Concluding your day with an initial examination is usually a pleasant endeavor. A family of 3 boys, ranging in age from 8 to 11 years, has just signed in for initial examinations, accompanied by their widowed mother. The family recently moved to your town from another state, and the mother is seeking an orthodontist to complete the boys’ treatment. Your clinical examination shows that all 3 children have balanced skeletal patterns. All have mixed dentitions with mild overjet and minimal mandibular anterior crowding. The maxillary first molars and incisors were bracketed less than 1 month before the family moved. The mother said that over $3000 per child was collected from public assistance by the previous orthodontist, even though he was aware that the family planned to relocate to another state.

You call the previous orthodontist to discuss your assessment but are told by his staff that he is too busy to take your call. The receptionist advises you that there is a $150 fee per child to duplicate the original records and an additional $150 charge to complete the transfer forms. You politely tell her that you will be in contact with the office after communicating this information to the boys’ mother.

Several ethical questions arise in this authentic scenario. Was the early treatment justified? Is collection of a significant fee appropriate when a practitioner is aware that the patient will soon relocate?

There are 3 types of “uncertainty” in prescribing orthodontic treatment. The first is every clinician’s incomplete mastery of the specialty’s cumulative knowledge bank. No practitioner, no matter how diligent, can maintain total knowledge of all aspects of specialty practice. The second is the limitation of the specialty’s knowledge bank. There are questions for which there are no answers. The third mode of uncertainty is a combination of the first two: a practitioner’s “personal ignorance “and the deficiency of the specialty’s knowledge bank. Combined with the lack of a standard of care, specific and absolute indications for early treatment remain difficult to identify.

The previous orthodontist’s decision to initiate treatment mere weeks before the family’s relocation to another state is difficult to defend. Maximizing the reimbursement when the orthodontist is aware of the family’s plan to move is also a dubious decision. The circumstances you now inherit place you in a difficult situation. How do you expect to be compensated for your services if second-party remuneration is unavailable? In some states, justification of state funding for orthodontic coverage must meet an objective set of criteria, often subject to review by an oversight panel.

The family’s trust and vulnerability were violated on multiple counts—especially since the orthodontist was keenly aware of the family’s plans to move. The one who reaps the most benefit from this scenario is the original orthodontist—as he smiles all the way to the bank!

In defining dentistry as a profession, ethicists have differentiated between the “normative” and the “commercial” concepts of practice. The normative concept implies that the practitioner should commit service to the benefit of the community and to the patients he treats. In other words, patient welfare is the overwhelming priority. In the commercial concept, the practitioner’s intent is to induce the sale of a service for profit: the higher the profit, the better. In this model, the priority is the practitioner’s bottom line, as in any other commercial transaction.

Where does this situation leave the single parent and her 3 boys in relation to their treatment needs? First, if orthodontic therapy is not presently indicated, treatment should be discontinued, and the children should be scheduled for surveillance appointments to monitor their future growth and development. If treatment is eventually indicated for any of them, the boys might require only abbreviated therapy. The requirement for treatment may sometimes be uncertain, but the need to respect a patient’s vulnerability is undisputed.