ETHICS IN ORTHODONTICS

When less might be more

Peter M. GrecoPhiladelphia, Pa

Your treatment of Susan, your daughter's 13-year-old classmate, finished beautifully. You had pre-dicted the 2mm diastemata that remains distal to

the undersized maxillary lateral incisors, so the familywas not surprised when you referred Susan to her generaldentist for augmentation to close residual spaces.

Before Susan's 1 month retainer check appointment,you receive a call from her concerned mother advisingyou that the maxillary retainer no longer fits since thedentist closed the spaces. When you see her later thatday to evaluate the problem, you are amazed to see thatshe now has 8 veneers, including maxillary first premolarto premolar, rather than a few composite restorations.You feel your pulse accelerate as you ask your assistantto produce a maxillary impression for a new retainer.

The ancient proverb in health care, “primum non no-cere,” is translated from Latin as “first do no harm.” It isa statement that is intended to admonish practitionersthat the priority in health care is to avoid hurting the pa-tient. Yet overtreatment may be physically, mentally, orfinancially deleterious to a patient's welfare. Overtreat-ment can be a violation of 3 ethical principles: veracity,nonmaleficence, and beneficence. Veracity is the tellingof truth. Nonmaleficence (avoidance of harm) andbeneficence (do good and benefit others) are consideredby some ethicists as tandem principles. The contrastbetween sufficient treatment and overtreatment is a bal-ancing act of veracity, nonmaleficence, and beneficence:judgment developed over decades of practice as a per-spective melded by the honesty to place the patient'sbenefit over financial gain, knowledge of therapeuticoptions, and the patient's needs and desires.

There are many examples of overtreatment in ortho-dontics. In addition to the authentic scenario describedabove, consider a report I received from a concernedorthodontist. He observed that 17 of the 24 third andfourth graders in an elementary school he visited werewearing maxillary expansion devices, including severalwho had no history of an activation schedule for jack-screw expansion. And overtreatment is not a new issue.I recall one of my instructors telling me that he knew of

Am J Orthod Dentofacial Orthop 2012;142:154

0889-5406/$36.00Copyright � 2012 by the American Association of Orthodontists.doi:10.1016/j.ajodo.2012.04.008

154

an orthodontist who quipped that he placed retainers foras many third graders as possible to keep them retained—in his office!

The American Association of Orthodontists' Principlesof Ethics and Code of Professional Conduct articulatesthe need for veracity in patient treatment. Section I,paragraph C, states: “Members shall make treatment de-cisions and render all related opinions and recommenda-tions based on the best interest of the patient withoutregard to a member's direct or indirect financial or bene-ficial interest in a product or service.”1 The Hippocraticoath clearly addresses the principles of nonmaleficenceand beneficence. It states that the practitioner's goal isto provide care “for the benefit of the sick according tomy ability and judgment. I will keep them from harmand injustice.”2 One test of the nonmaleficence and be-neficence principles is this pertinent question: will thepatient be better off if treatment is performed?3 In a prac-tical sense, is the 7-year-old who undergoes abbreviatedfixed appliance therapy to correct a Class II molar rela-tionship better off than if the sagittal dental relationshipwas addressed later? Is fixed appliance therapy indicatedfor diastema closure in a 9-year-old whose maxillary ca-nines have not yet descended? Are cone-beam computedtomography images necessary for every patient for whomyou plan full bonded therapy?

Although diagnostic procedures and treatment plan-ning should not be totally dictated by evidence-basedstudies, knowledge of the refereed literature, titrated byclinical experience, should form the basis for the proce-dures we prescribe. Less might be more in the case of ther-apeutic intervention. Yet, communication with ourcollaborating providers should always err on the side of ex-cessive when there is any possibility that our patientsmightbe susceptible to overtreatment. This is especially true if wetreasure our patients as much as we do our families.

REFERENCES

1. American Association of Orthodontists. Principles of ethics and codeof professional conduct, Section I, paragraph C; adopted May 1994;amended through May 2010.

2. Rule J, Veatch RM. Doing good and avoiding harm. In: Bywaters L,Harmon L, editors. Ethical questions in dentistry. 2nd ed. Chicago:Quintessence; 2004. p. 86.

3. Chambers D. Ethics fundamentals. J Am Coll Dent 2011;78:41-6.