ETHICS IN ORTHODONTICS
The need to know
Peter M. Greco
Philadelphia, Pa
F
ifty-two-year-old Mario Lenora, the junior tenor
of your city's famous opera company, was referred
to you by a prominent periodontist to determine
whether orthodontic therapy would enhance his peri-
odontal status. Mr Lenora has a generously spaced Class
I malocclusion with cylindrically shaped incisors. There is
tight coupling of the anterior teeth upon closure, and
the posterior teeth provide bilateral support of the verti-
cal dimension. The patient practices optimal hygiene but
displays 3 mm of generalized gingival recession
throughout his mouth. His periodontal charting and
radiographs disclose no other remarkable findings. As
your clinical examination concludes and the chair
returns to an upright position, Mr Lenora asks the ques-
tion you knew you'd be facing: “Do I need braces to pre-
serve the health of my teeth? My only concern is to keep
my teeth for the rest of my life.” You ponder for a mo-
ment, and in your mind's eye, you picture the dramatic
esthetic change your treatment could provide. You'd
certainly like to close those spaces for this high-profile
performer. You would like to tell him that your services
would enhance his dental health and prognosis—and
you wouldn't mind starting another patient—but how
should you respond?
In 1974, Amsterdam1 distinguished between physio-
logic and pathologic occlusions. He defined a physiologic
occlusion as one in which the patient is totally satisfied
with esthetics and function, and dental health is uncom-
promised. In contrast, a pathologic occlusion is one in
which the patient is dissatisfied with esthetics or func-
tion, or dental health is in jeopardy. He further stated
that “An orthodontic malocclusion is not necessarily
pathologic.” He meant that there is no longitudinal ev-
idence that a corrected occlusion has a better prognosis
than a “healthy” malocclusion. He recognized, however,
that if some aspect of a malocclusion contributes to dis-
ease progression (eg, occlusal trauma in a periodontally
susceptible patient), orthodontic correction might be
helpful.
Am J Orthod Dentofacial Orthop 2013;144:2
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.04.006
The orthodontist's ethical responsibilities in deter-
mining the need to treat a physiologic occlusion are
those of veracity and autonomy. If the orthodontist ver-
ifies that the malocclusion is not pathologic, he or she
should tell the patient that the malocclusion can be
maintained in health. The orthodontist should also allow
the patient to decide whether he is willing to seek elec-
tive improvement, even though orthodontic correction
might not be essential for maintaining his dentition.
To date, there is still a lack of consistent evidence to sup-
port orthodontic therapy solely to enhance dental
health. The orthodontist's prescription for treatment is
thus usually based on experience rather than on clinical
evidence.2,3
Just as malocclusions differ in complexity, the extent
to which malocclusions need correction is as varied. We
require to embrace this concept because orthodontic
therapy is most often elective. The recent results of a Gal-
lup poll indicating dentistry's return to the top 5 ranking
in the public's perception of honesty and ethical stan-
dards must be preserved by us, since trust is among
the greatest gifts we can give our patients. Only nurses,
pharmacists, physicians, and engineers enjoy more pub-
lic trust than we do.4
Your responsibility to Mr Lenora is clear. You should
give him the autonomy to choose whether he wishes to
proceed with orthodontic correction. You can certainly
explain the significant improvement in esthetics that
therapy can provide. And you should explain the highly
elective nature of his potential care. Orthodontic treat-
ment might improve his esthetic appeal to his audience
or perhaps enhance his chances of success as he audi-
tions for that leading role in Don Quixote, but correction
of his malocclusion might not be necessary to improve
his dental health. He needs to know that.
REFERENCES
1. Amsterdam M. Periodontal prosthesis: twenty-five years in retro-
spect. Alpha Omegan 1974;13-4.
2. Shaw B. Uncertainty of orthodontic benefit and the questionable
ethics of marketing. Semin Orthod 2012;18:210-6.
3. Ackerman MB. Selling orthodontic need: innocent business decision
or guilty pleasure? J Med Ethics 2010;36:275-8.
4. Dentists rank high in Gallup poll. ADA News 2012 Dec 10; Sect 43:
22 (col. 3).