The More Things Change
One of the more interesting aspects of editing JCO is the discovery, through the various surveys we publish, of how orthodontists practice. The 1990 Study of Orthodontic Diagnosis and Treatment Procedures, the first part of which appears in this issue, is a case in point. Readers will not only get an overview of what orthodontists are doing today, but they can compare the techniques and procedures of 1990 with those of 1986, when the first survey was conducted.
I've mentioned before that technological changes tend to be incorporated slowly, even when they offer overwhelming advantages. I can only guess at the reasons for this, but I have an idea it has something to do with an ancient genotype that exists in all primates. Jane Goodall tells how anxious chimpanzees become when confronted with new experiences, and humans may suffer from this same phobia of the unknown, preferring to approach it gradually.
So rather than revealing any dramatic changes in treatment procedures, the 1990 JCO survey shows that orthodontists are fairly comfortable practicing the way they did in 1986. Nevertheless, I think we can see some trends that may portend significant changes in the future.
For instance, more orthodontists are now relying on 35mm photographs than on 120mm or Polaroids. This could be due to the American Board of Orthodontists' request for slides or to changes in camera technology, but there has been a definite drop in the use of cameras other than 35mm. Another technique that didn't even show up in 1986 and is now only marginally represented is video imaging. Videography will certainly become more important as its cost lessens and as orthodontists see the benefits of immediate analysis, which they can share in print form with both patients and referring doctors.
The most used cephalometric analyses remain hard-tissue oriented--those developed by Downs, McNamara, Ricketts, Steiner, and Tweed, along with the Wits analysis. Use of the computer for tracing cephalograms has risen as clinicians discover how much time it can save. With video imaging on the increase, it wouldn't be unreasonable to expect that manual tracing will eventually become obsolete.
The percentages of orthodontists using preadjusted and standard edgewise appliances hasn't changed much in four years, which tells me that the sorting out of preferences has already occurred, and that clinicians are fairly well pleased with their appliances. Unless someone comes along with a radically different and highly effective new concept, orthodontists are probably not going to change their basic armamentarium. The major trend in fixed appliances continues to be the decline in the number of those who use the Begg technique routinely: there were less than half as many in 1990 as there were in 1986. Apparently many of these have moved into the combination Begg-edgewise category.
The jump in the use of ceramic brackets was predictable, considering they were brand-new in 1986. One of the most surprising discoveries of this Study to me, however, was that only 32 percent of the practitioners recycled any brackets. I would have expected a much higher rate, but apparently 68 percent of orthodontists have their reasons for preferring new brackets to recycled ones.
The most disturbing discovery was that only 54 percent of practicing orthodontists were using safety or breakaway headgears. With the devastating potential for permanent injury from traditional headgears, to say nothing of the enormous legal liability, I am stunned to see anyone still using them. But the figures are there.
Somehow I wasn't surprised to see that the percentage of extraction cases dropped by 10 percentage points over the past four years. I think if anyone ever develops an effective soft-tissue analysis, and if we ever break away from our reliance on numerical skeletal measurements, we will see even more nonextraction treatment.
One of the newer methods of nonextraction therapy has been air-rotor stripping, and although there is now wide appreciation for this technique, the number of orthodontists using it as a finishing procedure remained rather static. The omission of a separate question on space-gaining procedures from the questionnaire may have had something to do with this stasis, along with the fact that there are still many orthodontists who don't have air turbines.
More orthodontists than in 1986 have apparently decided they prefer bonded lingual retainers, and the only other retainer to show increased use was the clear slipover. The "invisible" slipover is an esthetic retainer that patients seem to accept, is relatively easy to make, and requires fewer laboratory skills than others, so its growing popularity is not surprising.
The number of clinicians who believe TMJ dysfunction is primarily due to malocclusion seems to have dropped dramatically, although the addition of "combination of causes" to the questionnaire may have provided an easy out for many respondents. If there has indeed been a change in beliefs about etiology, it isn't reflected in the way orthodontists treat these dysfunctions--more than half continued to report splints as their primary appliances. Nor have opinions about the success of their treatment methods changed, since the median success rate remained at 75 percent.
You wouldn't expect the majority of orthodontists to change the way they practice in only four years, but this Study certainly provides a glimpse of what we might see in the future. As Yogi Berra said, "You can observe a lot just by watching."