The impacted mandibular left canine was extracted when your 40-year-old patient was in midadolescence, and her referring dentist has requested that you redevelop space for an implant-supported replacement. The patient’s main objective in pursuing orthodontic treatment is to minimize the tooth reduction involved in delivering a conventional fixed bridge. You have now completed a full course of comprehensive orthodontic therapy, and your periapical film indicates that sufficient root divergence exists. However, the patient’s periodontist advises you that the computed tomography scan reveals that there is insufficient room for the implant. You explain to your patient that you have done everything possible to create space for the replacement and therefore suggest that an alternative restorative plan might be necessary.
The patient suddenly decides she can wait no longer and wants to learn the other restorative options. You provide an overview of a conventional fixed bridge or removable denture and refer her to her dentist with a follow-up note requesting he evaluate her for these possibilities. You remind her in lay terms that the fixed bridge would indeed involve tooth reduction. After his own consultation with the patient, the dentist requests that you deband and retain the teeth, as he will proceed with a conventional fixed bridge to replace the canine.
Two months later, the patient returns to your office. A short retainer visit evolves into an hour-long emotional catharsis. The patient is both dismayed and livid that the replacement of the canine has involved reduction of not just 3 but 5 virgin teeth as abutments for the canine replacement. She says she discovered the extent of the tooth reduction only after tooth preparation was completed, while rinsing at the dentist’s office. Her repeated frantic statement was, “I never knew he would turn so many perfectly good teeth into toothpicks to make this bridge.” Although her restoration appears functional and esthetic, your patient is now totally distrusting of her restorative dentist.
Autonomy in medical ethics is defined as the patient’s ability and opportunity to make treatment choices based on sufficient information provided by the health care provider. Autonomy has been described as the patient’s “right to privacy, freedom of choice and the acceptance of responsibility for one’s actions.” Our adult patients must make their own treatment choices without undue influence from associated parties, including their dentist. Although the provider has the obligation to fully disclose the risks and benefits of any given treatment course, the provider can assist in determining which plan will best serve the patient’s objectives in therapy. The final decision, however, lies with the patient alone.
Adult orthodontic therapy is now an accepted component of contemporary oral health care. All our patients, especially adults, must be provided with the opportunity to express their autonomy in treatment planning. Discussions involving the differences between removable and fixed appliance therapy, extraction versus nonextraction comparisons, surgical and nonsurgical plans, and so on should all be approached by frank discussions elucidating the scope of pros and cons of each treatment option. It has been shown that 65% of adult orthodontic patients require dual or multiple provider groups in collaborative management. Hence, co-therapists need to provide sufficient information in treatment planning to ensure that the patient is afforded maximum autonomy in making treatment decisions. The orthodontist should verify that this has occurred when multiple providers are involved in treatment. This is essential from both ethical and legal perspectives.
In our case, the ethical principle of autonomy was violated if the patient was not apprised of the number of teeth to be prepared for the bridge. Our patient’s frustration was reflected in her repeated assertion that she would never have consented to the restorative procedure had she known its extent.
The concept of autonomy is universal to all health providers, including orthodontists. Perhaps the most poignant theme in supporting autonomy is the age-old adage of effective human relationships: “Communicate, communicate, communicate.”