Analyzing the Subjectivity of ‘Need’

The American Dental Association House of Delegates had not approved recognition of a new dental specialty since endodontics became the eighth specialty in 1963. However, interest and activity in this area have not been lacking. In the past 13 years, the ADA Council on Dental Education has reviewed 16 applications for specialty recognition. Further, from 1994 through 1997, the council recommended five of seven applications it had received. Yet, from 1986 through 1997, the ADA House rejected all eight applications forwarded.

As a longtime observer of the ADA House actions, it is easy to understand the frustration that may have been felt by many in the organizations that have been denied recognition. For some organizations, that unhappy reality has been experienced two or three times. Despite a detailed review by the Council on Dental Education and its Committee G, and subsequent recommendations for approval by ADA Boards of Trustees in past years, the House actions on specialty recognition have often seemed to be swayed by subjective or emotional considerations.

In 1999, the process followed by the ADA Board in making its recommendations and a similar process employed at the ADA House seemed to suggest that the decisions reached by the House this year would be more objective than prior decisions had been. The process was straightforward. Each applicant needed to show compliance with six requirements. The ADA Board and House were each asked to base their assessments and votes for approval or denial on whether the organizations had met (or successfully addressed in their applications) each of the six requirements for dental specialty recognition as specified in ADA’s "Requirements for Recognition of Dental Specialties and National Certifying Boards for Dental Specialists." At the House, failure to receive approval on any one of the six requirements would automatically deny specialty recognition to the applicant.

The requirements are:

1. In order for an area to be recognized as a specialty, it must be represented by a sponsoring organization: (a) whose membership is reflective of the special area of dental practice; and (b) that demonstrates the ability to establish a certifying board.

2. A specialty must be a distinct and well-defined field which requires unique knowledge and skills beyond those commonly possessed by dental school graduates as defined by the predoctoral accreditation standards.

3. The scope of the specialty: (a) is separate and distinct from any recognized specialty or combinations of specialties; and (b) cannot be accommodated through minimal modifications of a recognized specialty or combination of recognized specialties.

4. In order to be recognized as a specialty, substantial public need and demand for services, which are not adequately met by general practitioners or dental specialists, must be documented.

5. A specialty must directly benefit some aspect of clinical patient care.

6. Formal advanced education programs of at least two years beyond the predoctoral curriculum as defined by the Commission on Dental Accreditation’s Standards for Advanced Specialty Education Programs must exist to provide the special knowledge and skills required for the practice of the specialty.

Three applications were forwarded by the Council on Dental Education and Licensure via the ADA Board for consideration by the 1999 ADA House. They were, in order of their consideration, from the American Academy of Oral and Maxillofacial Radiology, the American Society of Dental Anesthesiologists, and the American Academy of Oral Medicine. The applications for radiology and anesthesia were approved by the council, but only the application from radiology was endorsed by the ADA Board.

The House voting process, while closely linked to the requirements, nonetheless showed that one of the requirements is still vulnerable to subjective interpretation by those called upon to assess compliance, whether the assessments are at the council, Board, reference committee, or delegate level. In the House vote on radiology, all requirements except one were approved by a substantial majority of the delegates. However, requirement 4 regarding need was barely approved by a scant percentage. Nonetheless, oral and maxillofacial radiology was approved as a dental specialty, the first such recognition in 36 years.

The votes on the anesthesiology application were favorable on five of the six requirements, although the percentage of votes for approval of each was less than in the case of radiology. The vote on requirement 4 -- need -- fell short of the simple majority required for approval. It does seem to this observer that the manner of documentation of definition of need as it pertains to this requirement must be clarified. The current requirement still allows too much subjective interpretation. The fact that too many individuals on the Board and the Education Reference Committee to the House, as well as the delegates at large, were divided in their analysis of the requirement, provides strong testimony to the need for further clarification of this standard.

This process must remove all possibility of emotion or subjective opinion on major decisions influencing the future directions of organized dentistry and its components. It was clear that the process has been upgraded from what it has been in the past. However, it can still benefit from refinement before the next application is reviewed.

In the meantime, congratulations are in order for the American Academy of Oral and Maxillofacial Radiology. Satisfying the current requirement of need, even if by the breadth of a fine hair, qualifies as a significant achievement.