It may be worth considering restraint before the genie leaves the bottle

Imagine that you decided to attend a prestigious conference including clinicians from across the globe. You had a seat, and a charismatic speaker stepped onto the stage in a crowded lecture hall. They began their presentation with unsubstantiated claims and showed several cases with orthodontic treatment results that were clearly suboptimal. Despite the questionable occlusal results shown in the post-treatment photographs for nearly every case, their charming personality captivated some of the audience. Their persuasive style overshadowed the questionable quality of the case finishes shown, attracting countless followers.

The “patient was happy” reductionist sentiment has frequently been used to imply the pinnacle of treatment satisfaction for orthodontic treatment results in the past few years. However, the question arises: “Does the patient satisfaction metric encompass the full scope of comprehensive orthodontic treatment results?” Orthodontics is a value-driven specialty that encompasses tooth alignment and addresses skeletal, dental, and soft tissue components. The plan of treating the patient to “satisfaction” is a minimal outcome, barely a step above dissatisfaction or, worse, in some cases, litigation potential. While ensuring patient satisfaction is imperative, the treatment plan should address additional facets that the patient may not have been aware of or recognized, yet would provide significant benefit. This troubling trend is sometimes perpetuated by practitioners whose actions may not align with the patient’s best interest but, rather, with the provider’s goals. It is a disservice to the specialty when treatment modalities are selected based on the provider’s preferences rather than the patient’s needs.

Utilizing patient contentment as a blanket defense for suboptimal care or treatment plans undermines the specialty’s integrity and trivializes the nuanced and complex nature of individualized patient care. When a patient asks for a limited course of orthodontic treatment or “alignment only,” the practitioner offers the comprehensive treatment, presents its additional benefits, and signs an informed consent that declines the best or most reasonable option does not apply here. In essence, there will be those patients who choose early debonding despite being informed of the benefits of treatment continuation. The key here is obtaining informed consent and thorough documentation. The problem may arise only when the patient understands the benefits, and you can do better and don’t, or you justify an occlusal feature left unaddressed with the term, “but the patient was happy.”

In a world brimming with continuous advancements, orthodontists must still follow the bedrock of evidence-based science. Belief in the efficacy of upper and lower arch expansion appliances to achieve a significant increase in nasal capacity, enhancement of mid-facial development, alteration of swallowing patterns, and direction of facial growth is currently more mythological than evidence-based. Occasionally, novel concepts are proposed, making researchers busy for years. However, sometimes what is deemed to be “sufficient evidence” is still lacking. How much longer are we expected to wait for it to be proven or debunked?

Expansion plays a pivotal role in correcting transverse discrepancies, yet its implementation, particularly in children under six, demands careful consideration. Guided by thorough scientific research and clinical practice, it is evident that such early intervention is seldom necessary in young children.^[1] The malleability of the pediatric craniofacial structure does allow for intervention, but the imperative to avoid unnecessary intervention must guide the application of expansion techniques. Given the nuanced and complex nature of conditions such as obstructive sleep apnea (OSA), expansion for the treatment or prevention of OSA is rarely warranted or impactful alone. Has anyone considered the feasibility of a sleep medicine specialist conducting a study on the orthodontic ramifications of mandibular expansion? If not, what justifies the sole role of an orthodontist in managing OSA? It is worth mentioning that the expert panel convened at the recent American Academy of Dental Sleep Medicine conference reached a consensus that there is insufficient evidence to support the use of expansion to cure OSA in both adult and pediatric patients.^[2] Furthermore, the white paper on OSA by the American Association of Orthodontists emphasized a multi-disciplinary approach to the management of OSA.^[3] In cases in which OSA is suspected, the orthodontist’s role pivots from being a primary treatment provider to screening and referral to a certified sleep medicine specialist (CSMS). While the potential benefits of maxillary expansion for addressing transverse deficiency are recognized, a conservative approach aligned with what is suitable for the patient’s age is paramount.

To quote the words of Lysle Johnston, “When everything works well enough to pay the bills, orthodontic practice becomes an interesting test of personal ethics and resolve.”^[4] The use of expansion as a management alternative for OSA should not be implemented by an orthodontist unless specifically recommended by a CSMS following diagnostic confirmation through the gold standard of overnight sleep polysomnography or an out-of-center sleep test.^[3] The CSMS may also suggest a mandibular advancement appliance (MAA), at which point the orthodontist’s role comes into play only after receiving a referral. It is important to understand that MAAs are a treatment approach for OSA rather than a definitive cure. Therefore, the patient may need to wear the appliance indefinitely, which comes with associated costs. As we understand it, a light continuous force over a prolonged duration is regarded as the most effective method for tooth movement. Since MAA appliances are tooth-borne, they exert forces on the teeth that can eventually move them with long-term wear. An edge-to-edge bite or anterior crossbite is a common sequela of long-term MAA use.^[5] Their use entails acknowledging potential harm in pursuit of greater benefit.

Sometimes, the benefits of improved sleep outweigh the risks of long-term changes in occlusion. Suppose the patient is open to alternative options, such as continuous positive airway pressure, upper airway stimulation treatment, or maxillomandibular advancement. In that case, these may represent more ideal options.^[6] The conversation around maxillary expansion, particularly in young children, remains an ongoing dialogue within the field, melding caution with possibility, and science with clinical judgment. For now, collective wisdom leans toward restraint, using expansion primarily after age six as evidence suggests greater predictability and efficacy. Adopting a “watchful waiting” strategy for young children may be wiser, with intervention reserved for particular cases.^[7] While the urge to treat may stem from a desire to help, resisting and observing changes when in doubt is better. Although it may seem stern, treatment should not be seen as an opportunity to distinguish oneself from other orthodontists by branding an “airway-friendly” practice solely for profit.

The anecdotal assertion of “it works in my hands” without due consideration of existing scientific evidence should be disregarded. Denied facts are still facts. As practitioners committed to evidence-based care, orthodontists must balance early intervention and its necessity. The enthusiasm for proactive treatment must not overshadow the foundational principle that intervention should be backed by solid empirical evidence and clear clinical indications.

As we face the winds of change, let us be the steady and reliable lighthouse guiding our patients safely to shore. The foundation of evidence is our best defense against the storms of pseudoscience. Let us sail forward with caution, ensuring that each innovation we adopt has been navigated through the rigors of scientific research. In doing so, we preserve the integrity of orthodontics and ensure the health and well-being of those we are privileged to serve. Our commitment to our patients is not only to straighten teeth but also to uphold the principles of medical ethics: Offering safe, effective, and scientifically sound treatment. The recent, concerning trend toward unnecessary treatment of both children and adults brings us perilously close to a line that should not be crossed. We must resist the temptation to adopt unnecessary treatment protocols without the necessary validation. Let us prioritize a science-friendly approach rather than adopting the frequently used marketing gimmick, “airway-friendly.”