Peter M. Greco

Posttreatment tooth movement: for better or for worse.

P osttreatment tooth movement is inevitable, but its degree depends on a variety of factors that are both iatrogenic and innate to each patient. Although various retention techniques have been developed to minimize posttreatment movement, it is unrealistic to believe that the entire dentition can be retained in all dimensions. Relapse is usually considered an adverse phenomenon, but some dimensions of posttreatment tooth movement might actually enhance occlusal function and esthetics. Favorable movement is often considered as ‘‘settling’’ if that aspect of the occlusion is improved over time. In 1998, the American Board of Orthodontics (ABO) published an objective method of evaluating posttreatment results by using 7 cast measurements and 1 radiographic measurement. Formerly called the Objective Grading System, the ABO now refers to this as the Cast Radiograph Evaluation (C-R Eval). This evaluation technique is used to score final casts and the panoramic radiograph produced within 12 months of debanding. The 8 scoring parameters are alignment/rotations, marginal ridges, buccolingual inclination, overjet, occlusal contacts, occlusal relationships, interproximal contacts, and root angulation. The C-R Eval was developed to increase objectivity in evaluation of treatment results; it uses a point system with precise criteria for cast and radiographic grading to score the case result in terms of finishing and detailing. Each case is scored after individual and group calibration of examiners in an effort to secure equity in grading among all examiners. Hence, 8 aspects of the

Radiographic and periodontal requirements of the American Board of Orthodontics: a modification in the case display requirements for adult and periodontally involved adolescent and preadolescent patients.

The increased number of adults undergoing orthodontic treatment is one of the most dramatic changes in our specialty, at least partially due to the population’s elevated awareness of dental esthetics. Studies have shown an 800% increase in the number of adult orthodontic patients starting treatment between 1970 and 1990. In conjunction with the rise in the adult patient pool, orthodontic treatment complexity has likewise increased. Periodontal involvement in adults as young as 18 years has been documented in over 50% of subjects and in most adult patients over 45 years of age. Documentation of advanced periodontal disease has been shown to affect approximately 8% to 30% of the adult population, and many of these patients are unaware of it. It is logical that some patients who are prone to periodontal involvement will proceed with orthodontic therapy. Periodontal disease is site specific and usually occurs cyclically over the lifetime of a susceptible person. This site specificity is most common in the interdental areas, which are readily seen on appropriate radiographs. Studies have shown that over two-thirds of adults have radiographic bone loss even before orthodontic therapy, indicating an elevated susceptibility toward periodontal involvement. In a 2-year adult treatment course, it is therefore probable that exacer-

Let the truth be known

You enjoy teaching 1 day a week in the orthodontic residency program at your local university. At a clinic session that is slower than usual, you find time to chat with another part-time instructor interested in publishing a scientific paper. He says that he and a resident are developing a clinical study to assess peripubertal growth rates using pretreatment and posttreatment, large-field, cone-beam computed tomography (CBCT) scans. You ask how he expects to obtain institutional review board (IRB) approval for this project. You are aware that production of CBCTs for research stands little chance of approval in the United States. He explains that all his patients routinely receive CBCT scans, regardless of the severity of their malocclusion. He has petitioned the IRB with the statement that the investigation will be conducted retrospectively, using his routine CBCTs while treating his patients. “I should have no problem with the IRB,” he says, “because I explain that I need these films to treat my patients andassess their treatment results. I alsomake that quite clear to their parents!” You begin to ponder the ethical issues involved here. First, is it ethical to produce CBCTs for all patients regardless of the severity of their malocclusion? Do their parents understand that such exposure is not the accepted standard of care in theUnited States and is under stronger scrutiny in Europe? Is it ethical to sidestep the IRB by using films that are retrospectively introduced for a study? Finally, would every parent consent to CBCT imaging for a child if he or she knew the unanswered questions about this modality? A renowned philosopher who addressed human experimentationwas Hans Jonas (1903-1983). He believed that a subjects own prerogative to participate in a study was more important than his obligation to advance societys scientific knowledge. Except in an extreme emergency such as an uncontrolled plague or a state of war, a person has no societal obligation to sacrifice his welfare for the pursuit of knowledge. Jonas also stipulated that the subject must be knowingly committed to the experiments objectives before conceding to participate. Without these 2 conditions, subjects were merely “tokens” whose “threatened dignity” would sacrifice the uniqueness and

Common errors in preparing for and completing the American Board of Orthodontics clinical examination.

Attaining Board Certification should be a goal of every orthodontic resident, orthodontic educator, and practicing orthodontist. The Board Certification process requires commitment, persistence, firmness of purpose, and sacrifice. Procrastination is the first error along the way to becoming certified. There are many reasons in support of achieving Board Certification,butundoubtedly themost salient isthe inner satisfaction of knowing that one has done his or her best. From a practical perspective, certification will become increasingly important in the eyes of the public we serve. As directors of the American Board of Orthodontics (ABO), we receive ample testimonies to the value of the certification process from newly certified and recertified orthodontists. Many of these diplomates reflect their gratitude for the assistance of the ABO staff throughout the process, the information on the ABO Web site, and the preparation courses provided by the College of Diplomates. The value of the examination as a self-evaluation and self-improvement tool is probably the most frequent comment the ABO receives each year.

More than a contract

One of your patients is a college professor who has lost multiple teeth. The original treatment plan calls for uprighting the posterior quadrants followed by restorative rehabilitation with both conventional and implant-supported prostheses. As for all your interdisciplinary patients, you conduct a pretreatment conference with the restorative dentist and the periodontist, and then enroll the patient in a 24-month treatment plan consummated by a signed consent form and a financial contract. Despite the patient’s devotion to treatment, root divergence for implant placement after 27 months of fixed therapy is inadequate. A complication in case management is the sudden retirement of the restorative dentist because of newly diagnosed multiple sclerosis. The patient is dissatisfied with the dentist’s successor and implores you to find an alternate provider. You expend extra effort to satisfy both the patient and the collaborating periodontist by integrating the new dentist into the rehabilitation effort. After several more months of fixed therapy at no added fee, you obtain a treatment result that satisfies the patient, the periodontist, and yourself. Despite the best intentions of all involved, your commitment to this patient far surpasses your contracted 24-month treatment plan. Because there are so many other patients for whom you act as a liaison to other health care providers and consistently “go the extra mile,” it seems apparent that the doctor-patient relationship often exceeds that of a contract. By definition, a contract involves an offer and acceptance (presentation of treatment options followed by the patient’s agreement to proceed) in exchange for payment for professional services (consideration). In many cases, however, the orthodontist’s commitment and dedication to the patient’s welfare extends so much farther in time and effort. As an alternative to the basic notion of a contractual agreement, some medical ethicists describe highly effective relationships between doctor and patient as a covenant.

A new method of assessing aerosolized bacteria generated during orthodontic debonding procedures

Introduction The main objective of this study was to assess the efficacy of a new and innovative method of harvesting bacteria that are aerosolized during orthodontic debonding. Additionally, the protection efficacy of several commercially available masks from such aerosols was assessed in a pilot study. Methods Twenty-six subjects were debonded during aerosol sampling, by using an innovative collection system to harvest bonding dust liberated during debonding. Dark-field microscopy, gram-stain microscopy, and chemical identification were used to determine speciation of the collected aerosol from 23 subjects. Three additional subjects were used to test 3 commercial dental or protective masks to determine whether they provide effective protection from the aerosol. Results Twenty-one species of oral bacteria were identified by the new sampling technique. Two of the 3 masks that were tested offered no protection against the aerosolized bacteria. Conclusions A new and effective method for collecting airborne bacteria is presented. Some conventional dental masks offer no protection from aerosolized organisms liberated during debonding procedures. Further assessment of mask efficacy is ongoing.

Orthodontic examiners seek synchronization

O ne of the remarkable results of human effort is the precision with which 105 musicians coordinate their individual sounds to a single, collective note countless times during a symphony orchestra performance. The synchronization of a squadron flying in formation and a collegiate kick-line are similar in that the individual becomes a component of the whole, in perfect harmony of action. The American Board of Orthodontics (ABO) conducted its clinical examination during the last week in February, preceding the examination with a similar effort toward synchronization. Fifty examiners from the United States and 1 each from Canada and Mexico assembled in Dallas to assess candidates for certification or recertification. They underwent a calibration session in which they thoroughly scored 2 sets of patient records and compared their scores in case complexity, cast and radiograph grading, and treatment delivery to the mean scores of their examining group. The examiners also compared their scores to the measurements of experienced ABO directors, labeled as the ‘‘gold standard.’’ The intent of the exercise was to direct the examination team toward a mean to make the most severe examiners less critical and the most lenient ones more critical. Each of the 52 examiners scored at least 31 components of 2 full cases, for a total of 1612 scores. The results of the exercise were remarkable. Despite variations in education, practice experience, treatment

Who and where

The long-running conflict over water and endangered species on the Platte River is fundamentally a vegetation issue. Detailed knowledge of vegetation history and current dynamics of cottonwooddominated riparian woodlands is needed to assist managers in understanding the past causes of woodland expansion and to prescribe flows to maintain or increase channel widths for migrating cranes. Results from a 20-year study of tree demography address these needs by providing linkages between flow parameters and tree recruitment and seedling survival in the active channels of the river. The demography results indicate that the current channel to woodland balance can be maintained even in low flow years by making small, but critical changes in flow regime. This approach of “letting the river do the work” is recommended over the massive clearing of riparian vegetation that has indisputable value to nesting and migratory songbirds but unproven benefit to crane populations. _______________ Editors’ Note: Please refer to the following published sources for more information on Platte River research studies conducted by W. Carter Johnson: Johnson, W. C. 1994. Woodland expansion in the Platte River, Nebraska: patterns and causes. Ecological Monographs 64: 45-84. Johnson, W. C. 1997. Equilibrium response of riparian vegetation to flow regulation in the Platte River, Nebraska. Regulated Rivers and Management 13: 403-415.

Know when to fold 'em

Mrs Glasgow is the well-to-do owner of your town’s largest jewelry store, which has been in business for 3 generations. Complaining of temporalis pain upon awakeningwith episodic joint clicking, she was referred to you by her general dentist, who has no interest in treating temporomandibular disorders. Mrs Glasgow’s complaints appear to be linked to her severe bruxing and clenching habits, which are precipitated by stress. Despite her successful management of the jewelry enterprise, her marriage is strained, and she has disclosed to you that her 15-year-old son has recently been expelled from school for alcohol abuse. You are reluctant to become involved in her treatment because of the complexity of her symptoms, but you decide to attempt to help her with conservative therapy. After 3 months of splint wear, physical therapy, and a brief course of muscle relaxant use at bedtime, her symptoms remain refractory to your most earnest efforts. Yet Mrs Glasgow trusts you unconditionally and wants to remain with you for management of her problem. You sometimes wonderwhether your value to her ismore as a sympathetic ear than as a dental therapist. And she is totally unfazed by the considerable fees that you assess her each time you adjust her occlusal splint. When is it time to cease your service to her and guide her to a resource that might be more effective in meeting her needs? The delivery of care can generate a level of strong dependence between the patient and the doctor. The patients psychological dependence on the doctor—and the financial remuneration enjoyed by the doctor—might encourage an enticing synergy for both persons. There are many situations in orthodontics that lend themselves to dependency between the clinician and the patient. Consider a prolonged continuation of an early treatment regimen extending through full treatment completion: The youngster remains in appliances for years until the orthodontist decides to initiate final correction, with another few years of treatment to follow. Or consider repeated—possibly unproductive—splint modifications for a bruxing habit leading to minimal resolution of

A difference of opinion

Claudette is a 40-year-old dermatologist who was referred to you by your internist. Despite mild mandibular retrognathia with lip incompetence and slight nasal prominence, her facial features combine in an unorthodox form of beauty. Your intraoral examination shows an end-to-end molar relationship with divergent crown positions of the maxillary central incisors. There is posterior retrograde wear caused by the bilateral cusp-to-cusp relationship coupled with her bruxing habit. The crown divergence of the anterior teeth, combined with the poor posterior occlusion, clearly indicates the need for conventional fixed orthodontic therapy to effectively improve both function and esthetics. You believe that the degree of her malocclusion exceeds the realm of a lingual approach, at least in your hands. Full-bonded labial therapy is clearly the way to parallel the anterior teeth and correct the posterior occlusion to provide the esthetic improvement Claudette seeks and the functional enhancement she needs. The problem is that Claudette saw her general dentist last week, and he assured her that she could be effectively treated with a series of esthetic aligners. His treatment time estimate is half that of yours. Since her hesitation in commencing treatment with you revolves around the esthetics of fixed appliances, the notion of the removable approach is appealing to her. You cannot agree that the aligner approach is best in her case. As the visit concludes, you demonstrate the significant advantage of fixed therapy by reviewing your successful treatment of a similar case. She listens patiently to your explanation and then asks, “Thenwhy didmy dentist tell me that aligners would be fine for me?” You smile as you collect your thoughts to be certain that your response will be appropriate. Our title as doctors is derived from the Latin word doctus, meaning teacher. Doctus stems from the Latin word docere, which means “to teach.” As doctors, our responsibility as teachers of our patients is paramount. Theremay be a difference in the level of quality that various providers seek in treatment, and our role is to articulate that difference if it exists. Although patients may not be concerned