When less might be more

Your treatment of Susan, your daughter’s 13-year-old classmate, finished beautifully. You had predicted the 2 mm diastemata that remains distal to the undersized maxillary lateral incisors, so the family was not surprised when you referred Susan to her general dentist for augmentation to close residual spaces.

Before Susan’s 1 month retainer check appointment, you receive a call from her concerned mother advising you that the maxillary retainer no longer fits since the dentist closed the spaces. When you see her later that day to evaluate the problem, you are amazed to see that she now has 8 veneers, including maxillary first premolar to premolar, rather than a few composite restorations. You feel your pulse accelerate as you ask your assistant to produce a maxillary impression for a new retainer.

The ancient proverb in health care, “primum non nocere,” is translated from Latin as “first do no harm.” It is a statement that is intended to admonish practitioners that the priority in health care is to avoid hurting the patient. Yet overtreatment may be physically, mentally, or financially deleterious to a patient’s welfare. Overtreatment can be a violation of 3 ethical principles: veracity, nonmaleficence, and beneficence. Veracity is the telling of truth. Nonmaleficence (avoidance of harm) and beneficence (do good and benefit others) are considered by some ethicists as tandem principles. The contrast between sufficient treatment and overtreatment is a balancing act of veracity, nonmaleficence, and beneficence: judgment developed over decades of practice as a perspective melded by the honesty to place the patient’s benefit over financial gain, knowledge of therapeutic options, and the patient’s needs and desires.

There are many examples of overtreatment in orthodontics. In addition to the authentic scenario described above, consider a report I received from a concerned orthodontist. He observed that 17 of the 24 third and fourth graders in an elementary school he visited were wearing maxillary expansion devices, including several who had no history of an activation schedule for jackscrew expansion. And overtreatment is not a new issue. I recall one of my instructors telling me that he knew of an orthodontist who quipped that he placed retainers for as many third graders as possible to keep them retained—in his office!

The American Association of Orthodontists’ Principles of Ethics and Code of Professional Conduct articulates the need for veracity in patient treatment. Section I, paragraph C, states: “Members shall make treatment decisions and render all related opinions and recommendations based on the best interest of the patient without regard to a member’s direct or indirect financial or beneficial interest in a product or service.” The Hippocratic oath clearly addresses the principles of nonmaleficence and beneficence. It states that the practitioner’s goal is to provide care “for the benefit of the sick according to my ability and judgment. I will keep them from harm and injustice.” One test of the nonmaleficence and beneficence principles is this pertinent question: will the patient be better off if treatment is performed? In a practical sense, is the 7-year-old who undergoes abbreviated fixed appliance therapy to correct a Class II molar relationship better off than if the sagittal dental relationship was addressed later? Is fixed appliance therapy indicated for diastema closure in a 9-year-old whose maxillary canines have not yet descended? Are cone-beam computed tomography images necessary for every patient for whom you plan full bonded therapy?

Although diagnostic procedures and treatment planning should not be totally dictated by evidence-based studies, knowledge of the refereed literature, titrated by clinical experience, should form the basis for the procedures we prescribe. Less might be more in the case of therapeutic intervention. Yet, communication with our collaborating providers should always err on the side of excessive when there is any possibility that our patients might be susceptible to overtreatment. This is especially true if we treasure our patients as much as we do our families.

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Apr 8, 2017 | Posted by in Orthodontics | Comments Off on When less might be more
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