THE EDITOR'S CORNER
Hammers, Nails, and Misdiagnosis
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Hammers, Nails, and Misdiagnosis
The 20th-century psychologist Abraham HaroldMaslow is remembered as both the father of contemporaryhumanistic psychology and the developer of thefamous "Hierarchy of Needs", which is almost a catechismto every undergraduate psychology major. Butwhen I think of Maslow, what usually come to my mindare his keenly insightful aphorisms. For instance, wheneverI become discouraged about one or another aspect oflife, a Maslow quotation, "The good society is one inwhich virtue pays", seems to bring some sanity to anuncomfortable situation.
Such a situation arose recently, when I was called onto review a paper dealing with treatment of relapsed maxillaryincisor crowding in an adult female. The authors,while impeccably credentialed and unquestionablymeticulous in their measurements of tooth movement andtheir scientific technique, missed the entire point of thecase. It would never have relapsed if it had been treatedappropriately to begin with--and darned if the authorsdid not repeat the same diagnostic mistake all over again.Sure enough, one of Maslow's quotes went right to theheart of the matter: "If the only tool you have is a hammer,you tend to see every problem as a nail." The authorsof this paper seemed to have only one tool at their disposal,and that was straightening teeth. Because of theirnarrow diagnostic mindset, they couldn?t see that the casewould have been treated better with some judiciousrestorative dentistry and conservative cosmetic bonding.
Any prudent and caring clinician wants to please thepatient, and the patient's chief complaint is certainly atthe top of our diagnostic problem list. If the main problemin the patient's mind is "crooked teeth", the simplesolution is to straighten them in the easiest and cheapestway possible. If that can be done without braces, so muchthe better. All too often, though, orthodontists--and otherpractitioners as well--allow patients' wishes to skewtheir better judgment. Our professional training andexperience should allow us to point out that, for example,extractions may be necessary, or that while the teethcould be made straight by a simple removableappliance, the resulting tooth positions might beunstable and prone to relapse.
The case in question was just such a patient.She presented with a high-angle, Class Icrowded dentition, with crowded and flaredupper and lower incisors. It was a typical exampleof what Tweed referred to as a bimaxillaryprotrusion. If the original treatment had involvedextraction of four first bicuspids and some judicioususe of headgear, this retreatment wouldnever have been necessary. Unfortunately, in theminds of those who diagnosed the case after therelapse of crowding, the simple expedient oftooth straightening was in order. Their only toolwas a hammer, so the problem became a nail.They elected to retreat to the occlusion that wasimproperly treated in the first place. To complywith the patient?s wishes, the authors did not suggestextractions and relied on an inexpensive, butinappropriate, removable appliance. In this case,if the patient did not want extractions and braces,the best orthodontic treatment would have beenreferral to a cosmetic dentist. Not all malocclusionsshould be handled by orthodontics.
The authors of this paper used some impressivehigh-tech gadgets to record individualtooth positions in three dimensions as the caseprogressed. They kept enviable records. But theystill missed the forest for the trees; they treated arelapsed high-angle, Class I bimaxillary protrusivecase back to a high-angle, Class I bimaxillaryprotrusive case with straight teeth. It'sdoomed.
Any orthodontist worth his or her saltknows that there are many more subtle nuancesto malocclusions than just crooked teeth. Theauthors of this case report were well educatedand certainly well intended--they wanted to dowhat they could to make their patient happy. Thatinvolved simply giving the patient straight teethagain, without considering the long-term implications.Another of Maslow's quotes came tomind: "People are not evil, they are schlemiels."