dental radiologists to report on cone beam CT scans that, ideally, I'd like to prescribe for every patient with complex impacted teeth? Intra-oral scanners are a basic necessity in private practice but providing multiple scanners for hospital units is unlikely to happen within existing NHS budgets.

JM Globally, you can point to the economic and cost-of-living crisis. This will impact the profession - patients will have less disposable income, and to a degree private practice may be adversely affected.

That said, if you look at this through the prism of being a headwind, there are several tailwinds and positive trends to counterbalance the headwind. There's still an incredible level of demand for good, aesthetically pleasing teeth and smiles, so the demand will remain. With the challenges Claire spells out - especially for NHS orthodontists - patients don't want to wait for their treatment. There are too many instances of huge waiting lists for that to be a realistic possibility, so how do you make the most of that opportunity?

Dental Monitoring provides a quality, convenient platform for practitioners to free up their time and offer a level of service their patients expect. Time is becoming as much of a valuable commodity as money, and Dental Monitoring offers just that.

There's plenty of chatter about the remote management of orthodontic patients. What are your views on this, and can it be done safely and effectively?

CN Yes, it can. In my opinion, Dental Monitoring improves patient care. I'm almost at the point of concluding that it shouldn't be an optional extra; rather it's becoming a necessity. The treatment progress is assessed on a weekly basis, rather than every six to eight weeks, by AI, which is more acute than the human eye at picking up lost attachments or modules, for example. Problems are flagged up immediately, there's better dialogue between patients and their practitioner and a human being still makes the clinical decisions.

AI isn't flawless and doesn't pick up all problems, but it reduces unnecessary patient attendances and makes the necessary visits more purposeful. The orthodontist and team are still very involved from start to finish.

JM An accurate, initial assessment is critical - it means you can put that patient on the right track from very early in the process. There's a tendency to baulk at new ways of doing things, yet if it works for the patient and the practitioner, it has to be considered seriously. As always, it's all about the patient and their safety, and increased remote management can provide that.

What are the advantages and disadvantages of remote monitoring?

JM Chair time for the practice and wins for the patient, especially from a convenience perspective, would be high up on my lists. It's a process that takes a change in outlook - dentists will naturally think not seeing a patient is a bad thing. If you're constantly on top of the patient from afar, providing convenience for the patient and opening up chair time for new patients, that's a win for everyone.

CN For me, it's about working smarter, but not compromising on quality or patient safety as a result. It's been transformative. How was it possible for Queen's Gate Orthodontics to win 'Best Practice, UK' in 2020 and then to become the 'Most Transformed Practice' in the UKI in May 2022? I attribute this largely to embracing Dental Monitoring after the pandemic, in addition to being more adventurous with treating difficult malocclusions with Invisalign and other digital changes.

I audited our workflow to see how effective it was. I discovered that we'd saved 290 in-person appointments, equivalent to approximately 19 days' worth of work, between our previous analogue clinical practice (2019) and our digital practice (2021). The increased 'white space' in my diary enables new patients to be seen more quickly, for treatment problems to be addressed early, and for the team to have a better work/life balance, in addition to the ability to increase our caseloads.

The cost-of-living crisis is making its way into the wider profession. Is there any way practices and practitioners can effectively safeguard themselves against taking large hits?

JM There is only so much you can do to cut costs in a safe and effective way - once you tip over the precipice, it becomes dangerous. Once the rocky period is over, you're then not in a position to recover quickly, so ultimately it's not going to help in the long run.

That's not to say don't be sensible with costs - you have to be. If there's a way to grow the business in a positive, convenient and easy way, it's important you're in a position to invest and do so.

What does the future hold for the specialty?

JM Like in any forms of life, the more differentiated you are from someone providing the same service, the better. Orthodontists need to stand out and be different and lean on their vast experience in the field when compared to their GDP colleagues.

CN I think it's a bit bleak. There will always be a clinical need for specialist orthodontists, but as GDPs increase their orthodontic caseload, what will the workforce look like and who will treat dental disease? I fear for orthodontic therapists, for example, who risk being the last ones in and first ones out as recognised roles within the dental team. Their roles are prime for being replaced by technology, and I think the Australian model of a triple dental hygienist, dental therapist and orthodontic therapy qualification would be a welcome change to GDC registration.

The marketplace is becoming crowded, as younger GDPs wish to keep to low-risk procedures such as align, bleach and bond. Specialist orthodontists need to maintain this skill set to keep up with the competition and keep their social media profile high to connect directly with the public, as the traditional referral pathway becomes redundant. â—†

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