Fifty-two-year-old Mario Lenora, the junior tenor of your city’s famous opera company, was referred to you by a prominent periodontist to determine whether orthodontic therapy would enhance his periodontal status. Mr Lenora has a generously spaced Class I malocclusion with cylindrically shaped incisors. There is tight coupling of the anterior teeth upon closure, and the posterior teeth provide bilateral support of the vertical dimension. The patient practices optimal hygiene but displays 3 mm of generalized gingival recession throughout his mouth. His periodontal charting and radiographs disclose no other remarkable findings. As your clinical examination concludes and the chair returns to an upright position, Mr Lenora asks the question you knew you’d be facing: “Do I need braces to preserve the health of my teeth? My only concern is to keep my teeth for the rest of my life.” You ponder for a moment, and in your mind’s eye, you picture the dramatic esthetic change your treatment could provide. You’d certainly like to close those spaces for this high-profile performer. You would like to tell him that your services would enhance his dental health and prognosis—and you wouldn’t mind starting another patient—but how should you respond?
In 1974, Amsterdam distinguished between physiologic and pathologic occlusions. He defined a physiologic occlusion as one in which the patient is totally satisfied with esthetics and function, and dental health is uncompromised. In contrast, a pathologic occlusion is one in which the patient is dissatisfied with esthetics or function, or dental health is in jeopardy. He further stated that “An orthodontic malocclusion is not necessarily pathologic.” He meant that there is no longitudinal evidence that a corrected occlusion has a better prognosis than a “healthy” malocclusion. He recognized, however, that if some aspect of a malocclusion contributes to disease progression (eg, occlusal trauma in a periodontally susceptible patient), orthodontic correction might be helpful.
The orthodontist’s ethical responsibilities in determining the need to treat a physiologic occlusion are those of veracity and autonomy. If the orthodontist verifies that the malocclusion is not pathologic, he or she should tell the patient that the malocclusion can be maintained in health. The orthodontist should also allow the patient to decide whether he is willing to seek elective improvement, even though orthodontic correction might not be essential for maintaining his dentition. To date, there is still a lack of consistent evidence to support orthodontic therapy solely to enhance dental health. The orthodontist’s prescription for treatment is thus usually based on experience rather than on clinical evidence.
Just as malocclusions differ in complexity, the extent to which malocclusions need correction is as varied. We require to embrace this concept because orthodontic therapy is most often elective. The recent results of a Gallup poll indicating dentistry’s return to the top 5 ranking in the public’s perception of honesty and ethical standards must be preserved by us, since trust is among the greatest gifts we can give our patients. Only nurses, pharmacists, physicians, and engineers enjoy more public trust than we do.
Your responsibility to Mr Lenora is clear. You should give him the autonomy to choose whether he wishes to proceed with orthodontic correction. You can certainly explain the significant improvement in esthetics that therapy can provide. And you should explain the highly elective nature of his potential care. Orthodontic treatment might improve his esthetic appeal to his audience or perhaps enhance his chances of success as he auditions for that leading role in Don Quixote , but correction of his malocclusion might not be necessary to improve his dental health. He needs to know that.