Larry has been your accountant since you opened your practice decades ago. Usually, you reach out to solicit his advice, but this time his call brings a question to you. He tells you that his wife, Susan, wants to replace those 2 missing mandibular molars, but her dentist told her that tooth movement is needed to upright the adjacent teeth before the implants are placed. The dentist claimed that the progressive spacing of her maxillary incisors can also be addressed as the molars are uprighted. He believes that he has sufficiently controlled her periodontal disease for her to undergo comprehensive orthodontic therapy. When Susan asked the dentist for his referral to an orthodontist, the dentist says that he can do it all. Hence, Larry’s question to you: can a nonorthodontist safely treat Susan given the complexity of her case? And consequently, your question to yourself: are there ethical ramifications of such treatment by a nonspecialist?
The boundaries between providers of medicodental treatment have been of interest for centuries. The Hippocratic oath, written in the fifth century BCE, encourages the physician to work within his level of expertise. “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.” Consider the unfortunate patient who is admitted to the hospital emergency room after undergoing orofacial trauma. Which service is called to treat her? Oral-maxillofacial surgery? Otolaryngology? Plastic surgery? Or in comprehensive dentistry, who will do implant placement, gingival grafting, endodontic services, and so on. The patient has no idea which practitioner can best deliver these services, and cannot and should not make that decision. The clinician’s education, experience, and credentialing are all factors in the safety and quality of these services, and are beyond the patient’s capabilities of discernment. Licensed dentists are permitted to publicize any service they offer, but are prohibited from announcing that they are specialists in that service unless they are educationally qualified as a dental specialist.
The ethical principle of nonmaleficence (first do no harm) is integral to health care delivery. Although negligence and exploitation of patients are within the realm of maleficence, incompetence in treatment is equally applicable. This has concerned orthodontists for decades. The original objective of the founders of the American Board of Orthodontics in 1929 was to protect the public from incompetent practitioners. In the early 1960s, orthodontists were prohibited from participating in teaching “short courses” that were not in an approved, university-based orthodontics program to protect vulnerable patients.
The advent of multiple methods of providing tooth movement has amplified this concern. Commercially based educational programs are teaching dentists and dental students removable or fixed appliance therapy that can be effective and viable options in properly selected patients. Yet such therapy can be destructive in some situations. Inappropriate mechanotherapy in complex dentoskeletal malocclusions, or in patients with elevated periodontal susceptibility, is an example when such care might be best addressed by specialty services. Although a nonspecialist might not be held to the same level of care as a specialist, he or she must provide a level of care that “a reasonably prudent dentist would provide in a similar situation.”
Tooth movement is simple to initiate, but control of the movement resulting in a safe, desirable outcome is another story. You should explain to Larry that one of the most confounding and elusive aspects of dental education has been educating clinicians in the distinction between which patients should be treated, which should be referred, and which should not be treated at all. Hopefully, you will give him sufficient information and gentle guidance so that he and Susan can logically decide where she should be treated.