EDITORIAL
.Future shoe/c and adult orthodontics
F
uture shock’s influence on dentistry is revealed in the changing character of the orthodontic practice. Factors involved include a shift in the population balance with a decrease in the number of children, an increase in the number of orthodontists, and a growing proportion of adults seeking treatment. The general dentist is now attuned, through continuing education, to the orthodontic benefits of prevention, improved health, function, and esthetics for the adult and can refer more patients. Increased knowledge of the rewards derived through dentofacial corrections and their importance in social and business enterprise have whetted the appetite of the young adult for orthodontic treatment. With the onset of the American Association of Orthodontists’ new public relations program, we should see an increase in patients of all age groups into our offices. The balance is influenced somewhat by the structures of third party programs which have put treatment within reach of many mature persons. The futuristic orthodontist, therefore, must constantly remodel and expand his perception to meet this challenging development. Surveys of orthodontic offices indicate that the proportion of adult patients is increasing toward 25 percent of the average practice’s patient load. Most, if not all, of these surveys are subjective in nature, since few orthodontists have actually counted their active patients and placed them in age categories to determine the percentage of adults for each year in practice. Also, what age has been established to signify when an adolescent becomes an adult? Is it 16, 18, 21 years of age? Or should we use some other method? I suspect that the actual increase in the number of adults is less than the surveys indicate, but these surveys do give indications concerning the needs, desires, and direction from which new patients come to fill the void resulting from the decline in the child population. The term adult orthodontics requires clarification. The most significant factor for an orthodontic definition appears to involve the cessation of craniofacial growth. In some females this may be as early as 12 years of age, and in some males it may be as late as 25. Other methods of classification are related to individual state laws of maturity that specify “legal age” as the ability to vote or imbibe, ages 16 to 21, marriage, or self-support. These types of differentiation do not always address the physiologic, anatomic, or psychological fault line between children and adults. A near static dentofacial complex is characteristic of adult malocclusions. Other factors, such as changes in the periodontium, physiologic rebound, and psychological attitude, come with maturation and also vary from individual to individual. Consequently, it is beneficial to have some assessment of skeletal1 growth through a knowledge of family history and individual growth records related. to height, weight, cephalometric surveys, and hand-wrist films. Treatment of adult patients is often divided into categories of simple and complex without really defining goals. You have seen or heard the terms limited, partial, comooO2-9416/79/110577+04$00.40/0
0
1979 The C. V. Mosby
Co.
577
578
Editorial
Am. J.. &mod. November 1979
preliminary, and preventive used to suggest simple treatment. If your goals are to strive for excellence in treatment with ideal results, then I have seen few simple adult cases. By excellence and ideal, I mean esthetically and functionally pleasing to all involved, with improved health. This, in itself, will often necessitate the aid of general dentistry, periodontics, reconstructive procedures, and surgery. Harmony in a dynamic, functional occlusion, without interferences or irritations, even though these may manifest themselves only during times of distress, is paramount. The exchange, however, of esthetic improvement for potentially detrimental factors, such as bone loss, decalcification of crowns, root resorption, gingival deterioration, periodontal disease, emotional distress, discomfort, and TMJ focusing, may not be considered the most salubrious approach. All factors, including the patient’s personality, should be surveyed. From the foregoing discussion and your experience as a clinician, you know that, even in the correction of the most simple cross-bite, a functional shift usually is revealed, with its belated complexities. An apparent Class I occlusion may transform into a cusp-to-cusp Class II with an elongated or shortened tooth after a single-tooth cross-bite is corrected with a simple removable appliance. Or a “simple” posterior cross-bite correction may reveal some severe midlne discrepancies or mandibular shifts with related balancing interferences. Here lies the essence of the orthodontist’s reluctance to categorize which so-called “simple” problems should be delegated or performed by the general dentist. Other divisions of adult treatment are made according to the need for surgery, the presence of temporomandibular joint disturbances, the myofascial pain dysfunction syndrome, the degree of compromise necessary, periodontal rationale, the presence of a mutilated dentition, requirements for reconstructive or prosthetic dentistry, equilibration, esthetics, or splint therapy. Once categorized, this adult patient surge brings added responsibilities to all involved. Some orthodontists have opened separate offices or have segmented their existing offices for this adult phase of treatment. The adult orthodontic patient has priorities and problems quite unique from those of the adolescent orthodontic patient. There is no growth; treatment time for an ideal result is lengthened, with slower tooth movement; and increased lag time occurs between activations. We have bone aging with increased calcification and decreased cell structure and vascularity. The periodontium undergoes a decrease in vascularity and cell structure with siower healing. The temporomandibular joint is more sensitive to changes in its relationship with muscles and occlusion. There is less physiologic rebound from all systems. Systemic disorders are not uncommon along with interactions from the usual increased intake of medications. Without growth, there is little “settling in” of occlusion, and the patient’s expectations of results are usually higher than can be delivered. The fine tuning needed for a functional occlusion becomes magnified with the adult patient. The state of oral health is usually less than desired in adult orthodontic patients. They often exhibit a poor periodontium, restorations, and missing teeth. The great concern for an esthetic appliance sometimes hinders an expedient approach. This is not to say that alternative mechanotherapeutic systems cannot be designed for special cases with esthetic considerations and still produce improved dentofacial relationships.’ Factors that should flag down our enthusiasm toward quick starts are TMJ symptoms, unreasonable expectations concerning esthetics during treatment, expression of inability to cooperate in some phase of treatment, a need for a “perfect” final result, skeletal
promise,
Volume 16 Number 5
Editorial
579
disharmonies, a poor periodontium, a mutilated dentition, and local and systemic diseases. Orthodontics for adults poses a different challenge to the orthodontist, and all problems should be approached with a bit of caution and respect. An optimal treatment plan and goal can come only with a proper diagnosis derived from requesting adequate records that include medical and dental histories. The orthodontist faces increased risk and responsibility when treating adult patients. Orthodontic appointments can be long with a higher potential for patient distress. A larger percentage of adults are taking medications which have potential side effects. Some orthodontists are sedating their adult patients, and any drug for psychosedation increases risk.
Regardless of the trend toward specialization, all dentists have the responsibility to ensure the welfare of the patient by determining the patient’s physical limitations, diagnosis, a.nd treatment2 It is considered negligence not to take a medical history. The objective is to determine the ability of the patient to withstand the procedure and to reason whether medical guidance is necessary. Renewed familiarity with standard signs and symptoms becomes a responsibility. Standard medical questionnaires ask about past hospitalization, physician’s care, medications taken, excessive bleeding, heart trouble, congenital heart lesions, heart murmur, high blood pressure, anemia, rheumatic fever, asthma, cough, diabetes, tuberculosis, hepatitis, jaundice, kidney disease, glaucoma, arthritis, stroke, epilepsy, psychiatric treatment, or sinus trouble. If women patients are pregnant, elective procedures should not be done during the first 3 months or the last month of pregnancy. ‘These conditions should not be merely questions on an office form. A positive response to any of them should trigger an alteration in your approach to a diagnosis or treatment plan. Otherwise, they should be eliminated from your list. Diabetes mellitus, a disorder of carbohydrate metabolism, results in more ketones being produced than eliminated., thus causing ketosis or acidosis. Stress increases glycemia and the tendency to acidosis and coma. Healing of wounds is usually slow. The history of rheumatic fever in a patient may suggest the use of prophylactic antibiotics during banding, bonding, or debanding. Patients who have been on corticosteroids may have adrenal insufficiency and cannot respond to stress. This could cause them to go into shock during long procedures. Patients may be taking steroids for rheumatoid arthritis, lupus erythematosis, and allergies. Cardiovascular and cerebrovascular disease cannot be discarded as long as the adult clientele increases. Dyspnea, edema, and undue fatigue must be watched for. Short procedures without stress are important, along with medical consultation. Examination of skin, eyes, fingers, neck, ankles, and respiratory rates can give clues to potential problems. The use of antisialogogues is contraindicated for patients who wear contact lenses, have lkidney disease, or have a history of glaucoma. The increase in adult patients in your practice further necessitates familiarity with emergency procedures such as cardiopulmonary resuscitation. Many office emergencies represent acute demonstrations of chronic diseases that may be revealed in a medical history. This is particularly true in those offices in which anesthesia is used or adjunct periodontal procedures are perforemd. The care or prevention of episodes may come from
580 Editorial
Am. 1. Oielod. November 1959
the systematic identification of a specific condition through the study of its distinguishing signs-a diagnosis. Bernard3 said: “When we begin to base our opinions upon medical fact, on inspiration, or on more or less vague intuition about things, we are outside of science and are exemplars of that fanciful method fraught with the greatest dangers in that the health and life of the patient turn upon the whims of an inspired ignormaus. True science teaches us to doubt and, in ignorance, refrain.” It is vital that futuristic orthodontists constantly re-evaluate their practices and prepare themselves for a certain amount of remodeling in light of the changing patient clientele. y keeping perspectives in mind and a total involvement with the understanding of the adult patient’s needs from a medical history, a thorough diagnosis and treatment plan can be accomplished with added care, caution, and respect. Wayne G. Watson EFERENCES !. Baum, A. T.: The rationale for esthetic orthodontic treatment in the adult patient. AM. J. DRTHOD. 57: 304-315, 1975. 2. Parsons, Jeffrey R.: The principles of diagnosis, Dent. Clin. North Am. pp. 3-23, January, 1974. 3. Birnholz, J. C.: Clinical diagnostic pearls, Flushing, N.Y., 1971, Medical Examination Publishing Company, p.7.
.Future shoe/c and adult orthodontics
F
uture shock’s influence on dentistry is revealed in the changing character of the orthodontic practice. Factors involved include a shift in the population balance with a decrease in the number of children, an increase in the number of orthodontists, and a growing proportion of adults seeking treatment. The general dentist is now attuned, through continuing education, to the orthodontic benefits of prevention, improved health, function, and esthetics for the adult and can refer more patients. Increased knowledge of the rewards derived through dentofacial corrections and their importance in social and business enterprise have whetted the appetite of the young adult for orthodontic treatment. With the onset of the American Association of Orthodontists’ new public relations program, we should see an increase in patients of all age groups into our offices. The balance is influenced somewhat by the structures of third party programs which have put treatment within reach of many mature persons. The futuristic orthodontist, therefore, must constantly remodel and expand his perception to meet this challenging development. Surveys of orthodontic offices indicate that the proportion of adult patients is increasing toward 25 percent of the average practice’s patient load. Most, if not all, of these surveys are subjective in nature, since few orthodontists have actually counted their active patients and placed them in age categories to determine the percentage of adults for each year in practice. Also, what age has been established to signify when an adolescent becomes an adult? Is it 16, 18, 21 years of age? Or should we use some other method? I suspect that the actual increase in the number of adults is less than the surveys indicate, but these surveys do give indications concerning the needs, desires, and direction from which new patients come to fill the void resulting from the decline in the child population. The term adult orthodontics requires clarification. The most significant factor for an orthodontic definition appears to involve the cessation of craniofacial growth. In some females this may be as early as 12 years of age, and in some males it may be as late as 25. Other methods of classification are related to individual state laws of maturity that specify “legal age” as the ability to vote or imbibe, ages 16 to 21, marriage, or self-support. These types of differentiation do not always address the physiologic, anatomic, or psychological fault line between children and adults. A near static dentofacial complex is characteristic of adult malocclusions. Other factors, such as changes in the periodontium, physiologic rebound, and psychological attitude, come with maturation and also vary from individual to individual. Consequently, it is beneficial to have some assessment of skeletal1 growth through a knowledge of family history and individual growth records related. to height, weight, cephalometric surveys, and hand-wrist films. Treatment of adult patients is often divided into categories of simple and complex without really defining goals. You have seen or heard the terms limited, partial, comooO2-9416/79/110577+04$00.40/0
0
1979 The C. V. Mosby
Co.
577
578
Editorial
Am. J.. &mod. November 1979
preliminary, and preventive used to suggest simple treatment. If your goals are to strive for excellence in treatment with ideal results, then I have seen few simple adult cases. By excellence and ideal, I mean esthetically and functionally pleasing to all involved, with improved health. This, in itself, will often necessitate the aid of general dentistry, periodontics, reconstructive procedures, and surgery. Harmony in a dynamic, functional occlusion, without interferences or irritations, even though these may manifest themselves only during times of distress, is paramount. The exchange, however, of esthetic improvement for potentially detrimental factors, such as bone loss, decalcification of crowns, root resorption, gingival deterioration, periodontal disease, emotional distress, discomfort, and TMJ focusing, may not be considered the most salubrious approach. All factors, including the patient’s personality, should be surveyed. From the foregoing discussion and your experience as a clinician, you know that, even in the correction of the most simple cross-bite, a functional shift usually is revealed, with its belated complexities. An apparent Class I occlusion may transform into a cusp-to-cusp Class II with an elongated or shortened tooth after a single-tooth cross-bite is corrected with a simple removable appliance. Or a “simple” posterior cross-bite correction may reveal some severe midlne discrepancies or mandibular shifts with related balancing interferences. Here lies the essence of the orthodontist’s reluctance to categorize which so-called “simple” problems should be delegated or performed by the general dentist. Other divisions of adult treatment are made according to the need for surgery, the presence of temporomandibular joint disturbances, the myofascial pain dysfunction syndrome, the degree of compromise necessary, periodontal rationale, the presence of a mutilated dentition, requirements for reconstructive or prosthetic dentistry, equilibration, esthetics, or splint therapy. Once categorized, this adult patient surge brings added responsibilities to all involved. Some orthodontists have opened separate offices or have segmented their existing offices for this adult phase of treatment. The adult orthodontic patient has priorities and problems quite unique from those of the adolescent orthodontic patient. There is no growth; treatment time for an ideal result is lengthened, with slower tooth movement; and increased lag time occurs between activations. We have bone aging with increased calcification and decreased cell structure and vascularity. The periodontium undergoes a decrease in vascularity and cell structure with siower healing. The temporomandibular joint is more sensitive to changes in its relationship with muscles and occlusion. There is less physiologic rebound from all systems. Systemic disorders are not uncommon along with interactions from the usual increased intake of medications. Without growth, there is little “settling in” of occlusion, and the patient’s expectations of results are usually higher than can be delivered. The fine tuning needed for a functional occlusion becomes magnified with the adult patient. The state of oral health is usually less than desired in adult orthodontic patients. They often exhibit a poor periodontium, restorations, and missing teeth. The great concern for an esthetic appliance sometimes hinders an expedient approach. This is not to say that alternative mechanotherapeutic systems cannot be designed for special cases with esthetic considerations and still produce improved dentofacial relationships.’ Factors that should flag down our enthusiasm toward quick starts are TMJ symptoms, unreasonable expectations concerning esthetics during treatment, expression of inability to cooperate in some phase of treatment, a need for a “perfect” final result, skeletal
promise,
Volume 16 Number 5
Editorial
579
disharmonies, a poor periodontium, a mutilated dentition, and local and systemic diseases. Orthodontics for adults poses a different challenge to the orthodontist, and all problems should be approached with a bit of caution and respect. An optimal treatment plan and goal can come only with a proper diagnosis derived from requesting adequate records that include medical and dental histories. The orthodontist faces increased risk and responsibility when treating adult patients. Orthodontic appointments can be long with a higher potential for patient distress. A larger percentage of adults are taking medications which have potential side effects. Some orthodontists are sedating their adult patients, and any drug for psychosedation increases risk.
Regardless of the trend toward specialization, all dentists have the responsibility to ensure the welfare of the patient by determining the patient’s physical limitations, diagnosis, a.nd treatment2 It is considered negligence not to take a medical history. The objective is to determine the ability of the patient to withstand the procedure and to reason whether medical guidance is necessary. Renewed familiarity with standard signs and symptoms becomes a responsibility. Standard medical questionnaires ask about past hospitalization, physician’s care, medications taken, excessive bleeding, heart trouble, congenital heart lesions, heart murmur, high blood pressure, anemia, rheumatic fever, asthma, cough, diabetes, tuberculosis, hepatitis, jaundice, kidney disease, glaucoma, arthritis, stroke, epilepsy, psychiatric treatment, or sinus trouble. If women patients are pregnant, elective procedures should not be done during the first 3 months or the last month of pregnancy. ‘These conditions should not be merely questions on an office form. A positive response to any of them should trigger an alteration in your approach to a diagnosis or treatment plan. Otherwise, they should be eliminated from your list. Diabetes mellitus, a disorder of carbohydrate metabolism, results in more ketones being produced than eliminated., thus causing ketosis or acidosis. Stress increases glycemia and the tendency to acidosis and coma. Healing of wounds is usually slow. The history of rheumatic fever in a patient may suggest the use of prophylactic antibiotics during banding, bonding, or debanding. Patients who have been on corticosteroids may have adrenal insufficiency and cannot respond to stress. This could cause them to go into shock during long procedures. Patients may be taking steroids for rheumatoid arthritis, lupus erythematosis, and allergies. Cardiovascular and cerebrovascular disease cannot be discarded as long as the adult clientele increases. Dyspnea, edema, and undue fatigue must be watched for. Short procedures without stress are important, along with medical consultation. Examination of skin, eyes, fingers, neck, ankles, and respiratory rates can give clues to potential problems. The use of antisialogogues is contraindicated for patients who wear contact lenses, have lkidney disease, or have a history of glaucoma. The increase in adult patients in your practice further necessitates familiarity with emergency procedures such as cardiopulmonary resuscitation. Many office emergencies represent acute demonstrations of chronic diseases that may be revealed in a medical history. This is particularly true in those offices in which anesthesia is used or adjunct periodontal procedures are perforemd. The care or prevention of episodes may come from
580 Editorial
Am. 1. Oielod. November 1959
the systematic identification of a specific condition through the study of its distinguishing signs-a diagnosis. Bernard3 said: “When we begin to base our opinions upon medical fact, on inspiration, or on more or less vague intuition about things, we are outside of science and are exemplars of that fanciful method fraught with the greatest dangers in that the health and life of the patient turn upon the whims of an inspired ignormaus. True science teaches us to doubt and, in ignorance, refrain.” It is vital that futuristic orthodontists constantly re-evaluate their practices and prepare themselves for a certain amount of remodeling in light of the changing patient clientele. y keeping perspectives in mind and a total involvement with the understanding of the adult patient’s needs from a medical history, a thorough diagnosis and treatment plan can be accomplished with added care, caution, and respect. Wayne G. Watson EFERENCES !. Baum, A. T.: The rationale for esthetic orthodontic treatment in the adult patient. AM. J. DRTHOD. 57: 304-315, 1975. 2. Parsons, Jeffrey R.: The principles of diagnosis, Dent. Clin. North Am. pp. 3-23, January, 1974. 3. Birnholz, J. C.: Clinical diagnostic pearls, Flushing, N.Y., 1971, Medical Examination Publishing Company, p.7.
