The conclusion of your long week brings another second-opinion consultation for 9-year-old Jack and his mother. This is one of several within the last few days in which you are requested to determine whether early intervention is needed. The initial consulting orthodontist advised the family that palatal expansion should be initiated immediately. Jack’s mother is unsure of the necessity of such an urgent intervention because Jack’s pedodontist never suggested this therapy. As a single parent, her time and financial resources are somewhat stretched, yet she would never deprive her son of anything he needs. Your examination reveals a moderately crowded Class I relationship without crossbite and with a balanced facial form. The remainder of the examination is unremarkable, except that Jack could use some coaching in oral hygiene. Jack’s mom tells you that “every kid in Jack’s class gets an expander,” and she wonders whether the same treatment is appropriate for Jack.
“Homogenized” treatment is the application of a uniform, minimally varied treatment regimen applied to vast numbers of patients. Physicians have historically attempted to establish rigid guidelines leading to specific treatment plans. Targeted diseases range from cardiac problems to the common cold. Dentistry and orthodontics have likewise grappled with the task of identifying common treatment guidelines, even before these disciplines were recognized as professions. Unfortunately, treatment decisions in both medicine and dentistry often cannot be—and are not—governed by abundant evidence-based information, but rather by expert opinion and the clinician’s experience. This fact makes uniform treatment plan guidelines impractical and inappropriate.
There are many examples of the inadequacy of a uniform treatment regimen in orthodontic therapy. How many comprehensive cases are simply treatment planned as “band/bond both arches, level, and align” as a standard strategy—without control of vertical or sagittal anchorage in which the molars extrude and the incisors procline toward instability? And consider the extraction issue in orthodontics which has vacillated throughout the history of the specialty. The frequency of extraction therapy peaked at 76% in a prestigious university clinic in the mid-1960s before returning to about 30% several decades later. Soon after completion of my residency, I worked in a practice where so many patients were uniformly treated with 4 first-premolar extractions that the senior partner kept a printed pad of extraction orders in each operatory so that he could quickly dispense the prescriptions like Halloween candy. The current trend toward aligner therapy, by both orthodontists and nonorthodontists, irrespective of case complexity and patient age, is another example of homogenized treatment. As long as the patient accepts the fee, an appliance delivery date is chosen immediately, before the patient leaves the office. The diagnostic records are promptly relegated to the files without further review, solely for “peace of mind” in case future complaints arise. And in the early treatment population, a common question heard at the second opinion evaluation is “why do all the kids in Suzie’s second grade class have palate expanders and braces?”
Regardless of our financial motivation, we can never ignore the uniqueness of each patient from clinical, social, mental, and emotional perspectives. What works for Jack might not be good for James. We cannot abuse our position of authority as experts in orthodontic care to deprive our patients of the autonomy they deserve to understand other treatment options. If we do, that’s paternalism.
The decades we have invested in our orthodontic education and our continuing education should enlighten us sufficiently to discern the multifaceted, unique needs of each patient. Orthodontics has been—and always should remain—a thinking person’s specialty. Every patient is unique and should be treated as such. If we forget that, our specialty will become a mail-order commodity.