Orthodontics: The wild, wild West

LETTERS TO THE EDITOR Orthodontics: The wild, wild West To the Editor:

In this country during the 1800s the western frontier was certainly a wild place. For the most part, those who lived there were not bound by laws or restrictions. On the positive side, this almost total freedom was conducive to the rapid development of the territory, as a result of the atmosphere of creativity and ingenuity. It must have b~en a very exciting time and place. On the negative side, the people were frequently hurt by the selfish or reckless behavior of others. Of course, most people knew of this danger, and so they traveled "at their own risk." As the needs of society evolved, however, laws were put into place and the frontier became "civilized." In many ways our orthodontic specialty is analogous to the wild, wild West in that "anything goes." The orthodontic office is a very exciting and creative place (for the orthodontist), but also it is a dangerous place where the patient must travel "at their own risk." Actually, the main difference in this analogy is that, unlike the western frontier, our spec!alty is not yet "civilized." For us, it is still the wide open, wild West. Our specialty has no standards of care specifically related to treatment goals or techniques. Today, even previously accepted priniciples, such as the avoidance of dentoalveolar expansion or the value of centric relation, are vigorously challenged and ignored. Clinicians can and do use literally any appliance imaginable without regard for the scientific foundation of the treatment, let alone for any performance testing to prove its efficacy. We have practitioners who advocate treatment involving all nonextraction, all second molar extraction, or all first premolars enucleation. Some clinicians expand palates, beyond normal where no crossbite exists, expand mandibles with sagittal splitting appliances where no sagittal suture exists, or expand vertical dimension where no vertical deficiency exists. We hear claims that orthopedic appliances can grow jaws, stop jaws from growing, or direct jaw growth in any direction desired. Where this fails, we see surgical corrections of 1 and 2 mm, even on growing children. At our scientific meetings and in our publications, those championing these techniques are pitted against each other like dueling gunfighters, with the victors receiving admiration, awe, and even financial gain. Other sectors of our society, be they companies that sell products or services or other health fields, are held to certain standards of safety, efficacy, and truth in advertising and claims. For the orthodontic consumer, however, it is "buyer beware!" In this regard, our specialty is still in the 19th century. The reason for this retarded evolution might be that we are preoccupied with methods then in the end result. We care more about doing it nonextraction or with this appliance or with that appliance than we care about

orthodontic stability, dental health and function, or facial balance. We are more concerned with being on the cutting edge of technology and blazing new trails than we are with treatment goals. We have a true pioneer mentality. This state of affairs might be more tolerable if we were in our infancy as a specialty. However, orthodontics is a scientifically mature health field with far more known about anatomic boundaries, growth and development, and biomechanics than is being practiced. The American public needs more consistent and sophisticated treatment, not just more and more treatment. Any patient who has had the misfortune of transferring between two or more orthodontic offices can testify to this need. It is time for our national organization and, specifically, the American Board of Orthodontics, to lead the way toward a more "civilized territory" by adopting treatment standards that can help us to reduce this pioneer mentality without crushing creativity. Then we can get the gunfighters off the streets and enjoy a healthier place for all of us. Richard E. Gift, DDS, MS 20475 Farnsleigh Rd. Shaker Heights, OH 44122

Comments on "The Wrong Tooth" To the Editor:

The specialarticle entitled "The Case of the Wrong Tooth" appearing in the October 1991 issue of the JOURNAL iS a very important one. It correctly emphasizes the great importance of documentation and informed consent in the delivery of health care. Still, certain aspects of the process used by the authors are troubling to me. Apparently, patients having surgical procedures are given extraction notes. Why are identical notes not delivered to the surgeon? It seemed very imprudent for the surgeon of choice in this situation to perform a surgical procedure at the direction of the patient, whereas had orders been delivered from the orthodontist, there would have been no ambiguity. Another decision with which I had a problem was choosing the same oral surgeon to perform another procedure on the same patient. On the basis of the original injudicious act, I might have distanced myself, as much as possible, from that person. My question regarding the author's decision is an ethical one to which I do not have the answer. Perhaps another reader will have a different perspective. Finally, although this patient seemed well informed and was given options about treatment, I am curious about what the patient was told she could expect without treatment, for it seems to me that judging by the original condition, she might well have lived a happy and productive life without anything being done to her teeth. Julian Singer DDS, MS Los Angeles, Calif. 33A