In 1997, the U.S. Food and Drug Administration relaxed regulations requiring pharmaceutical companies to list side effects when promoting their medications. This heralded the start of direct-to-consumer drug advertising.1 Following this change in health care marketing, there has been growing interest in the “do-it-yourself” approach to health care — particularly over the past decade. Today, the profession of orthodontics is experiencing the effects of this sea change thanks to the introduction of aligner therapy offered to consumers without oversight of a licensed oral health professional.
Around the country, state legislatures and state dental boards are taking a hard look at the provision of orthodontic services with little to no professional supervision after initial models (some of which are made from impressions provided by patients) or intraoral scans (often done without the supervision of a licensed dentist) are sent to the company. The firm uses these to fabricate a series of aligners designed to straighten teeth and correct the bite. In some states, this scrutiny has resulted in litigation to restrict some aspects of providing dental care without professional supervision.
Passed last October, California Assembly Bill 1519 includes a provision supported by the California Dental Association that requires radiographic or equivalent bone imaging before the correction of “malpositions” of teeth.2 Opponents of the legislation argued the bill would restrict access to care for the economically and socially disadvantaged. They portrayed the situation as one in which teledentistry for the underserved would be unduly impacted due to the additional cost of imaging that is now required before teeth are moved within the supporting bony structures.
KEY QUESTIONS TO CONSIDER
This brings to the forefront questions that we in the orthodontic profession — as well as the overall dental profession — need to ask patients who are considering moving teeth without radiographic imaging of the dentition and supporting structures. As health care providers, we are held to the principles of medical ethics, which include nonmaleficence, or do no harm. How can we justify tooth movement without knowing the condition of the dentition’s supporting structures?
Professional evaluation is mandatory to ensure safe and effective treatment. This should include careful assessment of the:
- Condition of alveolar bone and housing
- Presence of disease within the bone that is not visible upon examination of the oral cavity and surrounding structures
- Status of the roots of the teeth not determined by visual examination
- Position of unerupted teeth
- Potential loss of root structure due to inappropriate tooth movement
Some have asked, “Why such a fuss about moving teeth with aligners only, without the use of braces?” It does not matter where the force used to move teeth originates — be it aligners, fixed appliances or other types of removable appliances. All tooth movement — regardless of the forces applied — subjects the dentition to the possibility of:
- Root resorption
- Periodontal implications, including the hard and soft tissues
- Movement of roots into each other, other anatomical entities that could prove harmful, and out of the alveolar housing
These types of complications can occur even with the best diagnosis, treatment plan, and execution of the treatment plan. In light of this, what are the possibilities for untoward effects of tooth movement if images of the supporting structures are not taken prior to tooth movement?
Ultimately, a key question is whether dental and orthodontic professionals are truly part of a larger group of health care providers who recognize disease processes that may primarily manifest in other parts of the body, but also have implications for the hard or soft oral tissues? And, if so, is foregoing radiographic imaging in order to reduce the cost of treatment neglecting our interdisciplinary responsibilities to the patient?
The last question I pose is who will bear the responsibility and subsequent liability when, in our haste to reduce cost and neglect necessary imaging prior to treatment, a tumor or metastatic lesion goes undiagnosed, when dentition is lost due to inappropriate tooth movement or compromised periodontium, or a promised result cannot be delivered due to unfavorable growth or, in some cases, no growth?
Speaking as a member of the orthodontic specialty for the better part of four decades, I suggest it is ill advised and neglectful to initiate orthodontic treatment without radiographic imaging. As a profession, we should resist this trend to self-treat without initial radiographs. I would not treat my spouse, children, loved ones, or any of my patients without radiographs, and for others to do so is to lessen these patients’ importance in society. And that is wrong.
- World Health Organization. Direct-to-Consumer Advertising Under Fire. Available at: who.int/bulletin/volumes/87/8/09-040809/en/. Accessed February 5, 2020.
- California Legislative Information. Assembly Bill No. 1519 Healing Arts 2019–2020. Available at: https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_ id=201920200AB1519. Accessed February 5, 2020.
From Decisions in Dentistry. March 2020;6(3):8–9.