The Past Is Prologue
Forecasting is an inexact science, so a review of the predictions made by JCO'S Senior Editor, Gene Gottlieb, at the beginning of this decade left me with a new appreciation for his skills of divination. Gene was right on target in predicting expanded duties for auxiliaries, an increased role for computers in the diagnosis and management of patients, more government intrusion into the professional lives of dentists, an increased number of adult orthodontic patients with a constant number of child patients, greatly increased numbers of working mothers and single parents, a discouraging upward trend in overhead rates, more accurate and esthetic appliances, and a new emphasis on consumerism.
But perhaps Gene's most perceptive prognostication for the '80s was that the success of orthodontists "will depend to a much greater extent than in the past on how well they are able to offer a service which enough people perceive to be beyond the ordinary."
It was only when orthodontists began to move beyond fully banded appliances to bonded ones that adults perceived a significant incentive for orthodontic treatment. Bonding relieved us and patients of the need to painfully separate the teeth and accommodate a half-inch or more of metal. There is no doubt that more adults are coming to us because they know that putting on braces no longer hurts as it used to.
But if the advent of bonding opened up the possibility of less painful orthodontic treatment, it opened up even more the possibility of innovative treatment designs. Begg and D'Amico published articles several decades ago about the size, shape, and attrition of teeth in primitive humans. In fact, this natural attrition was Begg's raison d'etre for reducing tooth substance in order to correct malocclusions. He chose the only method available at the time--extractions.
A decade ago, Begg advocates typically recommended the extraction of four bicuspids, and sometimes four bicuspids and four molars, for Class II corrections. Removing eight teeth may seem bizarre in this age of emphasis on nonextraction, but it was not that unusual just a short time ago.
The increased attention to esthetics had much to do with our re-evaluation of extraction therapy. Orthodontists, dentists, and consumers all began to look more carefully at the effect orthodontics had on the total facial appearance, and less at whether it fulfilled some numerically preconceived notion of normal. All of us saw a large collection of faces in our practices that we felt suffered from the routine extraction of bicuspids, and we began to search for alternative treatments. Larger and more accurate data bases improved and expanded our concept of normal and, combined with the increasing popularity of functional appliances, correctly focused our attention on accurate diagnosis. Improvements in orthognathic surgical techniques also opened new avenues.
But the most innovative technique developed to promote nonextraction therapy may be the air-rotor stripping (ARS) method championed by Jack Sheridan of LSU and updated in this issue of JCO. Jack modestly refuses to accept full credit (or blame) for this concept, and rightly identifies Begg's work, along with that of Harvey and Sheldon Peck, as pivotal precursors to his clinical application. It just seemed reasonable to him that if Nature could reduce interproximal enamel without increased susceptibility to caries or periodontal disease, then modern orthodontists could, too--if they would fully exploit the advantages of full-arch bonding, which opens all the interproximal areas to reshaping.
ARS dramatically increases our ability to treat more patients without extractions. In the recent past, knowledgeable orthodontists believed 5mm of tooth-arch discrepancy to be the maximum allowance for nonextraction therapy. Many of us therefore took out 15mm of teeth to treat a 5mm problem. That didn't make a lot of sense then, but it makes even less sense now. And orthodontists who still cling to this idea of treatment planning are running into stiff resistance from consumers who want and are entitled to have more to say about what happens to their mouths and faces.
More intriguing yet is the prospect of much faster treatment with ARS. Four-to-six-month treatment periods are not unusual, and that has great appeal for adults who might balk at two years of therapy. Certainly serious posterior malocclusions or jaw discrepancies can't be corrected in so short a time, but many potential adult orthodontic patients don't care to have these corrections made when faced with the time, expense, and surgery they may require. Small wonder that Jack Sheridan, who restricts his intramural practice at LSU to adults, has a six-month waiting list of patients. I think he has struck a new mother lode that all orthodontists could mine with optimum use of ARS. My personal experience indicates that patients enthusiastically accept, pay for, and recommend to others this quicker mode of treatment.
In the past many professionals had an attitude of "my way or the highway", but that sentiment is definitely passe in this age of active consumerism. Patients expect to play a larger role in making decisions about their personal health. And we need to listen, because by being attentive and responsive to their needs, we can simultaneously discover an untapped source of patients and a way to solve the rising overhead problem that threatens our economic existence.
I don't want to make any predictions of my own for the '90s, but the one Gene Gottlieb made at the onset of this decade about the necessity of being perceived as extraordinary will surely take on added significance. Innovations such as ARS could help us distinguish our practices as exceptional and memorable.