In 1932, there were only 4 medical specialties: ophthalmology, otolaryngology, obstetrics and gynecology, and dermatology and syphology. The American Medical Association (AMA) had controlled the specialty recognition process and kept new emerging medical specialties, such as cardiology, internal medicine, pediatrics, and surgery, from gaining specialty recognition. Therefore, these emerging medical specialties formed the American Board of Medical Specialties (ABMS) and took over the process of medical specialty recognition. As the AMA was (and is) a trade organization, the ABMS formed as a credentialing agency. A credentialing agency sets the standards, which include clinical and didactic standards, and diplomate’s examinations (psychometric written and, possibly, oral examinations).1
Specialization and Credentialing
Clinical innovations and discoveries require clinicians to become familiar with an emerging knowledge base and advanced clinical technology through training and education. As the knowledge base grows, it becomes ever more necessary for clinicians to specialize in more limited areas of clinical concern. Furthermore, with the increase in the clinical knowledge base, physicians established new standards with respect to demonstrating competence through residency accreditation and psychometric diplomate’s examinations.
The standards for the establishment of an emerging medical specialty are threefold: (1) the emerging medical specialty must demonstrate an evidence-based proven benefit to patient care, (2) the emerging medical specialty must demonstrate educational and training programs offering a pathway to both didactic and clinical proficiency, and (3) the emerging medical specialty must perform a psychometric evaluation process to ensure a level of minimum competency within the practice of the specialty. Any physician with an MD degree and a state medical license is entitled to practice general medicine; however, clinicians who have attained internal medicine or family medicine credentials have demonstrated that they have passed minimal competencies within these established fields of medical specialization. Therefore, medical specialization does not require specialized focus but, rather, credentialed competency. Patients can reference that a physician who is certified within a medical specialty has attained a level of competency within that specific specialty. There are now more than 20 recognized medical specialties and a number of emerging medical sub-specialties as well.2
Specialization Within Dentistry
In 1951, there were 7 dental specialties recognized by the ADA: prosthodontics, oral surgery (oral and maxillofacial surgery), orthodontics (dentofacial orthopedics), pedodontics (pediatric dentistry), periodontics, oral pathology (oral and maxillofacial pathology), and dental public health. Endodontics became a recognized dental specialty in 1963, and oral and maxillofacial radiology became one in 1999. A number of dental specialty applications were submitted to the ADA from such emerging dental specialties as oral medicine, dental anesthesia, orofacial pain, and implant dentistry, and these applications were all rejected, even when the dental specialty application had categorically been approved by the ADA specialty application evaluation committee.
The ADA specialty recognition process allowed (and allows) the ADA House of Delegates to have an up-or-down vote on recognition. This is a substantial conflict of interest, as it may be perceived that newly recognized dental specialties would compete economically with existing dental specialties and general dentists. As such, there was some possible “funny business” with respect to specialty recognition vote by the ADA House of Delegates concerning radiology both in 1996 and 1999. During this period of time, the ADA was concerned over a possible restraint of trade suit by the Federal Trade Commission (FTC). In 2015, 4 emerging dental specialties (oral implantology, orofacial pain, dental anesthesia, and oral medicine) formed the American Board of Dental Specialties (ABDS). The ABDS set up standards requiring an evidence-based appraisal of proven patient benefits and both clinical and didactic competency based upon established didactic and clinical education and training and psychometric testing to confirm (or deny) minimum standards of competency. All 4 of these emerging dental specialty boards were required to meet specific application standards before each of the boards could be formally accepted by the ABDS.2
The state dental boards actually control dental specialty recognition, and these boards are empowered by the state governments. Historically, many state dental boards have relied upon the ADA with respect to dental specialty recognition, although the ADA is a trade association and not a credentialing agency.
The ABDS and New Court Decisions
Recently, the 4 founding emerging dental specialty organizations of the ABDS sued the Texas State Board of Dental Examiners for not allowing clinicians within these organizations to advertise that they were indeed dental specialists. In January 2016, the United States District Court for the Western District of Texas ruled in favor of the plaintiffs against the Texas State Board of Dental Examiners (and the Texas Society of Oral and Maxillofacial Surgeons intervenor defendant who had joined the suit) with a summary judgment. The judgment “ordered, adjudged, and decreed that the Defendants are enjoined from enforcing Texas Administrative Code 108.54 to the extent it prohibits Plaintiffs from advertising as specialists or using the terms ‘specialty’ or ‘specialist’ to describe an area of dentistry not recognized as a specialty by the American Dental Association, or any other provision of Texas law inconsistent with this opinion.”3
Essentially, the emerging dental specialties proved that they were reasonably credentialed as dental specialists, and so the court decided that they were entitled to advertise as credentialed dental specialists to the public. The verdict was appealed to the United States Court of Appeals for the Fifth Circuit, and the appeal was not granted in June 2017. “The plaintiffs challenge a provision in the Texas Administrative Code regulating advertising in the field of dentistry. The district court held that the provision violated the plaintiffs’ First Amendment right to engage in commercial speech. It therefore enjoined enforcement of the provision applied to the plaintiffs. The defendants appealed; “We affirm.”3 Therefore, the Texas State Board of Dental Examiners’ appeal of the decision to allow emerging dental specialists to advertise as legitimate dental specialists was denied, as the decision of the United States District Court for the Western District of Texas allowing such was upheld.
With regard for the impending Texas appeal decision, the ADA published Resolution 65, which noted that the changing legal environment necessitated changes within the ADA Code of Ethics, particularly section H.4 Previously, the ADA held that any dentist holding himself or herself out as a specialist within a dental specialty not recognized by the ADA was not acting ethically. The resolution went on to state: “Consider a jurisdiction that recognizes oral medicine as a specialty and allows a dentist who has successfully completed an advanced dental education program in oral medicine accredited by the Commission on Dental Accreditation to announce as a specialist in oral medicine. A dentist who did so, however, might be accused of violating the code because oral medicine is not 1 of the 9 specialties recited for which ‘ethical specialty announcement’ is presently permitted. The Council proposes to amend Section 5.H. of the code so that it aligns with the changes in the scope of specialty recognition in some jurisdictions. The amendment to Section 5.H. of the code would permit educationally qualified dentists practicing in areas of dentistry recognized as specialties in their jurisdictions, but not by the ADA, to announce as specialists. The Council requested that the Council on Dental Education and Licensure (CDEL) review and comment on this proposed revision of Section 5.H. of the Code and have been informed that CDEL is supportive of the amendment.”4
They then stated the following: “A dentist may ethically announce as a specialist to the public in any of the dental specialties recognized by the [ADA]…including dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, and prosthodontics, and in any other areas of dentistry for which specialty recognition has been granted under the standards required or recognized in the practitioner’s jurisdiction, provided the dentist meets the educational requirements required for recognition as a specialist adopted by the…[ADA], or accepted in the jurisdiction in which they practice.”4 Such newly emerging dental specialties include laser dentistry, sleep dentistry, and general dentistry; and possibilities for the future include exodontia, urgent dental care, and treatment planning.
The Future
The ADA’s decision to move forward to some degree allows it to avoid future encounters with the FTC. However, the ADA has essentially passed the issue of recognition of emerging dental specialties up to the state boards of dentistry and state legislatures. In view of the Texas decision, the writing is on the wall that state dental boards may face expensive legal suits if they continue to disallow specialty recognition to dental specialties approved by the ABDS. Presently, several state dental boards are in the process of granting dental specialty status to ABDS-recognized dental specialties. A number of other emerging dental disciplines, as well as existing ADA-recognized specialties, have submitted or are in the process of submitting applications to the ABDS. At the moment, a number of state dental boards are in the process of accepting the credentials of ABDS-recognized dental specialties.
References
- Siegel MA. Member clarifies specialty recognition, CODA approval. Today’s FDA. 2005;17:13-14.
- Brown RS, Mashni M. Emerging dental specialties and ethics. J Am Coll Dent. 2015;82:31-38.
- American Academy of Implant Dentistry v Parker, 152 F Supp 3d 641 (WD Tex 2016).
- American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Amendment to Section 5.H of the ADA Principles of Ethics and Code of Professional Conduct. August 2016. http://orthopundit.com/wp-content/uploads/2016/10/ADA-Resolution.pdf. Accessed November 5, 2017.
Dr. Brown is a professor in the Department of Comprehensive Dentistry, Division of Oral Diagnosis & Radiology, at Howard University College of Dentistry in Washington, DC. He is an associate clinical professor in the Department of Otolaryngology at Georgetown University Medical Center in Washington, DC, and a volunteer clinical associate researcher at the National Heart, Lung, and Blood Institute of the National Institutes of Health, Hematology Branch in Bethesda, Md. He is a past president of both the American Academy of Oral Medicine and the American Board of Oral Medicine and was the first secretary of the American Board of Dental Specialties from 2015 to 2016. He can be reached at (202) 806-0020 or via email at rbrown@howard.edu.
Disclosure: Dr. Brown reports no disclosures.
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