The Social Six

Is that all there is?

Have you ever had a patient ask, “Can you just fix this one tooth that is crooked?” Or they may pose the question, “Do you have to put braces on all of my teeth?” Would you not assume, despite these innocent inquiries, that they’d truly like all teeth to be properly aligned? By the way, what really are “straight” teeth, and can we all agree on a definition?1 

How often have we been subjected to case reports with the end results justified with the inane and seemingly harmless statement, “But the patient was happy”? Is that enough? If so, then why would we ever bother with removing teeth, dispensing headgear or elastics, driving tiny screws in bone, or breaking jaws to fit the teeth together? If patients are only focused on aesthetics and not function,2 why bother? More important, why would we need a “dental specialty” to deal with just lining up the social six teeth?

Certainly, compromises are required during the daily practice of orthodontics. In the recent past, compromise often meant a camouflage alternative to surgery or drastically altering plans if extractions were refused. But in reality (or on “reality TV”), today’s patients might frequently elect not to have their “back teeth straight,” despite the fact that they might really benefit from it. As a simple analogy, patients prefer an aesthetic change with a rhinoplasty, but they also frequently appreciate (and would likely expect) normal function accompanying their nose job.

So does the fit of the back teeth really matter? Proper posterior occlusion was one of Edward H. Angle’s most fundamental tenets, so it would still seemingly be one of the most basic precepts in orthodontic residency. But once our matriculation is complete, does our quest for proper fit of teeth simply end? It appears that we may stop to think (cogita tute), but occasionally forget to start again.3 Perhaps it’s because we are subjected to what Snelson4 described as an ideological immune system where “educated, intelligent, and successful adults rarely change their most fundamental presuppositions.”

The American Board of Orthodontics5 is still concerned with proper fit of all teeth (including second molars);6 however, as interest in early treatment became de rigueur, this necessitated extremely long treatments until these teeth erupted. Could it be that we’ve focused so much on early treatment that the basics of fitting teeth together has become an afterthought? When comparing treatment results of patients treated by orthodontists versus those completed by general dentists (using the ABO index), the specialists’ results were significantly better—especially in terms of posterior occlusion.7 In fact, patients appear twice as likely to receive board-quality treatment from a specialist.7 Unfortunately, it has also been reported that many patients never experience a bracket on their second molars5,8 nor the effects of a wire that “fills” the bracket slot.9 This begs the question: Why would you buy a specific bracket prescription if you never use the properties of what you’re paying for? Andrews10 stated that, “As a teacher, I find it interesting how unconcerned some orthodontists are about the design features of the appliance they use,” and Sernetz11 noted, “For the orthodontic manufacturer, it is always amazing to see how noncritical the practitioner can be.”

There appears to be more concern for appliances than science. Slick brochures and proprietary newsletters cross our desks each day, flashing expensive magic braces and special light wires, recommending that we flap gums, cut holes in bone, or carve up the teeth, all promising “braces treatment in only 6–12 months2 and with no wire-bending”9; all with no reports of efficacy or long-term stability.

In stark contrast, it has also been recommended that we treat early and often, in the hope of doing good things for small children, despite the fact that this often requires longer, more expensive, and mostly redundant treatments. Perhaps the intent is to retain patients in practice rather than retain proper alignment of their teeth?12 Certainly, after examining research results from the past 2 decades,3, 13-16 it seems apparent that the routine use of early treatment has been a blind evolutionary path in the continuing development of an already mature specialty. In contrast, detractors have been overheard saying, “Oh, that’s what you get for listening to academics; they just don’t want to learn.” Consequently, there appears to be a fundamental conflict between science and the fiduciary responsibilities of entrepreneurs17 that has nothing to do with the quality, cost, or duration of a patient’s treatment. That’s the problem with mixing business and science.

Turpin18 correctly predicted many of our present concerns: “It is our business as dentists to clarify and prioritize for our patients what they need for long-term well-being. How long will it be before we are subjected to the wants of our patients, based on (newspaper,17 television,19 or Internet2,9,20 advertising) that has the ability to make every good thing seem as simple as securing a cold [soda]?” For example, what’s the difference between mutilating enamel between anterior teeth to fix crowded and rotated teeth with braces,2 plastic retainers, or by simply filling in those same gaps with bonding adhesive or blocks of porcelain (so-called “instant orthodontics”)? Do we simply bend to the whims of the patient without providing proper informed consent and careful consideration of the long-term consequences? Should quality of care be “close enough” for country music or precise enough for Prokofiev? Tuncay21 once stated, “The problem with much of the unorthodox orthodontic treatment provided is more serious: The susceptible patients are diverted and never make it to effective conventional care.”

It is rather curious when ardent followers of particular treatment “philosophies” argue fervently about the significance of fractions of millimeters in condylar and/or bracket position, yet, in the same breath, find it perfectly acceptable to sell straightening of just the “billboard teeth.” Perhaps this is due, in part, to the fact that smart people believe weird things because they are skilled at defending beliefs they arrived at for nonsmart reasons.22 

An even more perplexing situation confronts today’s orthodontic consumer, as an abbreviated treatment to line up just the front teeth with plastic aligners costs dramatically more than 2–3 years of the cheaper, but more comprehensive, treatment required to achieve an ideal alignment of all teeth. Can we really do “just about everything with plastic aligners”?23 If ever questioned, the party line is, “Now if you want your teeth ‘really straight,’ we’ll need to do more work with other devices or treatment methods (like braces).” Orthodontics is simple; it’s just not easy.24

Anecdotal case reports, often accompanied by a testimonial from a “happy patient” flashing straight, bleached teeth, are hardly impressive; especially when hope of long-term stability is flippantly discarded. This is especially unfortunate for patients, as they cannot even tell the difference between the results produced by specialists and general dentists just by looking at the social six.7 

Ackerman, Kean, and Ackerman25 have recommended that orthodontists “(re)define their role in the health system and their societal role more accurately” and focus on patient’s desires (“individual enhancement” of aesthetics within the marketing milieu of today’s “extreme makeover”). If that’s our destiny, then let’s at least be honest with ourselves and up front with patients. Johnston26 stated that, “Despite the inference that orthodontics may not be a conventional health care service; it is, however, a service that is valuable, valued, and governed by the laws of biology.” If this isn’t the case, then we need to brush away all the associated trappings such as research, referred journals, and university-based residencies. Then, perhaps we should embrace proprietary27 trade schools and, instead of attending postgraduate educational symposia,17 we only need a few loosely organized sales meetings.

Interestingly enough, today’s sales pitches beg important questions such as: Do “truly” light (so-called biocompatible) forces28 just fool the bone29 and muscles into stable expansion? Are the osteocytes and sarcomeres perceptive enough to actually tell the difference between the types of brackets28 or appliances pushing or tugging on the teeth?29 If, in fact, we’re just “uprighting” lower posterior teeth with Phase I expansion,30 what happens later, when we place a preadjusted appliance with 20–35 degrees of posterior lingual crown torque? Besides, expanded cases have consistently demonstrated more incisor crowding after retention than untreated controls,30-32 and who selects “no treatment“ for patients with crowding, anyway?

So if routine bimaxillary expansion in the mixed dentition is little more than a “practice-management decision (parents are said to demand it, and younger kids are easier to treat)”30 and the results might be found to be “about the same”30 as if it wasn’t done, then the decision to expand becomes one of economics,33 convenience (credo consolans), and aesthetic outcome. But can we really pretend that expanded faces and smiles look natural or that wide or profiles look better that “full”?34,35 Does data exist to support any of the previous claims?36-38 Unfortunately, we’ve also been told that 20 years of experience and successful results outweigh the need for research39 because if science applies clinically, it’s an accident.40 It has also been touted that you simply can’t base a “philosophy” of clinical treatment on the scientific literature. It may be a bitter pill for some, but scientific evidence is not just a theoretical nicety.

Although we have no universal acceptance of what constitutes “straight” teeth, if the practitioner does not self-assess with midcourse progress records, evaluation of post-treatment records or even peer assessment of cases,1,7 then how can the orthodontist determine that they are consistently meeting, at the very least, their own interpretation of “straight teeth”? If we never evaluate any objective criteria1,5,7(that is, outcomes assessment), then we’re simply back to using the number of case starts and patient-satisfaction surveys as a measure of clinical success, despite the possibility that suspect treatment methods may occasionally be in use.1,7

We are certainly driven to produce beautiful, stable, and healthy results, and yes, a happy end-user. Yet there is another unusual dichotomy: The demand for orthodontics has never been higher, but patient compliance has never been lower. Consequently, we hope to find treatments that are highly effective and efficient, while trying to maintain satisfied consumers. It is a difficult balance, to say the least. But just compromise a few times, and eventually more than simple complacency sets in.

Ackerman37 warned that the challenge facing orthodontists in the 21st century is the need to integrate the accrued scientific evidence into clinical orthodontic practice. Ismail and Bader41 recommended that we “Should combine the patient’s treatment needs and preferences with the best available scientific evidence, in conjunction with the dentist’s clinical expertise.” Hannapel and Johnston42 have cautioned that “The treatment plan is the patient’s destiny, and ‘regret’ is the difference between what a patient gets and what he/she should have had, given the best available treatment.” It appears that reducing regret for both orthodontist and patient should be a significant goal of our professional endeavors. Confucius said, “The superior man seeks what is right; the inferior one, what is profitable.”43 Consequently, finding a balance, as an average man, would seem to be a reasonable goal. Unfortunately, that may be just plain bitter medicine for some of us.28

S. Jay Bowman, DMD, MSD, developed and teaches the straightwire course at the University of Michigan and is an adjunct associate professor at St Louis University. He has a private practice in Portage, Mich. He can be reached at [email protected].

This article is reprinted with permission from the Australian Orthodontic Journal.

References 

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