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Myths and Misconceptions of Adult Diagnosis and Treatment Dr. David R. Musich Summary by: Dr. John Carter There are many problems associated with adult orthodontics that you need to overcome from time to time. Many of our treatment decisions and diagnoses are based on misconceptions (myths) rather than the reality that we must understand to properly deal with their case. First we need to define myth. A myth is "the collective belief that is built-up in the wishes of a group rather than an objective analysis." Our goals are to present the uniqueness of adult ortho patients and explore "myths" in four aspects of the treatment of adults. We will also present ways to reduce the risks of adverse legal action and to provide a few practical clinical "pearls" for adult orthodontic treatment. The "myths" related to adult treatment cover these six areas: 1. Goals of treatment 2. Diagnosis of the adult condition 3. Treatment planning 4. Mechanotherapy 5. "Closet cases" 6. Interdisciplinary treatment Myth #1 - Adult treatment goals - "Adult orthodontic patients should always achieve the idealized goals of therapy that are desired with today's technology." The reality is that with most adult orthodontic treatment, your treatment goals have to be prioritized at the expense of other goals to achieve a satisfactory result. Which goals are more important? Is function more important than facial esthetics? Example: a canine rise was established via extraction that resulted in a flattened upper lip with facial "aging" or is the total cost of treatment dictate whether you will close or open space with missing laterals. The goals of treatment pearls that you must remember are:
The reality is that "many lawsuits against orthodontists occur due to misdiagnosed periodontal disease and the misdiagnosis of the skeletal components of malocclusions has led to patent complaints and significant occlusal instability." The AAO research on risk management with adult treatment single out these three areas as their top sources of litigation:
The reasons for litigation with smoking patients are:
Other suggestions to more accurately formulate the best overall diagnosis is to use the "Bolton templates." The description and use of these templates is in Graber/Vanarsdall, third edition, pages 939-956. The template acetate placed over your patients ceph immediately shows you and your patient their key problem areas. The other diagnosis aid is the PA-Ceph. Only 8% of orthodontists surveyed by the JCO in 2001 used this additional diagnostic aid. This x-ray will help you identify transverse deficiencies that otherwise could be overlooked. Diagnostic pearls to remember are:
The reality is that each patent treatment plan has inherent risks and benefits. Individualized treatment plans that focus on the patient's chief concern are usually the most successful with adults. Be sure to reinforce with the patient that you are addressing his or her chief concern at four key times during their treatment. First, at their treatment conference before treatment has begun, second, at their progress conference with a current panoramic film, third, at their stabilization/retetion phase and finally after the completion of all of their treatment. Pearls for treatment planning include the following:
The reality is if appliance options are explained with choices clearly defined, compliance with mechanics is generally better with adults than children. New distraction techniques and new mini-implant anchorage techniques are helping us attain skeletal and dental changes that we couldn't do before. Myth #5 - Closet cases - "Closet cases should be kept in the closet so we do not have to face our diagnostic or treatment planning deficiencies." The reality is that these "closet cases" who seek orthodontic re-treatment should be studied closely so that we can learn the appropriate lessons from our diagnostic and treatment planning deficiencies. The most common re-treatment (failures) problems from a study of 100 patients were:
"Risk Preclusion" in dental practice begins with the acceptance of the premise that dentists are not perfect, that mistakes will be made and that society and the judicial system do not expect perfection. The most common causes of the breakdown of the doctor/patient relationship are disputes about fees, dissatisfaction with completed treatment, and misunderstanding about the proposal treatment and/or alternate treatments. To reduce the breakdown of communication, always personally inform the patient before rendering any treatment. The six major problems revealed from re-treatment cases are as follows. The first is undiagnosed maxillary transverse skeletal deficiency. The solution is to routinely include a PA Ceph in your pre-treatment records. These problems identified and treated early only require clinical expansion without surgery. The second problem is the treatment of growth problems that are too severe for the non-surgical management of the case. The solution is to show the patient with "Bolton" templates the cause and magnitude of their skeletal disharmony for one or both jaws. The third problem is unstable lower incisors. The solution would be to equilibrate the upper incisor marginal ridges and use long term bonded retainers when indicated. The fourth problem is "kick out" of teeth from an accidentally activated portion of a fixed retainer. The solution is to place positioners to realign and then follow with a new passive bonded retainer. The fifth problem is poor patient compliance and the reality of post treatment changes if the patient isn't finished to the ideal. The solution is a post treatment conference to prepare the patient for expected changes and a fee structure for re-treatment later if needed. Myth #6 - Interdisciplinary Therapy - "Interdisciplinary therapy has unreasonably high risks and costs with low proportionate rewards for the adult patients. Most patients are not interested in it or cannot afford it." The reality is advances in technology allow the interdisciplinary treatment used in oral rehabilitation to be reasonable in cost and risk. A well trained interdisciplinary team can provide adult patients with complex dental problems a life altering opportunity for a better quality of life. In closing, please avoid these common treatment mistakes with the treatment of adults. Avoid extracting upper first bicuspids when possible - it can cause facial aging. Treat these cases when possible with alignment along with mandibular advancement. Watch for the undiagnosed maxillary transverse constriction to avoid treating a narrow maxillae by tipping teeth out buccally instead of expanding orthopedically may cause periodontal breakdown. Identify Xerostomia because it is a hidden cause of accelerated gum disease and dental decay in adults. Many drug categories may cause Xerostomia. Some of these drug categories are as follows:
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