In 1997, the United States Food and Drug Administration reduced regulations on the listing of side effects that pharmaceutical companies were required to follow when promoting their medications, and the direct-to-consumer advertising of drugs began.1 Following this change in health-care marketing—particularly over the past decade—we have seen a significant increase in the “do-it-yourself” approach to health care. Today, the profession of orthodontics is experiencing the effects of this sea change with the introduction of aligner therapy offered to consumers without the oversight of a licensed oral health care provider.
Around the country, a number of 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 digital intraoral scans (often done without the supervision of a licensed dentist) are sent to the company. The company then fabricates a series of aligners designed to straighten the teeth and correct the bite. In some states, this “hard look” has resulted in litigation to restrict some areas of the provision of dental care without supervision.
California Assembly Bill 1519—which was passed on October 13, 2019—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 that 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 the imaging that is now required before teeth are moved within the supporting bony structures.
KEY QUESTIONS TO ASK
This brings to the forefront some questions that we in the orthodontic profession, as well as the overall dental profession, need to ask of those who consider moving teeth without radiographic imaging of the dentition and supporting structures an appropriate level of care. As health care providers, we are held to the principles of medical ethics, which includes that of nonmaleficence, or do no harm. How can we justify tooth movement without knowing the condition of the teeth’s supporting structures? An evaluation of the following is necessary to ensure safe and effective treatment:
- Condition of alveolar bone and housing
- Presence of disease within the bone that is not visible on 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
One question posed is, “Why such a fuss about the movement of teeth with only aligners, 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 following possibilities:
- Root resorption
- Periodontal implications, including both hard and soft tissues
- Movement of roots into each other, other anatomical entities that could prove harmful, and out of the alveolar housing
Some of these complications occur even with the best diagnosis, treatment plan, and execution of the treatment plan. How much will the untoward effects of tooth movement occur without the precaution of imaging the supporting structures prior to tooth movement?
A key question is this: Are we, as dental and orthodontic professionals, not part of a larger group of health care providers who recognize disease processes occurring that may primarily manifest in other parts of the body, but also have oral implications in either the hard or soft tissues? And if so, is deleting 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 of treatment and neglect necessary imaging prior to initiation of 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?
In my opinion, speaking as a member of the orthodontic specialty for the better part of four decades, it is ill advised and neglectful to initiate orthodontic treatment without radiographic imaging. As a profession, we should resist this movement of treating without initial radiographs. I would not treat my spouse, children, loved ones, or any of my patients without radiographs, and to do so to others is to lessen their 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 October 21, 2019.
- California Legislative Information. Assembly Bill-1519 Healing Arts 2019-2020. Available at: https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200AB1519. Accessed October 21, 2019.
From Dimensions of Dental Hygiene. November 2019;17(10):10,13.