THE EDITOR'S CORNER
Brave New World
Though I never studied the Begg technique in great detail, a number of my friends and colleagues are Begg devotees. Like the adherents of other "name" techniques - Tweed, Roth, Andrews, and so on - these followers are fascinated by their mentor's professional life as well as his teaching. Over the years, several of my Begg friends have related a story, the accuracy of which I have no way of verifying, about how Dr. Begg treated a case remotely across the breadth of Australia. The patient's parents worked on a ranch, or "station", somewhere in the vast interior of the country and, once the braces were placed in Begg's office, were unable to travel back on a regular basis. Apparently, Begg communicated with the patient and parents over shortwave radio; by having the parents describe what they saw in the patient's mouth and then telling the patient how to apply elastics and make other adjustments, he was able to successfully treat the entire case without seeing the patient more than two or three times.
If this story is indeed true - and I have no reason to doubt it - it would represent one of the earliest applications of "teledentistry", with most of the treatment prescribed remotely and delivered by the patient and parents rather than directly at the hands of the supervising doctor. In this issue of JCO, our Associate Editor, Dr. Neal Kravitz, and a team of co-authors explore more recent developments in an article entitled "Teledentistry, Do-It-Yourself Orthodontics, and Remote Treatment Monitoring".
In Begg's day, shortwave radio was about the only option he had for communicating with a patient in the Australian Outback. Today, of course, shortwave has been replaced by the Internet in even the remotest regions of the planet. Asking the parents to describe what they see in the patient's mouth has been replaced by real-time videoconferencing with intraoral imaging. Even do-it-yourself orthodontics has become a reality. As Dr. Kravitz and colleagues point out, "there has been an increase in mail-order, direct-to-consumer aligner systems that provide treatment without clinical examination by a professional. The appeal of this approach is not only the convenience, but the selling price - usually about $1,500, or 30% of the cost of Invisalign treatment at an orthodontic office."
Now, I fully respect the rights of others to have opinions different from mine, and you can call me old-fashioned but, to my mind at least, the thought of any kind of bargain-priced, do-it-yourself health care is terrifying. The very idea conjures up memories of an old vaudeville routine in which the comedian decides to save money by doing his own appendectomy. How hard can it be, right? But in researching this column, I found an account of Dr. Leonid Rogozov, the Russian surgeon who did indeed successfully perform an appendectomy on himself in 1961. He was the only physician at a remote Russian Antarctic research base, and as the polar winter rolled in, outside help was a hopeless prospect. It was do it yourself or die. That is roughly the level of motivation I would need to perform any skilled health-care procedure on myself.
While I personally would never subscribe to do-it-yourself orthodontics, the article by Dr. Kravitz and colleagues describes a clinical dilemma that has become very much a reality in our contemporary practice milieu, like it or not. Since I know all of these co-authors to be highly trained, highly accomplished specialists who have spent years in developing their expertise, I have to admire their objectivity in exploring the various ramifications of teledentistry, including historical perspectives, legal concerns, ethical issues, and future possibilities. I took some consolation from their description of remote treatment monitoring, in which a patient can be as far away as Dr. Begg's Australian and still be under direct supervision of an orthodontist by means of a smartphone app.
Still, as I read the successive drafts of this article, a quote from William Shakespeare's The Tempest kept coming to mind: "O brave new world,/That has such people in't!" If Internet-based do-it-yourself orthodontics truly gains widespread acceptance, we are facing a brave new world indeed.