News & Features » Miscellany

A battle between competing surgical fields spills into the courts, and patients are caught in the middle.

Oral Arguments

The state's primary physicians' association is cranking up its campaign to stop dentists specializing in oral and maxillofacial surgery from performing cosmetic procedures such as facelifts and nose jobs. And now the fight is personal. The Medical Society of Virginia, in a petition to the Richmond Circuit Court, seeks to prevent Richmond oral and maxillofacial surgeon Dr. Joseph Niamtu III and six of his associates from performing cosmetic surgery. The petition, filed in November, charges that they are practicing medicine without licenses. The underlying question — who needs such licenses? — is stirring debate in the Virginia General Assembly and in several other states, as well as in medical and dental associations. Caught in the middle, the public may get the unsettling feeling that they're putting their lives in the hands of surgeons in the middle of a war. The issue has become heated, with plastic surgeons questioning the abilities of dentists who are trained and certified in oral and maxillofacial surgery. One of the most vocal critics is Dr. Andrew Roth, a physician who practices cosmetic and reconstructive surgery in Roanoke and is president of the Virginia Society of Plastic and Reconstructive Surgeons. "A lot of people want to be a doctor by legislation, as opposed to medical school," Roth says. "It's easier." In the other camp, many oral and maxillofacial surgeons are convinced that plastic surgeons are merely riled up in a turf battle for patients — and for their own incomes. "Here, we have been sued because the Medical Society wants their members to have exclusive rights to the cash-paying patients of elective surgery," Niamtu's attorney W. Scott Johnson says in a written statement. And it all comes down to the interpretation of Virginia's 35-word legal definition of dentistry. Niamtu, whose practice includes five offices in the Richmond area, argues that he needs no license to practice medicine because he is covered by a license to practice dentistry and is certified as an oral and maxillofacial surgeon. In response to the Medical Society's petition, he and his associates have filed a counterclaim maintaining that the physicians' group is out to fatten the wallets of plastic surgeons and to hurt the reputation of his practice. Besides, Niamtu argues, the physicians are just plain wrong. The outcome of that fight could set a precedent and answer a question for which the public has no definitive answer. In Virginia, the two fields are overseen by separate bodies. Dentists are licensed by the Board of Dentistry; medical doctors are licensed by the Board of Medicine. But dentistry has evolved immensely in recent decades, and the line has blurred between professions. One of the most striking examples of that blurring is in the field of oral and maxillofacial surgery, a dental specialty. Typically, dental-school graduates who want to become oral and maxillofacial surgeons undergo a hospital-based surgical residency that lasts four to seven years. Here's where things get tricky. Some oral and maxillofacial surgeons hold two licenses: one to practice dentistry and one to practice medicine. But the Board of Dentistry says these surgeons don't need both licenses. "We license by general dentistry," says Marcia Miller, executive director of the Virginia Board of Dentistry. If people with dentistry licenses are trained in a specialty and receive the appropriate certification, then they may practice that specialty whether or not they hold medical licenses. So if a licensed dentist becomes trained and board-certified in oral and maxillofacial surgery, Miller says, "then they can hold themselves out as an oral and maxillofacial surgeon." Still, they must practice within Virginia's legal definition of dentistry, which describes the field as "the branch of the healing arts concerned with the prevention, diagnosis and treatment of diseases and restoration to health of the structure of the oral cavity, including teeth and surrounding and supporting structures." What does that mean? Well, that's the question. In 1996, an attorney questioned whether that definition covered such procedures as nose jobs, hair transplants and brow lifts, regardless of whether the procedures were cosmetic or medically necessary. The legislative and regulatory committee of the Board of Dentistry ruled that the answer was yes. With appropriate training, the committee said, those procedures would fall within the scope of the practice of dentistry. That answer didn't satisfy everyone. Some physicians worried that some people with dental licenses would branch out into face peels, acne treatments and plastic surgery. "Nobody is debating the advances in the practice of dentistry," says Marni Eisner, director of legislative affairs for the Medical Society of Virginia. "It's more for a concern for the potential … maverick who will be pushing the envelope." Litigation was springing up in other states over the issue. To avoid such problems in Virginia, physicians and dentists decided to clear things up by changing the legal definition of dentistry — something that would have to be approved by the General Assembly. Last summer, in an effort to avoid a public fight on the floor of the state Capitol, the Department of Health Professions convened an ad-hoc committee of representatives from the Board of Medicine, the Board of Dentistry and the professional associations of physicians and dentists, to hammer out a new definition. The board met three times, voted in August, and issued their definition, which among other things expands the legal definition to reflect the surgical work oral and maxillofacial surgeons currently do. There was only one problem: Some of the physician representatives on the committee never signed on to that definition. "There was no consensus in regard to that recommendation," says committee member Dr. Jonathan S. Jacobs, a plastic surgeon and board-certified oral surgeon in Virginia Beach. Jacobs, along with another physician representative, missed the final meeting. And he says some dentists don't agree with the definition, either. So it looks like there will be a legislative fight after all. State Sen. Warren E. Barry has put the new definition into a proposed bill before the General Assembly. Last week, a subcommittee of the Senate Committee on Education and Health approved the new definition and referred the proposed bill to the full committee for consideration this week. Now the battle is being waged on two fronts. While legislators argue the issue in the General Assembly, the Niamtu case is going before the Richmond Circuit Court (unless Niamtu is successful in his motion to have the case dismissed). Until one or both battles are complete, the two sides aren't budging. "There needs to be some precedent as to what is the practice of legal medicine," says the Medical Society's Eisner. Niamtu, meanwhile, isn't going anywhere. He plans to keep