Embrace Progress: Being Objective by Daniel Grob, DDS, MS, Editorial Director

How many of you have written down what your objectives of orthodontic treatment are? Better yet, how many of you can explain to a patient why treatment is necessary, what the end product is likely to be, and why?

To market and grow a practice, to train staff with the proper mechanics and to eventually manage or sell a practice, there has to be a defining statement or principle that guides everyday decisions made by the orthodontist and performance by the business or professional staff.

Of course, what logically follows is: When do we have the confidence to say, “You are ready to have your braces taken off”? There needs to be more than just trying to make teeth fit perfectly in plaster casts or, as the saying goes, put the plaster on the table.

When “perfect” isn’t the right answer
I was getting ready to write a column about standards of care when I noticed a post on Facebook from a highly visible orthodontist who enjoys stirring the pot and stimulating discussion in the orthodontic community. (I must admit, I enjoy doing so as well.) Although I’m not as prolific of a speaker or blogger as he is, and I don’t have the level of following he does, I agree with many of the challenges he makes to the “orthodontic elite” and widely held beliefs of the profession.

What caught my eye was a question asked of him about goals of treatment or standard of care. The question from a recent graduate was: “What is your treatment objective?”

This question was posed as a response to the doctor’s claimed reluctance to empirically extract teeth just to achieve a Class I canine relationship. I’ve seen some of the most respected orthodontists admit the same, only to be heralded as visionaries by their everyday followers. Some of the proclamations of late go like this: “I think Class I is overrated!” Or “May not be necessary to achieve Class?I in all situations!”

In a few hundred words, the ortho did the best he could to answer the question with as few specifics as possible. His response largely stated that we must not be “dogs blindly fetching a stick for our master” and instead, “Understand what your patients want and what they are willing to do to get there.”

This was an attempt to discourage “hero-dontics”­—overly aggressive and extended treatment times in an effort to obtain some textbook definition of a “perfect” result. This is a reasonable position to take, but what struck me about the response was that there were so few specifics or references to orthodontics.

More specifics, please!
Just then, a questionnaire for a research project appeared in my mail, asking me to do some version of just that. In the packet were multiple photos of patients gathered for a Virginia Commonwealth University study. The basic questions centered on evaluation of treatment outcomes.

The results of treatment were displayed as photos of digital casts of patients who have received either 18 or 24 months of active care. Evaluators were asked to suggest if more treatment would be necessary, and for how many months, to achieve their “ideal” result, assuming the patient is compliant or noncompliant. Casts only were included for evaluation. No chief complaint was mentioned. No other findings were included. Questions asked at the end of the study centered on the readers’ expected time in orthodontic treatment for patients.

I commend the VCU students for raising awareness of treatment time and cooperation However, like so many other topics in orthodontics, this focus on plaster teeth and treatment time seems to minimize all of the other factors involved in orthodontic care.

I believe this “24-month window” mentality leads to destruction of the orthodontic profession and practice, and marginalizes us as providers of a specific part of a patient’s oral health, rather than focusing on the big picture or “starting with the end in mind.”

Factors left out are such things as growth, habits and other medical and dental conditions that may affect results of the later care that we as orthodontists should be managing.

Variation from the norm
he AAO is even less helpful, and uses many more words. In a white paper with more than 400 citations, the group’s “Clinical practice guidelines for orthodontics and dento-facial orthopedics” does little to clearly define what an acceptable orthodontic result is. Evidence-based dentistry is mentioned early in the paper, with statements that it may be a part of treatment.

The white paper states: “There are various professionally accepted philosophies regarding orthodontic diagnosis. Deviations from these guidelines may be appropriate based on professional judgment and individual patient needs and preferences.

“The goals of orthodontic treatment are optimum dentofacial function, health, stability and aesthetics. While these goals are desirable, it should be recognized that individual patients have problems, concerns and conditions that may prevent the attainment of optimal results in every case, and that the non-attainment of some of the goals of orthodontic treatment in a particular patient is no indication of negligence by the orthodontist, even when no limiting factors are present.”

Easier by the dozens
You’ve likely heard me recite my saying about managing care for patients of almost all ages. In the “Treatment by 12s” philosophy, I identify the four elements of orthodontic treatment that affect our ultimate result:

• Eruption of the teeth.
• Growth of the facial skeleton.
• The function of the temporomandibular joints.
• Airway and muscular influence surrounding the teeth.

Analyzing these elements points to three times that we’re involved in active patient care:

• When the first 12 permanent teeth are erupting.
• When the next 12 permanent teeth are erupting.
• When the 12-year molars have erupted.

Treatment during these periods focuses on bringing the teeth into the mouth, correcting poor alignment, shifting jaws during closure and opening, and attempting to create that “great smile.” Care during these periods may not involve active orthodontic appliances, but could and should involve the input of an orthodontic specialist to assist in the decision-making and treatment decisions for the health of the patient. Whether the orthodontic specialist does all of the intermediate care or whether she hires assistants, associate dentists or hygienists will be up to her in practice.

Practically all patients see the dentist to get a great smile. Since we are the ones usually called upon to deliver, it only makes sense that we be involved from the beginning and until late in life.

If I were to summarize my treatment objectives, they would be: “I will create an attractive smile, coupled with healthy function around growing or grown jaws. I will utilize all of the tools available and agreed to by the patient to achieve this goal during several time periods during the patients’ life. In addition, I will utilize the services of other dental and medical professionals to assist in achieving this goal.”