Claudette is a 40-year-old dermatologist who was referred to you by your internist. Despite mild mandibular retrognathia with lip incompetence and slight nasal prominence, her facial features combine in an unorthodox form of beauty. Your intraoral examination shows an end-to-end molar relationship with divergent crown positions of the maxillary central incisors. There is posterior retrograde wear caused by the bilateral cusp-to-cusp relationship coupled with her bruxing habit. The crown divergence of the anterior teeth, combined with the poor posterior occlusion, clearly indicates the need for conventional fixed orthodontic therapy to effectively improve both function and esthetics. You believe that the degree of her malocclusion exceeds the realm of a lingual approach, at least in your hands. Full-bonded labial therapy is clearly the way to parallel the anterior teeth and correct the posterior occlusion to provide the esthetic improvement Claudette seeks and the functional enhancement she needs.
The problem is that Claudette saw her general dentist last week, and he assured her that she could be effectively treated with a series of esthetic aligners. His treatment time estimate is half that of yours. Since her hesitation in commencing treatment with you revolves around the esthetics of fixed appliances, the notion of the removable approach is appealing to her. You cannot agree that the aligner approach is best in her case. As the visit concludes, you demonstrate the significant advantage of fixed therapy by reviewing your successful treatment of a similar case. She listens patiently to your explanation and then asks, “Then why did my dentist tell me that aligners would be fine for me?” You smile as you collect your thoughts to be certain that your response will be appropriate.
Our title as doctors is derived from the Latin word doctus , meaning teacher. Doctus stems from the Latin word docere , which means “to teach.” As doctors, our responsibility as teachers of our patients is paramount. There may be a difference in the level of quality that various providers seek in treatment, and our role is to articulate that difference if it exists. Although patients may not be concerned about the enamel loss of several rotated molars that continue to undergo retrograde wear, for example, we need to communicate these findings to our patients. Sometimes, we even need to demonstrate them to our colleagues.
We know that ideal treatment is based on the development of a functional, stable occlusion rather than mere alignment of the anterior teeth without regard for function. This is integral to a thorough diagnosis and, ultimately, to the process of informed consent. Representing alignment of merely the “social 6” maxillary anterior teeth as adequate treatment might not be in our patients’ best interest. To neglect to communicate this might insinuate that our specialty does not place the ultimate emphasis on quality.
The critical management of a disagreement between 2 professionals is also pertinent. Although professional collegiality is essential from so many perspectives, we should first fulfill our obligation to our patients by informing them about the obvious and not-so-obvious aspects of their malocclusions. A difference of opinion must be communicated to both patient and colleague truthfully, yet tactfully.
The relationship between health care providers has historically been described as a brotherhood, dating back to ancient ethical codes, including the Hippocratic Oath. Yet as individuals and as professionals, we each have our own perspective regarding preferred treatment. These perspectives should be based on established principles of dentistry. The common denominator of our collaboration in treatment is that our patients’ interests and welfare remain primary.
You have explained to Claudette that mere alignment of her anterior teeth with a series of aligners is not in her best interest. Your challenge is then to communicate with her dentist to confirm your simultaneous support of him and Claudette, along with your treatment recommendation, without alienating either in the process. If you are effective, it will confirm that her welfare should—and does—reign supreme.