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Some Ethical Phases of Practice*
SOME ETHICAL PHASES OF PRACTICE*
By J. LOWE YOUNG, D.D.S., New York City
it is true that no two per sons are exactly alike, or work W HILE exactly alike, or use the same
appliances in exactly the same way, or employ an identical technic in adjust ment of appliances, or arrive at the same conclusions when diagnosing cases, it would seem that the fundamental prin ciples of ethical problems should be so phrased that they would serve as a guide for everyone. It would be egotistical for me to expect to draft regulations that would meet all requirements and be acceptable to every one, but by free and frank discussion, and fair criticism of what is to follow, honestly striving for our mutual benefit, we should be able to arrive at a method of procedure that will be acceptable to all. W e are im pressed that this subject is of vital in terest to the younger men in the profession, but there should not be a different standard for them from that for those who are well established in practice. As a specialist in dentistry, the or thodontist naturally expects patients to be referred to him from various sources, such as the dentist, the physician, other orthodontists and the satisfied patient. It is therefore desirable to discuss this question under the following headings: our relation with (1) the dentist, (2) ♦Read before the Section on Orthodontia at the Seventh International Dental Con gress, Philadelphia, Pa., Aug. 23, 1926.
Jour. A .D .A ., February, 1927
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the physician, (3) the orthodontist, and (4) former patients; and (5) our duty to the patient. R E L A T IO N W IT H T H E D E N T IST
The conscientious dentist who is conducting a family practice, and who desires to refer a patient to an ortho dontist, should either send a card of introduction with the patient or notify the orthodontist that he has referred the patient to him. The orthodontist should always send a note or card of acknowl edgement to the dentist who has shown sufficient confidence in him to refer a patient to him. The orthodontist should carefully examine the teeth and their investing tissues to ascertain whether there are any cavities that require fill ing, or inflammatory conditions needing treatment, and when - such are found he should confer with the dentist and insist that such cavities be filled before appliances are adjusted on the teeth, and that the investing tissues be restored to a state of health. This is necessary for his own protection, as well as for the welfare of the patient. It should never be assumed, when a dentist refers a patient to an orthodon tist, that he has included the whole family. The dentist has a right to see that the treatment and general handling of the patient meets with his expecta tions. This is particularly applicable where it is the first patient referred by him to this orthodontist. I f the parent
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should ask that a second child be ex amined, it is quite proper to examine the teeth in a casual way, but the ortho dontist should be noncommittal until he has talked with the family dentist. Prior to the discussion of treatment with the parent, it is advisable that ac curate models of the dental arches, a full set of dental radiograms and photo graphs of the face be procured. The orthodontist is entitled to a fee for these services, if, for any reason, the patient is not treated, and if it is so stated at the beginning, misunderstand ing and disagreement are obviated. In fact, such a procedure has been found to inspire confidence. If the dentist desires that the patient return to him from time to time, so that he may observe the condition of the child’s mouth, the orthodontist should cooperate with him in every way. He should be pleased that the dentist is interested in the welfare of his pa tient. I f the orthodontist’s adjustment of appliances is what it should be, he will have no cause for alarm, provided he has instructed the patient properly in, and insisted on his properly carrying out, home prophylaxis. When the pa tient fails in this, the orthodontist is justified in removing his appliances and dismissing the case. Before taking this step, it would seem advisable that a conference be arranged with the parent, the patient and the dentist. Wherever cavities occur in the teeth of a patient under orthodontic treat ment, he should be sent at once to the dentist who referred him to the ortho dontist. Just how to proceed in such cases is rather a delicate • question. Obviously, it is not desirable to offend the dentist. If he has a hygienist in his employ who treats the child every few weeks, it is considered good prac
tice to write him a note to the effect that when this patient comes in for prophylactic care, the teeth should be examined for cavities. If he does not employ a hygienist, but carefully looks after his patients by frequent inspection, it is advisable to communicate with him and ascertain when he is to see such a patient. Just previous to this visit, the appliances should be removed (not the bands, if they are securely cemented), so that he may not be hampered in his examination of the teeth. If he is known to be a dentist that sees his pa tients only when they are in trouble, it is advisable to mark on a chart just where the carious areas are and send this either to the dentist or to the parent of the patient. If to the latter, it is advisable to keep a carbon copy of the chart sent, bearing the date of the ex amination. Some dentists prefer that marked charts be sent showing where the carious areas are, giving as a reason that it saves their time in not having to examine all the teeth. It should be the dentist’s duty to explore carefully for cavities even if a marked chart is sent, for it is his obligation to fill all carious places. The orthodontist, for his own protec tion and the welfare of his patient, must see to it that the teeth and their investing tissues are not allowed to suf fer during the time the patient is under his care. As many cases of malocclusion are under observation and treatment for several years, it sometimes occurs that a patient becomes dissatisfied with the dentist who referred the patient. In such cases, the orthodontist is never justi fied in referring the patient to another dentist, without permission from the one who referred the case to him. This becomes a delicate question and should
Young— Some Ethical Phases of Practice
be handled in as delicate and diplomatic a manner as possible. It is difficult to outline a definite procedure in such emergencies. Each . case should be managed in the best possible manner so as not to give offense. While it is true that every professional man should strive to so conduct his practice that his clients are pleased with his efforts, it is equally true that no professional man should want to retain clients who have become dissatisfied. This applies equally to the general practitioner and the specialist. R E L A T IO N W IT H O T H E R ORTHO DON TISTS
It is not to be supposed that the orthodontist can please all patients re ferred to him or all patients under treatment. To do this, one would have to be superhuman. Then what shall be the method of procedure when a patient who has been under treatment by another orthodontist or dentist asks an opinion? Before discussing this question in de tail, we wish to state emphatically that the word of a patient should never be taken as evidence against a fellow prac titioner. Regardless of how honest and upright the patient may be, when a dis agreement arises between patient and professional man, the patient is liable to get the wrong point of view, and not state all the facts in the case. Besides, there are two sides to every controversy, and it is manifestly unfair to consider only the patient’s statements. I have made it a practice, whenever a patient or parent becomes dissatisfied with my efforts, to relinquish the case and to remove all appliances from the mouth. The patient is then free to consult some one else, and the dentist consulted is in no way hampered as to how he shall proceed. I have also
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thought it advisable to give to the dis satisfied patient the original models, radiograms and photographs, so that the dentist who is to continue the case will be in possession of all the data that will enable him to best serve the patient. Objections have been raised by several orthodontists to this method of proce dure, the reason being given that, for their own protection in case of suit by the dissatisfied patient, they wished to retain the original models and all the data in the case. I would advise that, in such emergencies, the original models be duplicated, and the duplicate set be given to the patient. As the radiograms are taken in duplicate, one set can be spared, and as the negatives from which the photographs are printed are on file, the photographs can be spared. In this connection, it may be stated that in over twenty-one years’ exclusive practice of orthodontics, I have never been called on to defend a suit with a dissatisfied patient. Whenever a patient comes in for an opinion, and examination of the mouth reveals appliances on the teeth, the pa tient, if a minor, is at once dismissed from the room and the parent informed that, under the circumstances, the case cannot be discussed in the absence of the dentist having the case under treat ment. The parent may say, “I just want you to tell me what you think of the work being done in my child’s mouth.” The answer to this should be that it is absolutely unfair to all con cerned to discuss the case or express an opinion of another’s efforts without possessing all the facts, and that, in no event, will the case, the appliances or efforts of another be discussed in his absence. Strict adherence to the foregoing is advisable, regardless of how well the
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appliances are adjusted or how well the case may appear, from a casual exami nation, for the reason that whatever is said may be misquoted or misunder stood. If the parent expresses a desire for consultation, he should be told that a conference must be arranged with the dentist treating the patient, who should bring with him all the data on the case. Obviously, this conference should be held in the office of the dentist con sulted. The patient should be present so that a thorough examination of the mouth can be made with all the data at hand after the dentist who has had the case under treatment has been permitted to express his views. Then, and then only, is one justified in examining the patient of another. If it is found that the case is progressing in a satisfactory manner, the parent should be advised to that effect. If it is considered that, for the patient’s welfare, some changes should be made in the method of treat ment or adjustment of appliances or faulty technic, one should not hesitate to state his views to the dentist in charge of the case. As a rule it is better that this be done after the patient and parent have been dismissed. A fee should be charged for such services to the patient or the parent. Under no circumstances should such a patient be accepted by the dentist consulted. When it is found that the dentist in charge of the patient is incompetent and grossly careless in his technic, so that injury to the teeth of the patient is liable to result, it becomes a delicate problem. The patient’s welfare should be the first consideration. It is mani festly unfair to accept a consultation fee and not give service in return. The parent is entitled to know the true facts, even though the feelings of the dentist
in charge of the case are wounded. In some instances, it may be possible to advise him so that he may continue the treatment without detriment to the pa tient. In other cases, it may become necessary t'o state to the parent that the dentist in charge is incompetent, and to advise that treatment be discontinued. Such a patient should not be accepted by the dentist consulted except on writ ten request of the dentist who had charge of the case. Again, if a parent should state “I have finished with the other man,” he should be advised to return the patient to the dentist in the case and to tell him frankly that it is desired that treat ment be discontinued and appliances re moved. This he should do, if he cannot convince the parent that the case is progressing in a proper manner, pro vided all financial obligations have been settled. Then one should be free to accept such a patient. If the parent refuses to take the pa tient back to the dentist treating the case and still desires to place the child in the care of the one consulted, the procedure should be as follows: If the parent will give the name of the ortho dontist who has had the child under treatment, an effort will be made to see whether satisfactory arrangements can be made for the case to be continued. If this request is refused, I dismiss the patient with the feeling that all con cerned have been dealt fairly with. You will observe that no attempt was made until the last to ascertain the name of the dentist who had the patient in charge. The reason for this is that if the patient is to return to him, it is just as well not to know the name of the one having the case under treat ment. In the event that the parent is willing to give the name of the dentist,
Young— Some Ethical Phases of Practice a co n feren ce should be arra n g e d w ith him so th a t you m ay get his views. I f he has the w e lfa re o f the p atient a t h ea rt and can n o t get alo n g w ith him , he should be w illin g to relinquish the case. In m any such cases, it w ill be fo u n d th a t the case is undesirable. W h e n a p atient is to be tem porarily rem oved so as to ren d e r it im practicable f o r h im to present h im self a t re g u la r in terv als, he should be re fe rre d to some one w h o is com petent to look a f te r his case. In such cases, it is im perative th a t a le tte r be w ritte n statin g ju st w h at one w o u ld like to have done f o r his p atient. T h e n the one to w hom the case is re fe rre d has no responsibility o th e r th a n ca rry in g out instructions given an d his fees should be arran g e d accordingly. T h e p atien t should be to ld th a t he m ust pay the dentist re n d e r in g such service directly. M a n y a p atien t req u irin g f u rth e r tre a tm e n t has been re fe rre d by one o r th o d o n tist to an o th er in a distant city, an d , according to the statem ent o f the p are n t, the entire fee has been paid fo r the com pletion o f the w ork, and he has been given to u n derstand th a t there w ill be no f u rth e r expense to him fo r the com pletion o f the w ork. I n the ab sence o f any com m unication reg a rd in g the p atien t, an d this is usually the case, the p a re n t’s w o rd should n o t be taken as final. A le tte r should be w ritte n to the dentist w ho re fe rre d the patient, asking him f o r all the data, and in q u irin g as to w h eth e r the entire fee has been paid. I f the first orthodontist confirm s the statem ents o f the paren t the second o rthodontist should be at liberty to decline to accept such a pa tien t. I t is not f a ir n o r ethical to expect an o th er to ren d e r services fo r w hich he is n o t rem unerated. I f the patient is to sojourn in a lo
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cality w here no in te llig e n t cooperation can be obtained, the appliances should be rem oved a n d the case be placed u n d er tem porary reten tio n f o r the period o f tim e the p atien t is to be absent. It should be considered grossly n eg lig en t and unethical to p erm it a patien t w ho has bands an d appliances on his teeth to go f o r several m onths w ith o u t proper care. I t is advisable, b efo re b egin n in g a case, to o utline c a re fu lly the tre a tm e n t necessary, to estim ate about how lo n g it w ill take to accom plish the result an d to state defin itely w h a t is expected o f the p atien t d u rin g the period o f trea tm e n t. T h e ignorance o f m any otherw ise in te llig e n t people in such m a t ters is surprising. I t should be considered u n eth ical fo r an orthodontist to begin a case an d give a fee f o r the com pletion o f it w hen he know s in advance th a t the patient is to m ove p erm an en tly to a distant city shortly a f te r the appliances are placed, an d th a t the case m ust be co n tin u ed by an o th er. In such cases, it is o nly proper an d ju s t to r e f e r th e patien t w ith o u t ad ju stin g appliances. W h e n a p atien t u n d er tre a tm e n t makes a p erm an en t change o f residence so th a t the case can n o t be continued by the den tist w ho began the w ork, the patient should be re fe rre d to some one w ho can continue the treatm en t. I n such cases, it is advisable th a t a ll data be sent to the one to w hom the case is re fe rre d and th a t a le tte r be sent statin g all the facts in the case, saying th a t he is a t liberty to change the appliances an d m ethod o f tre a tm e n t i f he so desires an d th a t he is to be responsible fo r th e com pletion o f th e case. A f te r a copy o f th is le tte r has been sent to the p aren t, the responsi bility o f the dentist w ho began the tre a t m e n t is te rm in ated . T h e one to w hom the p atient is re fe rre d should be at
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liberty to state his fee f o r the com pletion o f the case or to refuse to take the patient.
nearly as possible, the n o rm al a rra n g e m e n t o f teeth th a t w e, as specialists, can hope to m ain tain this stan d ard .
R E L A T IO N W IT H T H E PH Y SIC IA N
Specialists are consulted because they have had special tra in in g alo n g certain lines w hich should enable th em to re n der services n o t obtainable fro m the g en eral practitio n er. P aren ts w ho have p u t th e ir ch ild ren in the hands o f the specialist have a rig h t to expect expert, honest an d conscientious tre a tm e n t, w ith n o th in g essential to .the w e lfa re o f th eir ch ild ren le f t undone.
A s the practice o f o rthodontia is be com ing better fo u n d ed an d also better understood, physicians have become m ore interested an d are m uch m ore liable to r e f e r patients th an in fo rm e r years. A ll th a t has been deem ed nec essary w hen a physician re fe rs a case is to send him a note or card le ttin g him know th a t the p atient had come in an d th a n k in g him f o r his confidence. I f the case is one o f unusual character, it w o u ld be w ell to r e f e r the p atient back to his fo rm e r dentist so th a t he m ay be en lig h ten ed as to the possibili ties o f orthodontics. I n such cases, the orthodontist is a t liberty to r e f e r such a p atien t to a dentist i f the p are n t so desires.
R E L A T IO N W IT H FO R M E R PA T IE N T S W h e n e v e r a p atient is re fe rre d by a fo rm e r patient, a note o f acknow ledge m en t should be sent, expressing the pleasure in his confidence.
D U TY TO T H E P A T IE N T I n a ll professional w ork, the w e lfa re o f the p atien t should be upperm ost in ou r m inds an d this applies m ore to the specialist in orthodontics th an possibly to any oth er branch o f the d en tal pro fession a t the present tim e. T h e specialty o f orth o d o n tia is b u t a fe w decades old, an d it behooves each an d every one o f us to be m ost con scientious in serving ou r clients, so as n o t to lo w er the high sta n d ard th a t was set f o r us in the begin n in g o f the spe cialty. W e a ll know th a t it is an ex ac tin g practice, an d it is only by paying atten tio n to the m inutest details an d conscientiously striv in g to establish, as
DISCUSSION L lo y d S. L o u rie , C h ica g o , 111.: T h e suc cessful tre a tm e n t o f o rth o d o n tic cases requires the co o p eratio n o f a ll p a rtie s concerned and the f o r m u la tio n o f basic rules o f p ro c e d u re f o r them is m ost d esirable. W e a re indebted to D r . Y o u n g f o r ta k in g the in itia tiv e in this m a tte r, k n o w in g , as he d id , th e difficulties o f s a tis fy in g a ll interests. H e has succeeded in m a k in g a n u m b er o f eth ic a l ru le s to w hich th ere sh o u ld be no o b jectio n a n d he has m ade v a lu a b le su ggestions o f courtesy a n d policy, in the co n d u ct o f o rth o d o n tic p ractice. F o r the sake o f b rev ity , le t it be u n d ersto o d th at I ag re e w ith those p a rts o f the p a p e r w hich I do n o t discuss. D r . Y o u n g states quite c o rre c tly th a t “ In a ll p ro fe s sio n a l w o rk , the w e lf a r e o f th e p a tie n t sh o u ld be u p p erm o st in o u r m in d s,” b u t, u n fo rtu n a te ly , in his list o f topics f o r discussion, “ O u r d u ty to the p a tie n t” is p laced la st, a n d , in som e o f his m eth o d s f o r d e a lin g w ith c o n tro v e rs ia l or em b a rra ssin g situ atio n s, the in terest o f the p a tie n t seems to be cro w d ed o u t o r even p receded by business p o lic y a n d p ro fe ssio n a l courtesy. E n d e a v o rin g to keep the p a tie n t’s interests in the fo re g r o u n d , le t us consider som e o f these pro b lem s. U n d e r “ R e la tio n w ith th e d en tist,” D r. Y o u n g says, “ I t sh o u ld n e v e r be assum ed, w hen a d en tist re fe rs a p a tie n t to a n o rth o d o n tis t, th a t he has in clu d ed th e w h o le fa m ily . T h e d en tist has a p e rfe c t r ig h t to see th a t the tre a tm e n t an d the g e n e ra l h a n d lin g o f the p a tie n t m eets w ith his ex p ectatio n s. T h is is p a r tic u la rly ap p licab le w hen it is the first case re fe rre d by h im . I f th e p a r e n t sh o u ld ask th a t a second c h ild be ex am in ed , it is q u ite p ro p e r to exam ine th e teeth in a casual w ay , b u t the
Young— Some Ethical Phases of Practice o rth o d o n tis t sh o u ld be v ery n o n c o m m itta l u n til he has ta lk e d w ith th e f a m ily d e n tist.” T h is places th e o rth o d o n tis t in a p o sitio n sec o n d a ry to th a t o f th e d en tist w h en he sh o u ld be first, a n d a lso im p lies th a t th e o r th o d o n tist’s first resp o n sib ility is to th e r e f e r r in g den tist r a th e r th a n to th e p a tie n t, an id ea w ith w h ich I can n o t co n cu r. I f the d en tist w ishes to m ak e re se rv a tio n s in r e f e r r in g a p a tien t, these re se rv a tio n s sh o u ld be m ade to the p a tie n t h im s e lf o r to th e p a re n t, w h o has the r ig h t to k n o w w h e th e r th e re is an y lim ita tio n o f confidence in th e o rth o d o n tis t. B ut i f th e o rth o d o n tis t is asked by the p a re n t to ex am in e a n o th e r m em b er o f th e f a m ily , he sh o u ld do so, n o t casu ally a n d n o n c o m m itta lly b u t th o ro u g h ly , g iv in g his best advice. D r. Y o u n g feels th a t w h en cavities o ccu r in the teeth o f a p a tie n t u n d e r o rth o d o n tic tr e a t m en t, a d elicate qu estio n arises as to h o w the d en tist sh a ll be n o tified w ith o u t o ffen d in g h im , a n d sug g ests som e ro u n d a b o u t w ays o f d o in g th is. I see n o reaso n f o r the d en tist to ta k e offense a t directness in such a situ a tio n . T h e p a tie n t sh o u ld be in stru cted to a r ra n g e w ith h im a t once f o r th e necessary fillin g s. T h e m a rk e d ch a rts do save tim e a n d m isu n d e rsta n d in g . T h e n w e a re to ld th a t i f a p a tie n t becom es dissatisfied w ith the d en tist th a t r e fe rr e d th e p a tie n t th e o r th o d o n tist is n ev er ju stified in r e f e r r in g th e p a tie n t to a n o th e r d en tist, w ith o u t perm ission f ro m th e one w h o re fe rr e d th e case' to him . T h is is to o s tr o n g a n assertion, as the p a tie n t’s interests an d th e success o f the o rth o d o n tic tre a tm e n t m ig h t d ep en d on the o rth o d o n tis t assistin g th e p a tie n t in se lectin g a co m p eten t d en tist. H ere is a co n flict betw een the w el f a re o f th e p a tie n t a n d business p o licy . I h av e been c o w a rd ly e n o u g h to a v o id the re sp o n sib ility in m o st cases, b u t I fe e l th a t a b e tte r p la n w o u ld be to assist th e p a tie n t an d n o tif y th e d en tist. U n d e r “ R e la tio n w ith th e o rth o d o n tis t,” the sta te m e n t is m ade th a t “ I n n o ev en t w ill th e case, the ap p lian ces or th e effo rts o f a n o th e r be discussed in his a b sence.” I a g re e th a t ad v ice re g a r d in g a n o th e r o r th o d o n tis t’s case u n d e r tre a tm e n t sh o u ld n o t be g iv e n w ith o u t first h a v in g his ex p la n a tio n s a n d case h isto ry , b u t th e re seem to be several reasons w h y i t is n o t alw a y s necessary or ad v isab le th a t he be p resen t w h en th e opinion is g iv en . T h e first reaso n is th a t the p a tie n t is m o re lia b le to be g iv en an u nbiased o p in io n , o r a t least he w ill fe e l th a t th is is so. In
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a d d itio n , sh o u ld th ere be a difference o f o p in io n , th e o th e r o rth o d o n tis t m ig h t be saved th e e m b arra ssm e n t o f criticism in th e presence o f o th e r persons. F u rth e rm o re , he m ig h t fin d it in c o n v e n ie n t o r im possible to be present, p a r tic u la r ly i f his p ra c tic e is in a n o th e r city. I f he has n o t been p resen t, it w o u ld be c o u r teous to le t h im k n o w th e ad v ice g iv e n the p a tie n t. C o n c e rn in g the su b je ct o f co n su lta tio n s w ith o th e r o rth o d o n tis ts, w e a re to ld t h a t u n d e r no circum stances sh o u ld such a p a tie n t be accepted by th e one consulted. T h is w o u ld be a sa fe ru le by w h ich the one co nsulted m ig h t p ro te c t h im se lf f r o m th e sus p icion o f u n f a ir criticism f o r his o w n bene fit, b u t it m ig h t cause in ju stice to th e p a tie n t. F o r instance, the d en tist co nsulted m ig h t be the o n ly o th e r o rth o d o n tis t in the co m m u n ity , an d the p a tie n t m u st e ith e r co n tin u e w ith a m an w hose w o rk is u n sa tis fa c to ry , o r dis co n tin u e tre a tm e n t. E v e n i f th e re w ere o th er a v a ila b le o rth o d o n tis ts, th e one consulted sh o u ld be a t lib e rty to decide w h e th e r o r n o t the p a tie n t’s w e lf a r e req u ires th a t he take the case. I ag ree w ith D r . Y o u n g th a t w hen it is f o u n d th a t th e d en tist in c h a rg e o f the p a tie n t is in co m p eten t a n d g ro ssly careless in his technic, so th a t in ju r y to th e teeth o f the p a tie n t is lia b le to re su lt, the p a re n t is e n title d to k n o w th e tru e fa c ts, even th o u g h th e fe e lin g s o f the d en tist in c h a rg e are w o u n d ed , b u t I do n o t ag re e th a t it necessary to h av e a w ritte n req u est f r o m such a n in co m p eten t o r n e g le c tfu l o rth o d o n tis t, b e fo re a c c e p tin g th e p a tie n t f o r tre a tm e n t. W hen a dissatisfied p a tie n t com es in f o r c o n tin u a tio n o f tre a tm e n t, it is adv isab le, as D r . Y o u n g says, to a tte m p t to reconcile h im a n d his o rth o d o n tis t, if it a p p e a rs th a t th e tre a tm e n t is n o t a t f a u lt , o r i f it is possible to give advice th a t w o u ld enable the o th e r dentist to co n tin u e the w o rk , b u t, f a il in g in this, I th in k th a t it is n o t necessary to ask p e r m ission o f the o th e r o r th o d o n tis t b e fo re ac c e p tin g the p a tie n t. I t "w ould be p re fe ra b le th a t the p a tie n t r e tu rn to the first o rth o d o n tist f o r re m o v a l o f app lian ces, b u t, in some cases o f serious c o n tro v e rsy , it w o u ld be e m b a rra ss in g f o r b o th o f th e m a n d should n o t be insisted on. W h e n e v e r a c o n su lta tio n is given c o n c e rn in g a p a tie n t u n d e r tre a tm e n t by a n o th e r o rth o d o n tis t, as to w h e th e r he is to be ta k e n f o r tre a tm e n t o r n o t, m odels sh o u ld be m ad e sh o w in g th e c o n d itio n a t the tim e th e o p in io n is g iv en .
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H arold, C h a fm a n , L o n d o n , E n g la n d : F ew m en, i f an y , h av e h a d a lo n g e r o r w id e r ex p erien ce in th e exclusive p ractice o f o rth o d o n tia th a n has D r . Y o u n g , a n d none co u ld h av e h a d f e w e r difficulties o f a n eth ical n a tu re w ith p a r e n t a n d p atien ts. I h av e re a d th is p a p e r a n u m b e r o f tim es in the m o re c ritic a l s p irit, a n d each tim e th a t I suspected a p a r tic u la r p o in t h a d been o v e rlo o k e d , I f o u n d it th ere w h en I re a d it a g a i n ; n o r does th e p a p e r c o n ta in a n y statem ents w ith w h ich I w o u ld d isa g ree ex cep t in m in o r details. D r . Y o u n g has v e ry c lev erly in c lu d e d in his p a p e r e v e ry difficult situ a tio n th a t m ay arise. P o in ts w o rth y o f em phasis a r e : 1. P a re n ts sh o u ld be in f o rm e d p re v io u sly to a co n su lta tio n th a t a fe e is c h a rg e d f o r it. 2. C avities sh o u ld be fille d a n d gum s m ade h e a lth y b e fo re tre a tm e n t is b eg u n . 3. R e g u la r e x a m in a tio n b y th e d en tist f o r cavities, etc., is im p erativ e . +. H o m e p ro p h y la x is sh o u ld be insisted on. 5. T h e w o rd o f th e p a tie n t is n o t to be ac cepted w ith o u t c o n firm a tio n . 6. W h en p atien ts leav e o n e o rth o d o n tis t f o r anothe», a ll reco rd s sh o u ld be tr a n s f e r re d . 7. B e fo re a case is b eg u n , p a tie n ts sh o u ld be in fo rm e d a b o u t: ( a ) d u ra tio n o f tre a tm e n t; ( b ) n u m b e r o f v isits; ( c ) fees. T h e o rth o d o n tis t ta k in g o v e r th e case sh o u ld be g iv e n a f re e h a n d ; th is f a c t sh o u ld be expressed a n d n o t sim p ly im p lie d . O rth o d o n tists an d dentists, w hen th ey tr a n s f e r p a tie n ts, a re e x tre m e ly n e g le c t f u l to pass on in fo rm a tio n re g a r d in g the case; m o re o fte n th a n n o t, such p atien ts com e w ith o u t a n y re c o rd a t a ll, a n d th e den tist ta k in g o v e r th e case has to re ly en tire ly o n w h a t th e p a tie n t te lls h im ; w hereas, he sh o u ld k n o w ev ery d e ta il i f he is to co n tin u e th e tre a tm e n t to the best a d v a n ta g e . A g a in , th e s itu a tio n is difficult w hen such a p a tie n t is w e a r in g ap p lian ces w h ich u n d o u b te d ly are h a r m f u l a n d w h ich c o u ld be rep laced by o th ers to th e g r e a t a d v a n ta g e o f the p a tie n t. I h a v e been p e rp le x e d a n u m b e r o f tim es by such cases, a n d , th o u g h one w rites to th e d e n tist w h o r e fe rr e d the case, fre q u e n tly he gets n o re p ly . T h e ru le th a t p a tie n ts w e a r in g a p p lia n c e s a n d seeking a n o p in io n sh o u ld n o t b e seen ex cep t in the presence o f th e o r th o d o n tis t w h o has the case in ch a rg e seems to m e to need a little m o d ifica tio n i f one is to be ju s t to a ll p arties. As in the last case, so in th is one, th e so lu tio n w o u ld be easier i f th e tw o o rth o d o n tis ts m e t; b u t f r e q u e n tly distan ce alo n e is sufficient to m ake th is im p ro b a b le i f n o t im possible, an d the
m a tte r has to be discussed th ro u g h c o rre spondence. T h e re s u ltin g d elay m ay m ake it im possible f o r th e p a tie n t to be seen a g a in . I t seems to m e th a t, in such circum stances, th e one co n su lted sh o u ld exam ine the case th o r o u g h ly so th a t a r e p o rt m ay be m a d e ; i f th e r e p o rt is e n tire ly sa tisfa c to ry , I see n o reaso n w h y p a tie n t o r p a r e n t sh o u ld n o t k n o w a t o n ce; i f n o t e n tire ly fa v o ra b le , th en it m a y be d esirab le to co m m u n icate w ith the o r ig in a l o rth o d o n tis t, first in f o r m in g h im o f w h a t one in ten d s to r e p o rt to th e p a tie n t, a t th e sam e tim e re q u e stin g h im to g iv e his v iew s a n d com m ents first. T h e d u ra tio n o f tre a tm e n t is a difficult m a tte r to estim ate. I t h a s been m y custom to te ll p a re n ts th a t the case w ill ta k e so lo n g a n d cost so m u ch . It h ap p e n s in a n u m b e r o f cases th a t the le n g th o f tre a tm e n t is co n sid erab ly g re a te r th a n I estim ated ( I seldom say less th an th ree y e a r s ) , a n d , u n d e r the circum stances, the fe e sh o u ld be increased. W o u ld D r . Y o u n g te ll us h o w he deals w ith th is difficulty? D oes he ten d to ov erestim ate the tim e f a c to r a n d the fee, o r does he m ak e som e p ro v isio n as re g a rd s f u r th e r fees a f te r the e x p ira tio n o f the esti m a te d tim e? I f one gives a n estim ate as r e g a rd s tim e a n d fee, a n d the tim e is e x ceeded, the p a r e n t does n o t th in k th a t any a d d itio n a l fee sh o u ld be p ay ab le a n d if, u n d e r those circum stances, an a d d itio n a l fee is c h a rg e d , one m ay be accused o f d elib erately p r o lo n g in g a case f o r th e sake o f th e increased fe e . I f e e l th a t D r. Y o u n g can g iv e some v e ry h e lp f u l in f o rm a tio n in th is connection. A n o th e r p o in t o f difficulty o r r a th e r source o f e m b arra ssm e n t arises w hen th e p a r e n t tra n s f e rs th e p a tie n t f ro m the d en tist w h o r e fe rr e d th e case, to a n o th e r d en tist, w ith o u t m e n tio n in g th e f a c t, a n d the o rth o d o n tis t o n ly learn s o f th is by accid en t a t som e la te r p e rio d . I w o u ld ask D r. Y o u n g h o w he w o u ld advise th a t th e r e f e r r i n g o r o r ig in a l d en tist be in f o rm e d th a t th e o rth o d o n tis t has p la y e d no p a r t in the ch an g e in p lan s. I f u l ly endorse w h a t D r . Y o u n g says in r e g a r d to th a n k in g , b y le tte r, th e d en tist a n d the p h ysician w ho h as r e fe rr e d a case, b u t w h en a p a r e n t has done th is, I u su a lly w a it u n til I see h im an d express m y th a n k s p e rso n a lly . D r. Y oung spoke o f h om e p ro p h y la x is. T o discuss this is beyond o u r p u rv ie w , b u t i f D r . Y o u n g w o u ld say a fe w w o rd s on h o w th is is c a r rie d o u t, a ll h ere w o u ld ap p re c ia te his re m a rk s. I t is a d m itte d ly a difficult question.
Shearer— Pathology of the Mouth Som e c h ild re n com e in w ith th e ir ap p lian ces as clean as w h en th ey w ere p la c e d ; in o th e r cases, w e a re baffled as to h o w the ap p lian ces can becom e so u n h y g ien ic. W h e n I r e p o rt by le tte r to th e p a r e n t on th e n u m b e r o f visits, fe e , etc. (a s is m y p r a c tic e ) , I ta k e the o p p o rtu n ity to do p r o p a g a n d a w o rk , w hich inclu d es a sta te m e n t th a t e a rly tre a tm e n t, efficient m a stic a tio n a n d c o rre c t b r e a th in g a re in v a lu a b le a id s to o b ta in in g a g o o d resu lt. I also send a leaflet g iv in g in stru c tio n s on d iet in re la tio n to d e n ta l caries. I lo o k on this p a r t o f m y r e p o rt as o f g e n e ra l v alu e
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to th e c o m m u n ity a n d one w h ich it is a d u ty th a t w e, a s a p ro fe ssio n , sh o u ld c a rry o u t w h en su ita b le o p p o rtu n ity presents. I w as a b o u t to say th a t D r . Y o u n g h as presen ted a v a lu a b le p a p e r, b u t I re g a r d it as in v a lu able. I t is a code o f ethics f o r th e co n d u ct o f a n o rth o d o n tic p ractice. E v e ry o rth o d o n tis t w ill fin d in it h e lp f u l ad v ice in the v a ry in g circum stances w hich m a y arise, a n d n o one s ta rtin g in p ra c tic e can a ffo rd to o m it a ca re f u l stu d y o f th is p a p e r b e fo re he u n d ertak es h is first case, s to rin g in his m in d those rules w h ich a re so c le a rly set o u t in it.
PATHOLOGY OF THE MOUTH AND SURGICAL PRINCIPLES GOVERNING ITS REMOVAL* By WILLIAM L. SHEARER, B.A., M.D., D.D.S., F.A.C.S., Omaha, Nebraska S H A L L take up some o f the surgical principles incident to the rem oval o f teeth, plus the rem oval o f infections o f investing tissues. G re a t advance m en t in m ost fields o f surgery has taken place, but fro m the standpoint o f surgery o f the m o u th , g en erally speak in g , there is room f o r better train in g and refined technic, i f w e are to serve our clientele an d avoid some o f the m any com plications th a t can be placed at the door o f poor surgery. I f our patients are to be better served, w e m ust have m ore m en train ed f o r this field o f service. W e need not, I think, discuss the clinical an d bacteriologic phase o f in fections o f th e m outh o r th eir sequelae. T h e lite ra tu re is replete w ith w o n d er fu lly fine scientific research w ork. W e can say th a t individuals carry ing pulpless teeth, especially the type
I
* R e ad b e fo re th e A m erican Society o f O ra l S u rg eo n s a n d E x o d o n tists, L o u isv ille, K y ., Sept. 18-19, 1925.
th a t it is difficult, i f n o t impossible, to diagnose fro m radiographic evidence, are p laying w ith th e ir fu tu re h ealth on borrow ed capital. T h e g en eral com p lain t o f the p atien t m ay n o t be traced to so sm all a cause, an d his years sh o rt ened by lack o f know ledge on the p art o f the physician an d the dentist w ho have his h ealth in th eir care. I t is tru ly u n fo rtu n a te th a t the diseases o f the m outh are n o t associated w ith m ore local pain. T h a t the changes in the vestibular apparatus are so rem o tely as sociated w ith the tru e cause is o fte n the reason f o r overlooking m outh in fectio n s as its p rim ary or co n trib u tin g cause. Such secondary lesions as those o f the blood vessels, h ea rt and kidney are too o fte n n o t properly associated w ith a focus o f in fectio n . T h e im p o rta n t th in g f o r us to con sider, th en , is the m a n ag em en t o f m o r bid processes o f the jaw s, to standardize ou r technic, to be certain th a t all in
By J. LOWE YOUNG, D.D.S., New York City
it is true that no two per sons are exactly alike, or work W HILE exactly alike, or use the same
appliances in exactly the same way, or employ an identical technic in adjust ment of appliances, or arrive at the same conclusions when diagnosing cases, it would seem that the fundamental prin ciples of ethical problems should be so phrased that they would serve as a guide for everyone. It would be egotistical for me to expect to draft regulations that would meet all requirements and be acceptable to every one, but by free and frank discussion, and fair criticism of what is to follow, honestly striving for our mutual benefit, we should be able to arrive at a method of procedure that will be acceptable to all. W e are im pressed that this subject is of vital in terest to the younger men in the profession, but there should not be a different standard for them from that for those who are well established in practice. As a specialist in dentistry, the or thodontist naturally expects patients to be referred to him from various sources, such as the dentist, the physician, other orthodontists and the satisfied patient. It is therefore desirable to discuss this question under the following headings: our relation with (1) the dentist, (2) ♦Read before the Section on Orthodontia at the Seventh International Dental Con gress, Philadelphia, Pa., Aug. 23, 1926.
Jour. A .D .A ., February, 1927
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the physician, (3) the orthodontist, and (4) former patients; and (5) our duty to the patient. R E L A T IO N W IT H T H E D E N T IST
The conscientious dentist who is conducting a family practice, and who desires to refer a patient to an ortho dontist, should either send a card of introduction with the patient or notify the orthodontist that he has referred the patient to him. The orthodontist should always send a note or card of acknowl edgement to the dentist who has shown sufficient confidence in him to refer a patient to him. The orthodontist should carefully examine the teeth and their investing tissues to ascertain whether there are any cavities that require fill ing, or inflammatory conditions needing treatment, and when - such are found he should confer with the dentist and insist that such cavities be filled before appliances are adjusted on the teeth, and that the investing tissues be restored to a state of health. This is necessary for his own protection, as well as for the welfare of the patient. It should never be assumed, when a dentist refers a patient to an orthodon tist, that he has included the whole family. The dentist has a right to see that the treatment and general handling of the patient meets with his expecta tions. This is particularly applicable where it is the first patient referred by him to this orthodontist. I f the parent
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should ask that a second child be ex amined, it is quite proper to examine the teeth in a casual way, but the ortho dontist should be noncommittal until he has talked with the family dentist. Prior to the discussion of treatment with the parent, it is advisable that ac curate models of the dental arches, a full set of dental radiograms and photo graphs of the face be procured. The orthodontist is entitled to a fee for these services, if, for any reason, the patient is not treated, and if it is so stated at the beginning, misunderstand ing and disagreement are obviated. In fact, such a procedure has been found to inspire confidence. If the dentist desires that the patient return to him from time to time, so that he may observe the condition of the child’s mouth, the orthodontist should cooperate with him in every way. He should be pleased that the dentist is interested in the welfare of his pa tient. I f the orthodontist’s adjustment of appliances is what it should be, he will have no cause for alarm, provided he has instructed the patient properly in, and insisted on his properly carrying out, home prophylaxis. When the pa tient fails in this, the orthodontist is justified in removing his appliances and dismissing the case. Before taking this step, it would seem advisable that a conference be arranged with the parent, the patient and the dentist. Wherever cavities occur in the teeth of a patient under orthodontic treat ment, he should be sent at once to the dentist who referred him to the ortho dontist. Just how to proceed in such cases is rather a delicate • question. Obviously, it is not desirable to offend the dentist. If he has a hygienist in his employ who treats the child every few weeks, it is considered good prac
tice to write him a note to the effect that when this patient comes in for prophylactic care, the teeth should be examined for cavities. If he does not employ a hygienist, but carefully looks after his patients by frequent inspection, it is advisable to communicate with him and ascertain when he is to see such a patient. Just previous to this visit, the appliances should be removed (not the bands, if they are securely cemented), so that he may not be hampered in his examination of the teeth. If he is known to be a dentist that sees his pa tients only when they are in trouble, it is advisable to mark on a chart just where the carious areas are and send this either to the dentist or to the parent of the patient. If to the latter, it is advisable to keep a carbon copy of the chart sent, bearing the date of the ex amination. Some dentists prefer that marked charts be sent showing where the carious areas are, giving as a reason that it saves their time in not having to examine all the teeth. It should be the dentist’s duty to explore carefully for cavities even if a marked chart is sent, for it is his obligation to fill all carious places. The orthodontist, for his own protec tion and the welfare of his patient, must see to it that the teeth and their investing tissues are not allowed to suf fer during the time the patient is under his care. As many cases of malocclusion are under observation and treatment for several years, it sometimes occurs that a patient becomes dissatisfied with the dentist who referred the patient. In such cases, the orthodontist is never justi fied in referring the patient to another dentist, without permission from the one who referred the case to him. This becomes a delicate question and should
Young— Some Ethical Phases of Practice
be handled in as delicate and diplomatic a manner as possible. It is difficult to outline a definite procedure in such emergencies. Each . case should be managed in the best possible manner so as not to give offense. While it is true that every professional man should strive to so conduct his practice that his clients are pleased with his efforts, it is equally true that no professional man should want to retain clients who have become dissatisfied. This applies equally to the general practitioner and the specialist. R E L A T IO N W IT H O T H E R ORTHO DON TISTS
It is not to be supposed that the orthodontist can please all patients re ferred to him or all patients under treatment. To do this, one would have to be superhuman. Then what shall be the method of procedure when a patient who has been under treatment by another orthodontist or dentist asks an opinion? Before discussing this question in de tail, we wish to state emphatically that the word of a patient should never be taken as evidence against a fellow prac titioner. Regardless of how honest and upright the patient may be, when a dis agreement arises between patient and professional man, the patient is liable to get the wrong point of view, and not state all the facts in the case. Besides, there are two sides to every controversy, and it is manifestly unfair to consider only the patient’s statements. I have made it a practice, whenever a patient or parent becomes dissatisfied with my efforts, to relinquish the case and to remove all appliances from the mouth. The patient is then free to consult some one else, and the dentist consulted is in no way hampered as to how he shall proceed. I have also
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thought it advisable to give to the dis satisfied patient the original models, radiograms and photographs, so that the dentist who is to continue the case will be in possession of all the data that will enable him to best serve the patient. Objections have been raised by several orthodontists to this method of proce dure, the reason being given that, for their own protection in case of suit by the dissatisfied patient, they wished to retain the original models and all the data in the case. I would advise that, in such emergencies, the original models be duplicated, and the duplicate set be given to the patient. As the radiograms are taken in duplicate, one set can be spared, and as the negatives from which the photographs are printed are on file, the photographs can be spared. In this connection, it may be stated that in over twenty-one years’ exclusive practice of orthodontics, I have never been called on to defend a suit with a dissatisfied patient. Whenever a patient comes in for an opinion, and examination of the mouth reveals appliances on the teeth, the pa tient, if a minor, is at once dismissed from the room and the parent informed that, under the circumstances, the case cannot be discussed in the absence of the dentist having the case under treat ment. The parent may say, “I just want you to tell me what you think of the work being done in my child’s mouth.” The answer to this should be that it is absolutely unfair to all con cerned to discuss the case or express an opinion of another’s efforts without possessing all the facts, and that, in no event, will the case, the appliances or efforts of another be discussed in his absence. Strict adherence to the foregoing is advisable, regardless of how well the
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appliances are adjusted or how well the case may appear, from a casual exami nation, for the reason that whatever is said may be misquoted or misunder stood. If the parent expresses a desire for consultation, he should be told that a conference must be arranged with the dentist treating the patient, who should bring with him all the data on the case. Obviously, this conference should be held in the office of the dentist con sulted. The patient should be present so that a thorough examination of the mouth can be made with all the data at hand after the dentist who has had the case under treatment has been permitted to express his views. Then, and then only, is one justified in examining the patient of another. If it is found that the case is progressing in a satisfactory manner, the parent should be advised to that effect. If it is considered that, for the patient’s welfare, some changes should be made in the method of treat ment or adjustment of appliances or faulty technic, one should not hesitate to state his views to the dentist in charge of the case. As a rule it is better that this be done after the patient and parent have been dismissed. A fee should be charged for such services to the patient or the parent. Under no circumstances should such a patient be accepted by the dentist consulted. When it is found that the dentist in charge of the patient is incompetent and grossly careless in his technic, so that injury to the teeth of the patient is liable to result, it becomes a delicate problem. The patient’s welfare should be the first consideration. It is mani festly unfair to accept a consultation fee and not give service in return. The parent is entitled to know the true facts, even though the feelings of the dentist
in charge of the case are wounded. In some instances, it may be possible to advise him so that he may continue the treatment without detriment to the pa tient. In other cases, it may become necessary t'o state to the parent that the dentist in charge is incompetent, and to advise that treatment be discontinued. Such a patient should not be accepted by the dentist consulted except on writ ten request of the dentist who had charge of the case. Again, if a parent should state “I have finished with the other man,” he should be advised to return the patient to the dentist in the case and to tell him frankly that it is desired that treat ment be discontinued and appliances re moved. This he should do, if he cannot convince the parent that the case is progressing in a proper manner, pro vided all financial obligations have been settled. Then one should be free to accept such a patient. If the parent refuses to take the pa tient back to the dentist treating the case and still desires to place the child in the care of the one consulted, the procedure should be as follows: If the parent will give the name of the ortho dontist who has had the child under treatment, an effort will be made to see whether satisfactory arrangements can be made for the case to be continued. If this request is refused, I dismiss the patient with the feeling that all con cerned have been dealt fairly with. You will observe that no attempt was made until the last to ascertain the name of the dentist who had the patient in charge. The reason for this is that if the patient is to return to him, it is just as well not to know the name of the one having the case under treat ment. In the event that the parent is willing to give the name of the dentist,
Young— Some Ethical Phases of Practice a co n feren ce should be arra n g e d w ith him so th a t you m ay get his views. I f he has the w e lfa re o f the p atient a t h ea rt and can n o t get alo n g w ith him , he should be w illin g to relinquish the case. In m any such cases, it w ill be fo u n d th a t the case is undesirable. W h e n a p atient is to be tem porarily rem oved so as to ren d e r it im practicable f o r h im to present h im self a t re g u la r in terv als, he should be re fe rre d to some one w h o is com petent to look a f te r his case. In such cases, it is im perative th a t a le tte r be w ritte n statin g ju st w h at one w o u ld like to have done f o r his p atient. T h e n the one to w hom the case is re fe rre d has no responsibility o th e r th a n ca rry in g out instructions given an d his fees should be arran g e d accordingly. T h e p atien t should be to ld th a t he m ust pay the dentist re n d e r in g such service directly. M a n y a p atien t req u irin g f u rth e r tre a tm e n t has been re fe rre d by one o r th o d o n tist to an o th er in a distant city, an d , according to the statem ent o f the p are n t, the entire fee has been paid fo r the com pletion o f the w ork, and he has been given to u n derstand th a t there w ill be no f u rth e r expense to him fo r the com pletion o f the w ork. I n the ab sence o f any com m unication reg a rd in g the p atien t, an d this is usually the case, the p a re n t’s w o rd should n o t be taken as final. A le tte r should be w ritte n to the dentist w ho re fe rre d the patient, asking him f o r all the data, and in q u irin g as to w h eth e r the entire fee has been paid. I f the first orthodontist confirm s the statem ents o f the paren t the second o rthodontist should be at liberty to decline to accept such a pa tien t. I t is not f a ir n o r ethical to expect an o th er to ren d e r services fo r w hich he is n o t rem unerated. I f the patient is to sojourn in a lo
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cality w here no in te llig e n t cooperation can be obtained, the appliances should be rem oved a n d the case be placed u n d er tem porary reten tio n f o r the period o f tim e the p atien t is to be absent. It should be considered grossly n eg lig en t and unethical to p erm it a patien t w ho has bands an d appliances on his teeth to go f o r several m onths w ith o u t proper care. I t is advisable, b efo re b egin n in g a case, to o utline c a re fu lly the tre a tm e n t necessary, to estim ate about how lo n g it w ill take to accom plish the result an d to state defin itely w h a t is expected o f the p atien t d u rin g the period o f trea tm e n t. T h e ignorance o f m any otherw ise in te llig e n t people in such m a t ters is surprising. I t should be considered u n eth ical fo r an orthodontist to begin a case an d give a fee f o r the com pletion o f it w hen he know s in advance th a t the patient is to m ove p erm an en tly to a distant city shortly a f te r the appliances are placed, an d th a t the case m ust be co n tin u ed by an o th er. In such cases, it is o nly proper an d ju s t to r e f e r th e patien t w ith o u t ad ju stin g appliances. W h e n a p atien t u n d er tre a tm e n t makes a p erm an en t change o f residence so th a t the case can n o t be continued by the den tist w ho began the w ork, the patient should be re fe rre d to some one w ho can continue the treatm en t. I n such cases, it is advisable th a t a ll data be sent to the one to w hom the case is re fe rre d and th a t a le tte r be sent statin g all the facts in the case, saying th a t he is a t liberty to change the appliances an d m ethod o f tre a tm e n t i f he so desires an d th a t he is to be responsible fo r th e com pletion o f th e case. A f te r a copy o f th is le tte r has been sent to the p aren t, the responsi bility o f the dentist w ho began the tre a t m e n t is te rm in ated . T h e one to w hom the p atient is re fe rre d should be at
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liberty to state his fee f o r the com pletion o f the case or to refuse to take the patient.
nearly as possible, the n o rm al a rra n g e m e n t o f teeth th a t w e, as specialists, can hope to m ain tain this stan d ard .
R E L A T IO N W IT H T H E PH Y SIC IA N
Specialists are consulted because they have had special tra in in g alo n g certain lines w hich should enable th em to re n der services n o t obtainable fro m the g en eral practitio n er. P aren ts w ho have p u t th e ir ch ild ren in the hands o f the specialist have a rig h t to expect expert, honest an d conscientious tre a tm e n t, w ith n o th in g essential to .the w e lfa re o f th eir ch ild ren le f t undone.
A s the practice o f o rthodontia is be com ing better fo u n d ed an d also better understood, physicians have become m ore interested an d are m uch m ore liable to r e f e r patients th an in fo rm e r years. A ll th a t has been deem ed nec essary w hen a physician re fe rs a case is to send him a note or card le ttin g him know th a t the p atient had come in an d th a n k in g him f o r his confidence. I f the case is one o f unusual character, it w o u ld be w ell to r e f e r the p atient back to his fo rm e r dentist so th a t he m ay be en lig h ten ed as to the possibili ties o f orthodontics. I n such cases, the orthodontist is a t liberty to r e f e r such a p atien t to a dentist i f the p are n t so desires.
R E L A T IO N W IT H FO R M E R PA T IE N T S W h e n e v e r a p atient is re fe rre d by a fo rm e r patient, a note o f acknow ledge m en t should be sent, expressing the pleasure in his confidence.
D U TY TO T H E P A T IE N T I n a ll professional w ork, the w e lfa re o f the p atien t should be upperm ost in ou r m inds an d this applies m ore to the specialist in orthodontics th an possibly to any oth er branch o f the d en tal pro fession a t the present tim e. T h e specialty o f orth o d o n tia is b u t a fe w decades old, an d it behooves each an d every one o f us to be m ost con scientious in serving ou r clients, so as n o t to lo w er the high sta n d ard th a t was set f o r us in the begin n in g o f the spe cialty. W e a ll know th a t it is an ex ac tin g practice, an d it is only by paying atten tio n to the m inutest details an d conscientiously striv in g to establish, as
DISCUSSION L lo y d S. L o u rie , C h ica g o , 111.: T h e suc cessful tre a tm e n t o f o rth o d o n tic cases requires the co o p eratio n o f a ll p a rtie s concerned and the f o r m u la tio n o f basic rules o f p ro c e d u re f o r them is m ost d esirable. W e a re indebted to D r . Y o u n g f o r ta k in g the in itia tiv e in this m a tte r, k n o w in g , as he d id , th e difficulties o f s a tis fy in g a ll interests. H e has succeeded in m a k in g a n u m b er o f eth ic a l ru le s to w hich th ere sh o u ld be no o b jectio n a n d he has m ade v a lu a b le su ggestions o f courtesy a n d policy, in the co n d u ct o f o rth o d o n tic p ractice. F o r the sake o f b rev ity , le t it be u n d ersto o d th at I ag re e w ith those p a rts o f the p a p e r w hich I do n o t discuss. D r . Y o u n g states quite c o rre c tly th a t “ In a ll p ro fe s sio n a l w o rk , the w e lf a r e o f th e p a tie n t sh o u ld be u p p erm o st in o u r m in d s,” b u t, u n fo rtu n a te ly , in his list o f topics f o r discussion, “ O u r d u ty to the p a tie n t” is p laced la st, a n d , in som e o f his m eth o d s f o r d e a lin g w ith c o n tro v e rs ia l or em b a rra ssin g situ atio n s, the in terest o f the p a tie n t seems to be cro w d ed o u t o r even p receded by business p o lic y a n d p ro fe ssio n a l courtesy. E n d e a v o rin g to keep the p a tie n t’s interests in the fo re g r o u n d , le t us consider som e o f these pro b lem s. U n d e r “ R e la tio n w ith th e d en tist,” D r. Y o u n g says, “ I t sh o u ld n e v e r be assum ed, w hen a d en tist re fe rs a p a tie n t to a n o rth o d o n tis t, th a t he has in clu d ed th e w h o le fa m ily . T h e d en tist has a p e rfe c t r ig h t to see th a t the tre a tm e n t an d the g e n e ra l h a n d lin g o f the p a tie n t m eets w ith his ex p ectatio n s. T h is is p a r tic u la rly ap p licab le w hen it is the first case re fe rre d by h im . I f th e p a r e n t sh o u ld ask th a t a second c h ild be ex am in ed , it is q u ite p ro p e r to exam ine th e teeth in a casual w ay , b u t the
Young— Some Ethical Phases of Practice o rth o d o n tis t sh o u ld be v ery n o n c o m m itta l u n til he has ta lk e d w ith th e f a m ily d e n tist.” T h is places th e o rth o d o n tis t in a p o sitio n sec o n d a ry to th a t o f th e d en tist w h en he sh o u ld be first, a n d a lso im p lies th a t th e o r th o d o n tist’s first resp o n sib ility is to th e r e f e r r in g den tist r a th e r th a n to th e p a tie n t, an id ea w ith w h ich I can n o t co n cu r. I f the d en tist w ishes to m ak e re se rv a tio n s in r e f e r r in g a p a tien t, these re se rv a tio n s sh o u ld be m ade to the p a tie n t h im s e lf o r to th e p a re n t, w h o has the r ig h t to k n o w w h e th e r th e re is an y lim ita tio n o f confidence in th e o rth o d o n tis t. B ut i f th e o rth o d o n tis t is asked by the p a re n t to ex am in e a n o th e r m em b er o f th e f a m ily , he sh o u ld do so, n o t casu ally a n d n o n c o m m itta lly b u t th o ro u g h ly , g iv in g his best advice. D r. Y o u n g feels th a t w h en cavities o ccu r in the teeth o f a p a tie n t u n d e r o rth o d o n tic tr e a t m en t, a d elicate qu estio n arises as to h o w the d en tist sh a ll be n o tified w ith o u t o ffen d in g h im , a n d sug g ests som e ro u n d a b o u t w ays o f d o in g th is. I see n o reaso n f o r the d en tist to ta k e offense a t directness in such a situ a tio n . T h e p a tie n t sh o u ld be in stru cted to a r ra n g e w ith h im a t once f o r th e necessary fillin g s. T h e m a rk e d ch a rts do save tim e a n d m isu n d e rsta n d in g . T h e n w e a re to ld th a t i f a p a tie n t becom es dissatisfied w ith the d en tist th a t r e fe rr e d th e p a tie n t th e o r th o d o n tist is n ev er ju stified in r e f e r r in g th e p a tie n t to a n o th e r d en tist, w ith o u t perm ission f ro m th e one w h o re fe rr e d th e case' to him . T h is is to o s tr o n g a n assertion, as the p a tie n t’s interests an d th e success o f the o rth o d o n tic tre a tm e n t m ig h t d ep en d on the o rth o d o n tis t assistin g th e p a tie n t in se lectin g a co m p eten t d en tist. H ere is a co n flict betw een the w el f a re o f th e p a tie n t a n d business p o licy . I h av e been c o w a rd ly e n o u g h to a v o id the re sp o n sib ility in m o st cases, b u t I fe e l th a t a b e tte r p la n w o u ld be to assist th e p a tie n t an d n o tif y th e d en tist. U n d e r “ R e la tio n w ith th e o rth o d o n tis t,” the sta te m e n t is m ade th a t “ I n n o ev en t w ill th e case, the ap p lian ces or th e effo rts o f a n o th e r be discussed in his a b sence.” I a g re e th a t ad v ice re g a r d in g a n o th e r o r th o d o n tis t’s case u n d e r tre a tm e n t sh o u ld n o t be g iv e n w ith o u t first h a v in g his ex p la n a tio n s a n d case h isto ry , b u t th e re seem to be several reasons w h y i t is n o t alw a y s necessary or ad v isab le th a t he be p resen t w h en th e opinion is g iv en . T h e first reaso n is th a t the p a tie n t is m o re lia b le to be g iv en an u nbiased o p in io n , o r a t least he w ill fe e l th a t th is is so. In
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a d d itio n , sh o u ld th ere be a difference o f o p in io n , th e o th e r o rth o d o n tis t m ig h t be saved th e e m b arra ssm e n t o f criticism in th e presence o f o th e r persons. F u rth e rm o re , he m ig h t fin d it in c o n v e n ie n t o r im possible to be present, p a r tic u la r ly i f his p ra c tic e is in a n o th e r city. I f he has n o t been p resen t, it w o u ld be c o u r teous to le t h im k n o w th e ad v ice g iv e n the p a tie n t. C o n c e rn in g the su b je ct o f co n su lta tio n s w ith o th e r o rth o d o n tis ts, w e a re to ld t h a t u n d e r no circum stances sh o u ld such a p a tie n t be accepted by th e one consulted. T h is w o u ld be a sa fe ru le by w h ich the one co nsulted m ig h t p ro te c t h im se lf f r o m th e sus p icion o f u n f a ir criticism f o r his o w n bene fit, b u t it m ig h t cause in ju stice to th e p a tie n t. F o r instance, the d en tist co nsulted m ig h t be the o n ly o th e r o rth o d o n tis t in the co m m u n ity , an d the p a tie n t m u st e ith e r co n tin u e w ith a m an w hose w o rk is u n sa tis fa c to ry , o r dis co n tin u e tre a tm e n t. E v e n i f th e re w ere o th er a v a ila b le o rth o d o n tis ts, th e one consulted sh o u ld be a t lib e rty to decide w h e th e r o r n o t the p a tie n t’s w e lf a r e req u ires th a t he take the case. I ag ree w ith D r . Y o u n g th a t w hen it is f o u n d th a t th e d en tist in c h a rg e o f the p a tie n t is in co m p eten t a n d g ro ssly careless in his technic, so th a t in ju r y to th e teeth o f the p a tie n t is lia b le to re su lt, the p a re n t is e n title d to k n o w th e tru e fa c ts, even th o u g h th e fe e lin g s o f the d en tist in c h a rg e are w o u n d ed , b u t I do n o t ag re e th a t it necessary to h av e a w ritte n req u est f r o m such a n in co m p eten t o r n e g le c tfu l o rth o d o n tis t, b e fo re a c c e p tin g th e p a tie n t f o r tre a tm e n t. W hen a dissatisfied p a tie n t com es in f o r c o n tin u a tio n o f tre a tm e n t, it is adv isab le, as D r . Y o u n g says, to a tte m p t to reconcile h im a n d his o rth o d o n tis t, if it a p p e a rs th a t th e tre a tm e n t is n o t a t f a u lt , o r i f it is possible to give advice th a t w o u ld enable the o th e r dentist to co n tin u e the w o rk , b u t, f a il in g in this, I th in k th a t it is n o t necessary to ask p e r m ission o f the o th e r o r th o d o n tis t b e fo re ac c e p tin g the p a tie n t. I t "w ould be p re fe ra b le th a t the p a tie n t r e tu rn to the first o rth o d o n tist f o r re m o v a l o f app lian ces, b u t, in some cases o f serious c o n tro v e rsy , it w o u ld be e m b a rra ss in g f o r b o th o f th e m a n d should n o t be insisted on. W h e n e v e r a c o n su lta tio n is given c o n c e rn in g a p a tie n t u n d e r tre a tm e n t by a n o th e r o rth o d o n tis t, as to w h e th e r he is to be ta k e n f o r tre a tm e n t o r n o t, m odels sh o u ld be m ad e sh o w in g th e c o n d itio n a t the tim e th e o p in io n is g iv en .
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H arold, C h a fm a n , L o n d o n , E n g la n d : F ew m en, i f an y , h av e h a d a lo n g e r o r w id e r ex p erien ce in th e exclusive p ractice o f o rth o d o n tia th a n has D r . Y o u n g , a n d none co u ld h av e h a d f e w e r difficulties o f a n eth ical n a tu re w ith p a r e n t a n d p atien ts. I h av e re a d th is p a p e r a n u m b e r o f tim es in the m o re c ritic a l s p irit, a n d each tim e th a t I suspected a p a r tic u la r p o in t h a d been o v e rlo o k e d , I f o u n d it th ere w h en I re a d it a g a i n ; n o r does th e p a p e r c o n ta in a n y statem ents w ith w h ich I w o u ld d isa g ree ex cep t in m in o r details. D r . Y o u n g has v e ry c lev erly in c lu d e d in his p a p e r e v e ry difficult situ a tio n th a t m ay arise. P o in ts w o rth y o f em phasis a r e : 1. P a re n ts sh o u ld be in f o rm e d p re v io u sly to a co n su lta tio n th a t a fe e is c h a rg e d f o r it. 2. C avities sh o u ld be fille d a n d gum s m ade h e a lth y b e fo re tre a tm e n t is b eg u n . 3. R e g u la r e x a m in a tio n b y th e d en tist f o r cavities, etc., is im p erativ e . +. H o m e p ro p h y la x is sh o u ld be insisted on. 5. T h e w o rd o f th e p a tie n t is n o t to be ac cepted w ith o u t c o n firm a tio n . 6. W h en p atien ts leav e o n e o rth o d o n tis t f o r anothe», a ll reco rd s sh o u ld be tr a n s f e r re d . 7. B e fo re a case is b eg u n , p a tie n ts sh o u ld be in fo rm e d a b o u t: ( a ) d u ra tio n o f tre a tm e n t; ( b ) n u m b e r o f v isits; ( c ) fees. T h e o rth o d o n tis t ta k in g o v e r th e case sh o u ld be g iv e n a f re e h a n d ; th is f a c t sh o u ld be expressed a n d n o t sim p ly im p lie d . O rth o d o n tists an d dentists, w hen th ey tr a n s f e r p a tie n ts, a re e x tre m e ly n e g le c t f u l to pass on in fo rm a tio n re g a r d in g the case; m o re o fte n th a n n o t, such p atien ts com e w ith o u t a n y re c o rd a t a ll, a n d th e den tist ta k in g o v e r th e case has to re ly en tire ly o n w h a t th e p a tie n t te lls h im ; w hereas, he sh o u ld k n o w ev ery d e ta il i f he is to co n tin u e th e tre a tm e n t to the best a d v a n ta g e . A g a in , th e s itu a tio n is difficult w hen such a p a tie n t is w e a r in g ap p lian ces w h ich u n d o u b te d ly are h a r m f u l a n d w h ich c o u ld be rep laced by o th ers to th e g r e a t a d v a n ta g e o f the p a tie n t. I h a v e been p e rp le x e d a n u m b e r o f tim es by such cases, a n d , th o u g h one w rites to th e d e n tist w h o r e fe rr e d the case, fre q u e n tly he gets n o re p ly . T h e ru le th a t p a tie n ts w e a r in g a p p lia n c e s a n d seeking a n o p in io n sh o u ld n o t b e seen ex cep t in the presence o f th e o r th o d o n tis t w h o has the case in ch a rg e seems to m e to need a little m o d ifica tio n i f one is to be ju s t to a ll p arties. As in the last case, so in th is one, th e so lu tio n w o u ld be easier i f th e tw o o rth o d o n tis ts m e t; b u t f r e q u e n tly distan ce alo n e is sufficient to m ake th is im p ro b a b le i f n o t im possible, an d the
m a tte r has to be discussed th ro u g h c o rre spondence. T h e re s u ltin g d elay m ay m ake it im possible f o r th e p a tie n t to be seen a g a in . I t seems to m e th a t, in such circum stances, th e one co n su lted sh o u ld exam ine the case th o r o u g h ly so th a t a r e p o rt m ay be m a d e ; i f th e r e p o rt is e n tire ly sa tisfa c to ry , I see n o reaso n w h y p a tie n t o r p a r e n t sh o u ld n o t k n o w a t o n ce; i f n o t e n tire ly fa v o ra b le , th en it m a y be d esirab le to co m m u n icate w ith the o r ig in a l o rth o d o n tis t, first in f o r m in g h im o f w h a t one in ten d s to r e p o rt to th e p a tie n t, a t th e sam e tim e re q u e stin g h im to g iv e his v iew s a n d com m ents first. T h e d u ra tio n o f tre a tm e n t is a difficult m a tte r to estim ate. I t h a s been m y custom to te ll p a re n ts th a t the case w ill ta k e so lo n g a n d cost so m u ch . It h ap p e n s in a n u m b e r o f cases th a t the le n g th o f tre a tm e n t is co n sid erab ly g re a te r th a n I estim ated ( I seldom say less th an th ree y e a r s ) , a n d , u n d e r the circum stances, the fe e sh o u ld be increased. W o u ld D r . Y o u n g te ll us h o w he deals w ith th is difficulty? D oes he ten d to ov erestim ate the tim e f a c to r a n d the fee, o r does he m ak e som e p ro v isio n as re g a rd s f u r th e r fees a f te r the e x p ira tio n o f the esti m a te d tim e? I f one gives a n estim ate as r e g a rd s tim e a n d fee, a n d the tim e is e x ceeded, the p a r e n t does n o t th in k th a t any a d d itio n a l fee sh o u ld be p ay ab le a n d if, u n d e r those circum stances, an a d d itio n a l fee is c h a rg e d , one m ay be accused o f d elib erately p r o lo n g in g a case f o r th e sake o f th e increased fe e . I f e e l th a t D r. Y o u n g can g iv e some v e ry h e lp f u l in f o rm a tio n in th is connection. A n o th e r p o in t o f difficulty o r r a th e r source o f e m b arra ssm e n t arises w hen th e p a r e n t tra n s f e rs th e p a tie n t f ro m the d en tist w h o r e fe rr e d th e case, to a n o th e r d en tist, w ith o u t m e n tio n in g th e f a c t, a n d the o rth o d o n tis t o n ly learn s o f th is by accid en t a t som e la te r p e rio d . I w o u ld ask D r. Y o u n g h o w he w o u ld advise th a t th e r e f e r r i n g o r o r ig in a l d en tist be in f o rm e d th a t th e o rth o d o n tis t has p la y e d no p a r t in the ch an g e in p lan s. I f u l ly endorse w h a t D r . Y o u n g says in r e g a r d to th a n k in g , b y le tte r, th e d en tist a n d the p h ysician w ho h as r e fe rr e d a case, b u t w h en a p a r e n t has done th is, I u su a lly w a it u n til I see h im an d express m y th a n k s p e rso n a lly . D r. Y oung spoke o f h om e p ro p h y la x is. T o discuss this is beyond o u r p u rv ie w , b u t i f D r . Y o u n g w o u ld say a fe w w o rd s on h o w th is is c a r rie d o u t, a ll h ere w o u ld ap p re c ia te his re m a rk s. I t is a d m itte d ly a difficult question.
Shearer— Pathology of the Mouth Som e c h ild re n com e in w ith th e ir ap p lian ces as clean as w h en th ey w ere p la c e d ; in o th e r cases, w e a re baffled as to h o w the ap p lian ces can becom e so u n h y g ien ic. W h e n I r e p o rt by le tte r to th e p a r e n t on th e n u m b e r o f visits, fe e , etc. (a s is m y p r a c tic e ) , I ta k e the o p p o rtu n ity to do p r o p a g a n d a w o rk , w hich inclu d es a sta te m e n t th a t e a rly tre a tm e n t, efficient m a stic a tio n a n d c o rre c t b r e a th in g a re in v a lu a b le a id s to o b ta in in g a g o o d resu lt. I also send a leaflet g iv in g in stru c tio n s on d iet in re la tio n to d e n ta l caries. I lo o k on this p a r t o f m y r e p o rt as o f g e n e ra l v alu e
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to th e c o m m u n ity a n d one w h ich it is a d u ty th a t w e, a s a p ro fe ssio n , sh o u ld c a rry o u t w h en su ita b le o p p o rtu n ity presents. I w as a b o u t to say th a t D r . Y o u n g h as presen ted a v a lu a b le p a p e r, b u t I re g a r d it as in v a lu able. I t is a code o f ethics f o r th e co n d u ct o f a n o rth o d o n tic p ractice. E v e ry o rth o d o n tis t w ill fin d in it h e lp f u l ad v ice in the v a ry in g circum stances w hich m a y arise, a n d n o one s ta rtin g in p ra c tic e can a ffo rd to o m it a ca re f u l stu d y o f th is p a p e r b e fo re he u n d ertak es h is first case, s to rin g in his m in d those rules w h ich a re so c le a rly set o u t in it.
PATHOLOGY OF THE MOUTH AND SURGICAL PRINCIPLES GOVERNING ITS REMOVAL* By WILLIAM L. SHEARER, B.A., M.D., D.D.S., F.A.C.S., Omaha, Nebraska S H A L L take up some o f the surgical principles incident to the rem oval o f teeth, plus the rem oval o f infections o f investing tissues. G re a t advance m en t in m ost fields o f surgery has taken place, but fro m the standpoint o f surgery o f the m o u th , g en erally speak in g , there is room f o r better train in g and refined technic, i f w e are to serve our clientele an d avoid some o f the m any com plications th a t can be placed at the door o f poor surgery. I f our patients are to be better served, w e m ust have m ore m en train ed f o r this field o f service. W e need not, I think, discuss the clinical an d bacteriologic phase o f in fections o f th e m outh o r th eir sequelae. T h e lite ra tu re is replete w ith w o n d er fu lly fine scientific research w ork. W e can say th a t individuals carry ing pulpless teeth, especially the type
I
* R e ad b e fo re th e A m erican Society o f O ra l S u rg eo n s a n d E x o d o n tists, L o u isv ille, K y ., Sept. 18-19, 1925.
th a t it is difficult, i f n o t impossible, to diagnose fro m radiographic evidence, are p laying w ith th e ir fu tu re h ealth on borrow ed capital. T h e g en eral com p lain t o f the p atien t m ay n o t be traced to so sm all a cause, an d his years sh o rt ened by lack o f know ledge on the p art o f the physician an d the dentist w ho have his h ealth in th eir care. I t is tru ly u n fo rtu n a te th a t the diseases o f the m outh are n o t associated w ith m ore local pain. T h a t the changes in the vestibular apparatus are so rem o tely as sociated w ith the tru e cause is o fte n the reason f o r overlooking m outh in fectio n s as its p rim ary or co n trib u tin g cause. Such secondary lesions as those o f the blood vessels, h ea rt and kidney are too o fte n n o t properly associated w ith a focus o f in fectio n . T h e im p o rta n t th in g f o r us to con sider, th en , is the m a n ag em en t o f m o r bid processes o f the jaw s, to standardize ou r technic, to be certain th a t all in