If you wouldn’t extract a permanent tooth from a family member, why would you extract one from someone else’s?

From the newsletter of the IAFGG (International Association for Facial Growth Guidance), June 2010

Over the last several decades orthodontic technology has evolved through many permutations of what I believe is essentially the same treatment for young patients:  retraction of the upper front teeth with or without extractions.

Dr. John Mew, this year’s IAFGG Symposium’s keynote speaker has been fighting for decades to bring regulations to the industry that would force dentists and orthodontists to disclose Facial Growth Guidance as an alternative to traditional orthodontic treatments for kids.  His motivation for pursuing such regulation has been his passionate belief in non-extraction/non-retractive orthodontia techniques and the massive variances he has observed in aesthetic results depending on the orthodontic protocol chosen to treat a patient.  John has been fighting his fight for over 40 years in Europe to achieve his goal and I admire his tenacity.

But,  I think it is time that we take disclosure one step further than he has suggested.  As my colleague Karen O’Rourke pointed out, dentistry prides itself on being well ahead of most other medical disciplines when it comes to placing a meaningful and effective emphasis on disease prevention.  But, I think we fall far short, in comparison to our peers in the other medical specialties when it comes to disclosure.

I believe that informed consent in orthodontics is woefully inadequate.  We are in the business of permanently removing, adding and/or changing the structure of body parts (exactly what surgery does), yet we do not come close to holding ourselves to the same standard disclosure that surgeons do.

When a surgery is performed in The United States, the surgeon, by law, must inform the patient of all of the potential adverse outcomes that are known to have occurred in a statistically significant number of similar cases in the past.  After being told of the negative outcomes that are possible from the surgical procedure being recommended, the patient then makes a decision.  If you have ever had a surgery performed or accompanied a loved one to a pre-surgical consultation, you know that the majority of that final meeting primarily consists of the patient asking the surgeon for clarity on exactly what these negative outcomes are, how often they happen and what the long term consequences are.  After that meeting, the surgeon is politely thanked, then the patient goes home, turns on the computer, looks up all of the negative results on the internet and makes an appointment for a second opinion.  The patient arrives at the second opinion appointment with a stack of evidence to discuss with the surgeon. If the original surgeon is lucky, he gets to go through that same stack of internet print outs and explain why he is the one to do the job.  That’s how it works in the world of “medicine”.  It’s the law.

But, not for us.  We get a pass on all of that.  Why?

With few exceptions, when I speak to dentists and orthodontists in private, they admit to me that they would never allow permanent teeth to be extracted for their own children.  When I ask them why, they tell me that, were they to extract, they would have concerns about the impact on the esthetics of their child’s face and the impact on their child’s airway.  Some would even whisper that they were concerned about TMJ problems developing down the road.  (They would whisper about the TMJ part because the party line is that there is no relationship, but they know better.)

But, let’s just put the extraction/non-extraction debate aside for just a moment.  Goodness knows it gets more than its fair share of discussion and it is irrelevant to the inquiry I’m making to you here.

I think we can all agree on two points when it comes to retractive mechanics.  There are a statistically significant number of documented cases where retractive mechanics have had a negative impact on the esthetics of the face and the airway.  Yet, when we recommend corrections for our orthodontic patients, we get a pass on these two disclosures.  What if an Esthetic Impact Statement and and Airway Impact Statement were added to our informed consent?  What do you think would change in the final meeting between the patient, parent and dentist/orthodontist before the extractions happened?  Would there be more questions asked?  Would we be forced to justify our recommendations and bring more clarity to the potential downsides of such treatments?  Would patients blindly sign on the line or go home and search the internet to get themselves more educated as they do with other surgical procedures. (Remember, extraction of permanent teeth is a surgical procedure.)

I think we know they would.  I think we know that they would come back to the office with pictures they found on the internet of severely recessed chins, gummy smiles, vertically growing faces, hooked noses, etc..  They would be much more likely to ask for before and after pictures of cases we had treated where the pre-treatment conditions were similar to theirs.  And, they would study those after pictures…with educated eyes.  They would ask for before and after lateral head x-rays too.  (It’s not hard to tell whether an airway has gotten bigger or smaller over time.) They would have questions about snoring and Obstructive Sleep Apnea (OSA) too.  And, we would be forced, if we wanted the case, to explain exactly how we were going to lower the odds of those things happening to the patient.

In short, they would ask us for evidence that we were equipped to handle the case.  Evidence.  It’s a word we banter about all of the time in our profession. (A quick Google search of “evidence based dentistry” brings up 449,000 results.  When I entered “evidence based orthodontics”, I got 137,000 results)   We always want to see each the evidence when a new treatment comes along…just to be sure that the wool is not being pulled over our eyes.   I wonder what would happen if we were forced to show patients and parents our evidence before we treated their children.  Would we be able to sit back on the laurels of our reputations as nice people and community leaders?  Or, would  we be forced to search for better and better ways to address the problems inherent in our treatment protocols?


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