Marc Bernard Ackerman

Selling orthodontic need: innocent business decision or guilty pleasure?

The principal objective for most patients seeking orthodontic services is a detectable improvement in their dentofacial appearance. Orthodontic treatment, in the mind of the patient, is something that makes you look better, feel better about yourself, and perhaps enhances your social possibilities, ie, to find a companion or make a positive impression during a job interview. Orthodontics, as a speciality, has collectively advanced the idea that enhanced occlusion (bite) improves the health and longevity of the dentition, and as a result many patients seeking orthodontic services affirm that their secondary goal of treatment is an oral health benefit. It would appear that there is some disparity between the end-user of orthodontic services and the orthodontic providers perception of what constitutes orthodontic need. The aim of this paper is to examine two contrasting models that characterise how dentists ‘sell’ orthodontic services to patients and to discuss the conflict between professional ethics, practice management and evidence-based decision-making in orthodontic practice.

Microsensor technology to help monitor removable appliance wear.

Retention is routinely prescribed after orthodontic treatment to prevent relapse. Orthodontists often notice a discrepancy between what a patient reports about retainer wear and what a clinical examination shows. In these cases, is the patient misreporting wear, or is the retainer at fault? Scientific Compliance (Atlanta, Ga) has invented, patented, and produced the Smart Retainer environmental microsensor that can be easily incorporated into many types of removable orthodontic appliances to monitor compliance. The technology behind the Smart Retainer environmental microsensor is possible because of recent reductions in electronic component sizes and power requirements. A proprietary USB-powered Smart Reader uses wireless technology to download information about actual usage from the Smart Retainer. The information is decrypted and analyzed, and can be shown to the patient in easy-to-understand charts. The orthodontist can use this information to discuss actual retainer usage vs prescribed retainer usage with the patient or parent and make data-driven recommendations about future retention.

E-space preservation

OBJECTIVE To determine the relationship of E-space preservation with lingual holding arches to mandibular permanent second molar impaction. METHODS Two hundred consecutively treated patients undergoing nonextraction treatment for incisor crowding were entered into the study. Lower incisor crowding was assessed by the Little Irregularity Index. Treatment involved E-space preservation via a passive lingual arch placed prior to exfoliation of the second primary molar. Panoramic and cephalometric radiographs were analyzed for any significant relationship of mandibular permanent second molar impaction relative to molar angulation, spacing, growth pattern, and skeletal relationships. RESULTS Twenty-nine patients had at least one impacted second molar (14.5%). Of a possible 400 mandibular second molars, 34 were determined to be impacted (8.5%). Only the mandibular first molar-second molar angulation was found to be significant (P < .001). Pretreatment intermolar angulation of 24 degrees had a positive predictive value of 1. CONCLUSION Impaction of permanent second mandibular molars in patients undergoing nonextraction via E-space preservation with a passive lingual arch is 10 to 20 times more prevalent than that observed in the general population. Risk of impaction is best predicted by the pretreatment intermolar angulation between first and second permanent mandibular molars.

The myth of Janus: orthodontic progress faces orthodontic history

As a third-generation orthodontist, I am often asked by the parents of my patients to explain how the practice of orthodontics has changed over the past century. Many of the children I treat are second or third generation orthodontic patients, so this question is especially probing. The parents are asking, in effect, how will their child’s orthodontic experience differ from their own? To answer this question, we must view today’s mode of orthodontic practice in light of a century of orthodontic history. Traditionally, the key attributes of a clinical orthodontic practice have been the infrastructure (office equipment and materials), the clinical staffing, the diagnostic technique, the treatment-planning regimen, the clinical treatment rendered, and the philosophy of retention. Each component contributes to how we treat a malocclusion. But missing from this list is the individual orthodontic patient with his or her chief concern and physiologic and anatomic limitations. Today, the patient is the single most important element in orthodontic treatment planning. Without summarizing the numerous advances in orthodontic office design, staff training, material science, bioinformatics, and information technology, I will examine our progress in clinical orthodontic practice. The doctrine of informed consent and the emphasis on the interaction between the orthodontist and the patient shifted our practice paradigm in the 1990s. Before then, patients and orthodontists were thought to have the same goal in treatment: an occlusion characterized by the interdigitation of the mesiobuccal cusp of the maxillary first permanent molar into the buccal groove of the mandibular first molar with little overjet and overbite within the framework of acceptable esthetics and reasonable stability. Orthodontists took a paternalistic stance, viewing all deviations from this ideal as disease and the patient as needing a cure. Although some clinicians defined malocclusion as more of a malformation than a malady, mainstream orthodontics was still wed to the idea of disease. Wylie defined malocclusion as “disproportion between facial parts— parts which in themselves may be within the limits of normal variation, but which are disproportionate when combined with other facial structures and lead therefore to a disproportionate whole.” The central tenet in Angle’s paradigm was that attaining the occlusal ideal would concomitantly produce harmony and balance in the face. Summa’s skull, referred to as Old Glory or Secretum Apertum, was the basis for “ideal” dentoskeletal hard tissue relationships, and the face of Apollo Belvedere was the model for soft tissue facial beauty, balance, and harmony. Even without the aid of modern computer analysis, one can readily discern the lack of correlation between the bimaxillary dentoalveolar pattern of Summa’s skull and the orthognathic facial profile of Apollo Belvedere. Aligning all 32 teeth would not ensure a beautiful profile, as Angle had thought. Although Tweed’s reintroduction of extractions as part of orthodontic treatment was clearly an advance, his reduction of the decision-making process to a simplistic formula, ie, FMIA, was as dogmatic as Angle’s nonextraction philosophy. Today, with the reemergence of the soft tissue paradigm in orthodontics, we recognize that facial appearance and animation, in particular the smile, are multifactorial. When did orthodontic practice diverge from assessing and integrating soft and hard tissue interrelationships? I would argue that the advent of cephalometric radiography was central to this disconnect. Broadbent and Hofrath gave clinicians the ability to look within the dentoskeletal complex and quantify hard tissue relationships. Although this tool was later applied to the integumental profile, it was better suited for measuring hard tissues. Cephalometric radiography allowed orthodontists to serially measure craniofacial growth. Growth studies in Cleveland, Ann Arbor, and Philadelphia used this new technology to create normative data sets. Cephalometric analyses abounded in the 1940s and 1950s, with angular and linear measures used to quantify craniofacial structures. Data from small crosssectional studies and the large longitudinal growthcenter databases were included with these analyses and Am J Orthod Dentofacial Orthop 2003;123:594-6 Copyright

Longitudinal trends in discharge patterns of orthognathic surgeries: is there a regionalization of procedures in teaching hospitals?

OBJECTIVE The aim of this study was to determine if there is regionalization of orthognathic surgeries to teaching hospitals during the study period. STUDY DESIGN The Nationwide Inpatient Sample for years 2000-2008 was used. Every hospitalization that had an orthognathic surgery was selected. Patient and hospital level variables were examined. The odds of an orthognathic surgery procedure being performed in a teaching hospital over the study period was computed with the use of a multivariable logistic regression model. RESULTS During the study period, a total of 108,264 hospitalizations underwent orthognathic surgeries in the United States. The average age ranged from 27 years during the years 2006-2008 to 28.2 years during the years 2000-2002. After adjusting for multiple patient and hospital level factors, the year of procedure was not a significant predictor of increasing odds of an orthognathic surgery being performed in a teaching hospital. CONCLUSIONS There is no evidence of concentration of orthognathic surgical procedures in teaching hospitals.

People with intellectual disabilities must be designated a medically underserved population

It has been estimated that there are 6 million people in the United States with intellectual disabilities (ID). Access to care for individuals with ID falls far short of their medical and dental needs in primary, secondary, tertiary, and rehabilitative care. Although these individuals may face many of the same challenges in navigating the health care system as the general population, they are also dealing with health issues exacerbated by their specific pathophysiology and cognitive deficits. These factors often increase their risk and burden of disease, their likelihood of not seeking preventive or early treatment, and the inevitability of their experiencing far greater adverse effects such as recurrent infections and social isolation to name just a few. So with a tremendous national emphasis on health care reform and the goal of universally enhancing an individual’s quality of life, what is the probability that people with ID will gain better access to care in the immediate future? Slim to none. The four principal and interrelated factors that obstruct access to care for people with ID are professional attitudes, clinical competency, financial barriers, and public perception. Most health care providers receive little or no education in caring for people with ID during their formal training. The lack of adequately trained and willing providers is the single greatest barrier to care for people with ID. From a provider’s financial standpoint, there is a complete lack of incentives to treat this patient population and the existing public programs are poorly funded with below average reimbursements. On the patient side of the balance sheet, having a child with ID is costly and can directly impact a family’s stability and decline toward poverty. The general public’s impression is that people with ID have greater access to care, which is based largely on the national prominence of health screening programs like Special Olympics Healthy Athletes. However, the public’s view is overly optimistic and not in line with reality. So how, at an institutional level, can the government remove many of these barriers to care for people with ID? People with ID must be formally designated by the U.S. Government as a medically underserved population (MUP). Population groups seeking MUP designation must have economic barriers (low-income or Medicaid-eligible populations), or cultural and/or linguistic barriers to primary medical care services.1 The U.S. Department of Health and Human Services established criteria for designation of MUP’s based on the Index of Medical Underservice (IMU). The IMU is calculated via a four-step process. The first calculation is the weighted value for poverty and is based on the percent of the population with incomes at or below 100% of the poverty level in the area of residence for the population group. The second calculation is the weighted values for percent of population age 65 and over. The third calculation is the infant mortality rate. The fourth and final calculation is the ratio of the full-time equivalent (FTE) primary care physicians serving the population group per 1000 persons in the group. If the total weighted values V1–V4 is 62 or less, the population group qualifies for designation as an IMU-based MUP. However, under the provisions of Public law 99–280, enacted in 1986, a population group which does not meet the established criteria of an IMU less than 62 can nevertheless be considered for designation if “unusual local conditions which are a barrier to access to or the availability of personal health services” exist and are documented. When the IMU is computed for people with ID, it is 54.2,2 yet despite the recommendations from HRSA’s own Advisory Committee on Training in Primary Care Medicine and Dentistry, the federal government has yet to designate this population as a MUP. The MUP designation can benefit practitioners who care for an underserved population in many ways. Often, student loan repayment programs are available to practitioners who focus on serving an MUP. Special research grants are directed toward researchers who study MUPs. Even Medicaid reimbursements can be enhanced under specific programs focused on serving MUPs. These benefits ultimately translate into greater access and better quality care for the patient population in question. In 2010 the Secretary of Health and Human Services appointed a Negotiated Rulemaking Committee on the Designation of Medically Underserved Populations “to consider and develop new methodologies for designating medically underserved communities and populations.”3 The process has reached an impasse. Regardless of the “new math” that will probably evolve from this reconsideration one thing remains consistent, people who are medically underserved are people who do not receive ongoing, competent, collaborative and comprehensive healthcare oversight and intervention, and that defines, describes and demarcates individuals with ID. No formulas, equations, coefficients, or footnotes will change that reality. It’s time to put the pens down and address the stark reality that as a nation we are not supporting, honoring and caring for our most vulnerable population. Spec Care Dentist 33(5): 207-208, 2013

Technology, evidence and the future of Special Care in Dentistry.

It is a daunting task to take over the Editorship of Special Care in Dentistry from such a distinguished former Editor and Editorial Review Board. I would be remiss if I didn’t thank Dr. Ronald Ettinger for his many years of service to and his many accomplishments in strengthening the scope and content of this Journal. Dr. Ettinger has been exceedingly gracious to me during this transition. I am pleased to report that a steady stream of manuscripts is arriving via electronic submission each week from individuals and institutions from around the globe. English is often not the native language of many of our prospective authors. In order to help these authors, our publisher Wiley, has provided excellent author resources located on their website at http://authorservices.wiley. com/bauthor/english_language.asp . My advice to would be authors is to visit our Journal’s website as well as that of the publisher to better understand the language requirements for publication and to obtain more specific technical instructions related to electronic submission. I gladly welcome new submissions in the form of scientific articles or case reports and it is my preference to publish systematic reviews in lieu of traditional narrative literature reviews. Special Care in Dentistry is at crossroads. Our Journal is a global resource for primary information on the dental treatment of patients with special needs. The speed of information transfer has picked up exponentially over the past decade. Online submissions and peerreview provide an Editor some exceedingly useful tools to advance the speed with which manuscripts of sufficient scientific priority are published. With that being said, we can’t always be everything to everyone. The primary mission of Special Care in Dentistry is to publish the highest level of evidence on the provision of oral care services for people with physical, medical, developmental, or cognitive conditions, which limit their ability to receive routine dental care. The Journal also shares the mission of the Special Care Dental Association, which is devoted to improving oral health in people with special needs. Historically, oral health care professionals have largely had to rely on anecdotal evidence and case reports in their treatment of the special needs patient. In today’s evidence-based world, it is incumbent on the oral health care provider to present the patient with the best possible information (evidence) in order to aid the patient in making an informed decision about any treatment choice. It is important that our readership recognize this evidence-based clinical practice model. 1,2 Evidence-based clinical practice is defined as decision-making and problemsolving using a hierarchy of scientific evidence culled from scientific research. Scientific studies must be weighted by the clinician based on their vulnerability to bias. The hierarchy of evidence for therapeutic interventions listed in ascending order of bias are randomized controlled clinical trials, nonrandomized controlled clinical trials, cohort studies, case-control studies, cross-over studies, cross-sectional studies, case studies, and consensus reports reflecting the opinions of experts in a given field. In order for the evidence-based clinical practice model to work, the clinician must take this ranked scientific evidence, apply his or her accrued clinical experience, appreciate the patient’s preferences as they relate to their treatment needs, present options, and then achieve consensus. In sum, this practice model helps the clinician determine whether to apply interventions and which specific interventions to apply based on weighing benefits and risks, inconvenience, and costs within the context of patient values. Practicing with this model will help the clinician obtain truly informed consent. On behalf of the 2013 Editorial Board, I would like to thank those authors with manuscripts in press and I would like to encourage additional authors to send their manuscripts to Special Care in Dentistry in the future. Marc Bernard Ackerman, DMD, MBA, FACD

Ethics, Changing Populations, and the Dental Profession

This review emphasizes the worldwide and U.S. evolving population demographics and the need for the dental profession to exercise its professional and ethical duty to expand its traditional patient base to provide needed services.

Indebted to the bank or the profession? New doctor debt and its effect on access to care.

A key line that foreshadowed the crux of immoral behavior in a political thriller many years ago was “follow the money.” This phrase has contemporary meaning when applied to the education of health professionals today. How is medical and dental education financed and how in turn does that influence the way in which our new graduates will practice and to what specialties they will apply? It is our contention that the exponential rise in the debt load of new graduates has and will continue to affect what specialties to which they apply and for which populations they choose to provide their professional services.