LETTERS TO THE EDITOR Comment on Legal Aspects a ticle To the Editor:
I read, with interest, the article by Donald E. Machen, DMD, MSD, JD, titIed "Legal Aspects of Orthodontic Practice--Oral Hygiene Assessment: Plaque Accumulation, Gingival Inflammation, Decalcification, and Caries" (AM J ORTHOD DENTOFACORTHOP,July 1991:93-4). These types of articles elicit in me a variety of emotional responses that usually go away. However, this article generated some real concerns that I feel need to be addressed. Most notably, in assigning responsibility for care, the author makes no mention as to the responsibility of the patient and/or the patient's parents in the orthodontic treatment process. Dr. Machen's first paragraph indicates we have been given by the courts the =supervision of the overall oral care of the patient throughout the orthodontic treatment process." He seems eager to pick up this gauntlet and support it. It appears to me we need to define where our responsibility stops and the patient's responsibility begins. I would be willing to accept total responsibility if our patients were inanimate, but they are not. Patients and parents are complicated biosystems who often defy what we, in this specialty, perceive as logic. Today, a judicial system that probably has little concept of the total orthodontic treatment process is deciding what is "correct" treatment protocol. Our specialty, at present, is developing an opinion concerning various areas of TMJ dysfunction. These opinions are based on research that was probably prompted, in part, by the judicial process. There are several areas in our specialty, including oral hygiene, about which a consensus position could be developed. I find no fault with Dr. Machen's first paragraph of his discussion where he indicates we need to diagnose our patient's health thoroughly before treatment. I also agree that patients and parents, where applicable, need to be kept informed. Most doctors teach good oral hygiene techniques and, unfortunately, a typical parental response is, "1 understand your message and I have tried to tell my child, but he won't listen." I recently conducted a subjective oral hygiene survey of 100 consecutive patients. Granted, this is not scientific, but the evaluation method is one that is used on a daily basis in our office. Of this group, 57% had good hygiene at the survey evaluation appointment, and 59% had a good to fair hygiene trend for their entire past treatment period. This means that approximately 40% of the orthodontic treatment group is possibly at risk for damage to the dentition and/or periodontium. We also noted that of those given intensive oral hygiene instructions, very few showed long-term improvement. 24A
Dr. Machen indicates oral hygiene should be good before commencing treatment. I agree and, in the vast majority of cases, hygiene is acceptable. Dr. Machen further states that, if hygiene is not up to a specified standard, the patient should be terminated or seen weekly. A basic problem here is that not all patients that demonstrate poor oral hygiene during treatment, demonstrate damage to the dentition or periodontal tissues afterwards. Considering that 40% of my active patients may be "at risk," that would be a considerable number of patients to terminate on the possible chance of tissue damage. In many of these cases, I would not want to leave the occlusion as is. I also do not think patient and/or parent support of this policy would be very high. The suggested =termination of treatment" policy would likely have a catastrophic effect on the reputation of our office as a result of the unfavorable communications involved. Dr. Machen indicates his protocols would take little practitioner time. In recent years, offices are involved with many new responsibilities, OSHA being a recent example. These all take time and increase overhead. As one who has tried a variety of options over the years to improve hygiene, I can assure Dr. Machen it takes considerable practitioner time for delegated procedures just to monitor staff compliance for every patient, every day. In closing, I agree we need to address this ethical issue. Many of us have seen the following medical analogy, which I see as an exact ethical parallel. A physician's patient, who has previous coronary disease, is under active treatment. His physician knows he has risk factors, such as poor diet and smoking, and informs him to make corrections. To my knowledge and inquiry, the physician is not responsible for new cardiac disease if the patient has chosen not to make the appropriate risk reductions. Granted this analogy could have more serious consequences but where is the difference between the responsibility of the physician and the dentist. In our zeal to avoid litigation, the AAO should entertain serious discussion pertaining to the relegation of responsibility in the orthodontic treatment process. At the same time they should actively oppose suggesting and supporting unrealistic and undocumented protocols. J. Franklin Whipt~s, DMD, MS Centralia, IlL
Reply To the Editor:
Thank you for the opportunity of responding to the letter from Dr. Whipps. Enclosed is my response to his letter. Although Dr. Whipps is critical of the courts finding liability with the orthodontist for the periodontal problems and decalcifications during orthodontic care, and is also critical of my support for the implementation of protocols
I read, with interest, the article by Donald E. Machen, DMD, MSD, JD, titIed "Legal Aspects of Orthodontic Practice--Oral Hygiene Assessment: Plaque Accumulation, Gingival Inflammation, Decalcification, and Caries" (AM J ORTHOD DENTOFACORTHOP,July 1991:93-4). These types of articles elicit in me a variety of emotional responses that usually go away. However, this article generated some real concerns that I feel need to be addressed. Most notably, in assigning responsibility for care, the author makes no mention as to the responsibility of the patient and/or the patient's parents in the orthodontic treatment process. Dr. Machen's first paragraph indicates we have been given by the courts the =supervision of the overall oral care of the patient throughout the orthodontic treatment process." He seems eager to pick up this gauntlet and support it. It appears to me we need to define where our responsibility stops and the patient's responsibility begins. I would be willing to accept total responsibility if our patients were inanimate, but they are not. Patients and parents are complicated biosystems who often defy what we, in this specialty, perceive as logic. Today, a judicial system that probably has little concept of the total orthodontic treatment process is deciding what is "correct" treatment protocol. Our specialty, at present, is developing an opinion concerning various areas of TMJ dysfunction. These opinions are based on research that was probably prompted, in part, by the judicial process. There are several areas in our specialty, including oral hygiene, about which a consensus position could be developed. I find no fault with Dr. Machen's first paragraph of his discussion where he indicates we need to diagnose our patient's health thoroughly before treatment. I also agree that patients and parents, where applicable, need to be kept informed. Most doctors teach good oral hygiene techniques and, unfortunately, a typical parental response is, "1 understand your message and I have tried to tell my child, but he won't listen." I recently conducted a subjective oral hygiene survey of 100 consecutive patients. Granted, this is not scientific, but the evaluation method is one that is used on a daily basis in our office. Of this group, 57% had good hygiene at the survey evaluation appointment, and 59% had a good to fair hygiene trend for their entire past treatment period. This means that approximately 40% of the orthodontic treatment group is possibly at risk for damage to the dentition and/or periodontium. We also noted that of those given intensive oral hygiene instructions, very few showed long-term improvement. 24A
Dr. Machen indicates oral hygiene should be good before commencing treatment. I agree and, in the vast majority of cases, hygiene is acceptable. Dr. Machen further states that, if hygiene is not up to a specified standard, the patient should be terminated or seen weekly. A basic problem here is that not all patients that demonstrate poor oral hygiene during treatment, demonstrate damage to the dentition or periodontal tissues afterwards. Considering that 40% of my active patients may be "at risk," that would be a considerable number of patients to terminate on the possible chance of tissue damage. In many of these cases, I would not want to leave the occlusion as is. I also do not think patient and/or parent support of this policy would be very high. The suggested =termination of treatment" policy would likely have a catastrophic effect on the reputation of our office as a result of the unfavorable communications involved. Dr. Machen indicates his protocols would take little practitioner time. In recent years, offices are involved with many new responsibilities, OSHA being a recent example. These all take time and increase overhead. As one who has tried a variety of options over the years to improve hygiene, I can assure Dr. Machen it takes considerable practitioner time for delegated procedures just to monitor staff compliance for every patient, every day. In closing, I agree we need to address this ethical issue. Many of us have seen the following medical analogy, which I see as an exact ethical parallel. A physician's patient, who has previous coronary disease, is under active treatment. His physician knows he has risk factors, such as poor diet and smoking, and informs him to make corrections. To my knowledge and inquiry, the physician is not responsible for new cardiac disease if the patient has chosen not to make the appropriate risk reductions. Granted this analogy could have more serious consequences but where is the difference between the responsibility of the physician and the dentist. In our zeal to avoid litigation, the AAO should entertain serious discussion pertaining to the relegation of responsibility in the orthodontic treatment process. At the same time they should actively oppose suggesting and supporting unrealistic and undocumented protocols. J. Franklin Whipt~s, DMD, MS Centralia, IlL
Reply To the Editor:
Thank you for the opportunity of responding to the letter from Dr. Whipps. Enclosed is my response to his letter. Although Dr. Whipps is critical of the courts finding liability with the orthodontist for the periodontal problems and decalcifications during orthodontic care, and is also critical of my support for the implementation of protocols
