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The Dental Professional’s Role in the Treatment of Morbid Obesity–None!
Responds to The Limits of Dentistry…see below.
Revised Jan. 14, 2013.
In response to Dr. Moskowitz’s editorial entitled “The Limits of Dentistry” published in the December 2004 issue of the NYS Dental Journal I offer counter-arguments that refute the editorialist’s rigid adherence to ideas that lack scientific basis. In addition, dentists should better understand the various categories of being overweight.
I share the editor’s opinion that dentists are reaching into “the province of some other health profession” when they provide jaw wiring (fixed) or removable (DDS System) to the “morbidly obese“.
Still, I wonder if he would not modify his position if a bariatric surgeon himself referred the patient to us to lose 40-50 pounds in preparation for the surgery he intended to do given its mortality rate of 1/300. Indeed, I have encountered this situtation.
The morbidly obese (BMI* ≥ 40 e.g., 5’8”, 260 pounds) are beyond the help of the dental profession. It is our role to help those who are not as yet morbidly obese who seek our services as one of their last resorts (BMI ≥30, e.g., 5’8” 190 pounds). I include in this group the “becoming overweight” whose BMI ranges between 27 and 29.9. Dentists who choose to provide their expertise will make their own judgment call when they select their patients.
Dentists are ideally positioned and well-suited to provide a chance of improving the health of the people of our nation who are battling the nation-wide obesity epidemic. Dentists would be remiss if they failed to offer their expertise.
Medicare and Medicaid have declared in 2004 that being overweight is a disease in itself. Moreover, the overweight population is increasing. M and M are now paying $30,000-$40,000 per surgical intervention. They are seeking safe and effective alternative methods that will ease a growing financial burden. Dentists can and should provide their services to the overweight. Moreover “Binge Eating” has now been listed as a distinct category in the The 5th edition of the Manual of Diagnostic Disorders (“DSM5″) written by the American Psychiatric Association.
Arguably on can state the OJW has gained prominence as an alternative treatment modality for this problem. To prove this just Google ‘OJW” and Orthodontic Jaw Wiring”.
I am optimistic that health insurance companies will someday provide benefits to their clients and those who provide the OJW service to their patients who are are good candidtes.
Bariatric surgeons have been made aware that dentists are now part of the healthcare team for the overweight and obese, and they are paying serious attention. Dentists are now equipped to provide the interceptive and prophylactic measures that can stay at least some obese from reaching that level of obesity that makes them candidates only for surgery. One of those measures is OJW.
Is Orthodontic Jaw Wiring (OJW) a service within the scope of dentistry as it applies to the overweight/obese whose BMI is ≥30, but<40?
Following is a direct quote from Dr. Milton Lawney, the Executive Secretary of the State Board of Dentistry, given to Dr. Ted Rothstein on Thursday, October 14, 2004 in answer to the above question: “It is not within the scope of dentistry to diagnose and treat independently the condition of obesity. Dental appliances aimed at weight loss may be prescribed if the condition is diagnosed by the proper authority.” — Interpretation of Article 133 § 6601 – Dr. Milton Lawney.
This means if a member of the medical community provides you or your patient with a note indicating that their patient is overweight/obese, and there are no contraindications to that patient commencing a “properly supervised” liquid diet, you may choose to provide that patient with orthodontic jaw wiring as stated in the OJW Informed Consent**. Of utmost importance is that you consider a variety of patient “selection criteria” beginning with for example, normal TM joint, no mobile teeth, and a host of others that you should be aware of.
Dr. Larry Jerrold, orthodontist, Interim Dean and Program Director of the Department of Orthodontics at Jacksonville University, and the foremost legal analyst in the field of risk management and legal liability holds that dentists/orthodontists who provide OJW may initiate such a service after the patient’s primary care provider has diagnosed the need for weight loss, and has given notice that the patient may choose a supervised liquid diet as the means of attaining their weight loss goals via OJW.
It is sufficient for the dental professional to provide OJW after the patient’s “doctor” has provided the dental professional with a note stating “the patient may proceed with a long-term, low-calorie liquid diet”.
Dentists have been glacially slow to recognize their position as rightful providers as part of a broad spectrum health care team that includes the physician as well psychotherapeutic counselors. However, recent articles in the Journals of the ADA and the AAO are showing evidence they are recognizing obesity in their offices.
I would like to quote D. Walter Cohen, Dean Emeritus, University of Pennsylvania said, “The problem with overeating starts with the mouth – and dentists are responsible for caring for the mouth”.
Other dental professionals may well use the DDS System to achieve a behavioral modification where weight loss has been recommended by a physician, a psychotherapist or registered dietician. Jaw wiring is a unique method of weight control chosen by thoughtful and intelligent persons who have carefully considered its pros and cons after experiencing and examining a myriad of other available options.
I am seriously bothered by Dr. Moskowitz’s rhetorical question: “Are members of our profession…prepared to oversee the medical needs of these individuals as they rapidly lose weight?” The answer is in the question posed. Medical problems are always overseen by the patient’s physician. The sole responsibility of the dental professional is to provide the appliances and periodically check the teeth, gums and jaw joints for the presence of disease or dysfunction. It is not the dentist’s role/responsibility to oversee, no less to guarantee, that the patients lose weight, as I have indicated in the OJW Informed Consent.***
It is the provider’s job to “fit/place” the appliance properly and then to examine the patient periodically to certify that the appliance itself has not caused any harm. I follow the exact same protocol when I treat my orthodontic patients. I am especially interested in possible stiffening of the TM joint. It is in this area that more research should be directed when utilizing the OJW protocol that I follow.
Dr. Moskowitz, is an orthodontist who casts a jaundiced view when it comes to the general dentist or orthodontist who wishes to provide services to the overweight. His opinion makes them feel uneasy, even fearful of providing a service that is safe and effective. I know its benefits because I have been providing this service for the past seven years and receiving in turn the happiness that comes with letters of delight from patients I have “treated,” even from some of those who regained some of the weight.
I say offer the service, choose your patients carefully, do the OJW methodically and be responsive to patient’s needs. Like in the movie Field of Dreams, the hero says: “Build it (a baseball field in an Iowa cornfield) and they will come”
I am confident that, in time, OJW will become a service that dentists provide with pleasure, and in return, receive the esteem of the citizens they serve. I have no doubt that there will never cease to be members of the dental and medical community who look upon OJW with disdain as was orthodontics looked upon before it earned its patina of social and therapeutic acceptance.
As the field of dentistry grows, its services modify and expand. Witness, the AAO has just expanded its insurance coverage to cover those orthodontists who provide intra-oral sleep appliances to patients who have been “properly diagnosed” with obstructive sleep apnea by their physician. Does Dr. Moskowitz ask what business is it of the orthodontist to be providing such a service? After all, as he puts it: ”We, as dentists, do not receive adequate predoctoral or postdoctoral training to address this complex matter.”
As for the editor’s comments regarding “death from the accidental swallowing of vomitus, that could result from a patient having his or her jaws wired shut,” I say let any dentist, oral surgeon or insurance company provide us with data that an event such as described has ever occurred except as the hypothetical argument offered by Dr. Moskowitz when he acknowledges jaw wiring as “….a time-honored procedure practiced by dentists in cases of trauma and for reconstruction or other forms of dentofacial surgery.”
I called fifteen oral surgeons representing one hundred and seventy-five years of oral surgical experience, and found that not one of them ever heard of such an event occurring in the population they treat. Furthermore, the patient is always trained in quick-release technique to prevent the unlikely occurrence of such an event.
The editor’s use of this hair-raising specter is a misguided argument. Dentists do not stop practicing dentistry just because there is risk of injury. Indeed, we become all the more careful to implement protective measures for our patients. The editor is preferential to throwing out the baby with the bath water.
Finally, I take serious objection the statements: (Referring to patients who had jaw surgery to enhance their looks): “These patients keep their weight off because of attitude changes, stemming largely from an improved self-image as a result of remarkable and often dramatic changes in their dentofacial appearance. “However (Referring to patients who had jaw wiring simply to lose weight): “… without behavioral changes (exercise, sensible life-long eating habits, etc.), there is little hope that such a procedure [OJW] would succeed.”
Not a single scientific study was ever done to support or deny either statement. On the other hand, nobody would deny that the achievement and maintenance of a “healthy” BMI, viz., 23-27, requires “exercise, sensible life-long eating habits, etc.”
If members of the dental profession step forward and recognize their responsibility to care for selected patients who meet the criteria of being overweight /obese, the leaders of the ADA and AAO will be obliged to clearly define the dental profession’s role in providing services to the overweight. Consequently, liability underwriters will take cognizance of changing attitudes and provide the necessary coverage to put their assured’s worries to rest in the same way they did for the providers of appliances for sleep apnea.
In the meantime, I urge members of the dental profession to see past the arguments posed by the editor and recognize that providing services to the overweight is a win-win situation. And even if some patients regain the weight they lost, they will never hold you responsible, as I have learned.
In conclusion, judging from the positive feedback I have received from my OJW patents over the years I have no misgiving about providing OJW to those who I deem to be good candidates (likely to succeed in reaching their OJW Goal weight.)
No patient has suffered any problems as result of OJW. The only failing of OJW is that failing to which is common to ALL weight loss methods i.e., regaining the lost weight.
Ted Rothstein, DDS, PhD
Specialist in Orthodontics for Adults and Children
Member American Association of Orthodontists
Founder DPOJW (Dentist Providers of Orthodontic Jaw Wiring)***
35 Remsen Street
Brooklyn, NY 11201
718 852 1551 Fx 718 852 1894
* Body Mass Index http://nhlbisupport.com/bmi/bmicalc.htm
January 5, 2005
The Limits of Dentistry
The State Dental Practice Act offers a definition of dentistry that does not include jaw wiring for the morbidly obese.
DENTISTS SHOULD HAVE an intuitive understanding of their role in any individual patient’s overall healthcare. If for some reason, they do not, they can refer to the New York State Dental Practice Act (§6601), which defines the practice of dentistry as follows:
…”diagnosing, treating, operating, or prescribing for any disease, pain, injury, deformity, or physical condition of the oral and maxillofacial area related to restoring and maintaining dental health. The practice of dentistry includes the prescribing and fabrication of dental prostheses and appliances. The practice of dentistry may include performing physical evaluations in conjunction with the provision of dental treatment.”
If we were to use the Dental Practice Act as a fundamental resource—and I believe that we should—then the dentist’s role in treating morbidly obese patients via jaw wiring (orthodontic or otherwise) needs to be viewed as an outlandish attempt to get into the province of some other health profession.
There are many causes for obesity. Cultural, hormonal, psychological, physical, biochemical, socio-economical and other factors play a role in determining an individual’s ability to control his or her weight. We, as dentists, do not receive adequate predoctoral or postdoctoral training to address this complex matter. Furthermore, the dentist’s liability in this area appears to be limitless. I can think of many potentially adverse reactions, including death from the accidental swallowing of vomitus, that could result from a patient having his or her jaws wired shut.
For many obese individuals, the loss of significant weight must be accompanied by close medical attention and the monitoring of vital functions. Are members of our profession who practice jaw wiring for obese patients prepared to oversee the medical need of these individuals as they rapidly lose weight?
Jaw wiring is a time-honored procedure practiced by dentists in cases of trauma, and for reconstruction or other forms of dentofacial surgery. We are trained to do this for a specific purpose; and it is well within the purview of dental practice. Jaw wiring to prevent someone from eating could, no doubt, “jump start” a diet. However, without behavioral changes (exercise, sensible life-long eating habits, etc.), there is little hope that such a procedure would succeed. The positive that we see, for example, in some pre-operative obese patients who undergo orthognathic surgery (and having intermaxillary fixation) are due to factors other than merely the fact that they had their jaws wired for a specific period of time. These patients keep their weight off because of attitude changes, stemming largely from an improved self-image as a result of remarkable and often dramatic changes in their dentofacial appearance. This is an entirely different matter from jaw wiring performed solely to cause a patient to lose weight.
Dentists are also engaged in the construction of other intra-oral appliances intended to result in weight loss as a consequence of the patient eating more slowly and, perhaps, less, than he or she would without these appliances. NYSDJ readers who are contemplating offering the placement of such intraoral appliances or engaging in other weight-loss protocols for patients are strongly urged to read Margaret Surowka Rossi’s legal column, “Don’t Be a Loser”, in this issue. It contains an important and urgent message to all NYSDA members.
Lastly, I would suspect that our malpractice carriers and, quite possibly, the State Education Department would take a dim view of this irresponsible and uncharted attempt by dentists to include jaw wiring and other procedures for the treatment of the morbidly obese under the auspices and interpretation of the letter and spirit of our current dental laws.
Dentists who continue this practice of jaw wiring for the morbidly obese do so at great risk for themselves and their patients.
Elliot Moskowitz D.D.S M.Sd.
Editor NYSDJ ● December 2004
DON’T BE A LOSER
In your zeal to help your patient’s manage their weight, you could be putting your dental license in jeopardy
Margaret Surowka Rossi, J.D., NYSDA General Counsel
AS I FLIPPED THROUGH THE PAGES of a weekly magazine, I came across an advertisement for a new weight – loss method. The ad stated: “Want to Lose Weight? Call Your Dentist.” The item being marketed is an oral retainer – like appliance that when worn, apparently, forces the individual to eat more slowly, thereby leading the person to eat less and lose weight. The company that created the device has been aggressively marketing it to dentists, urging them to become “certified” to prescribe the device for patients.
There may be several hundred such “certified” dentists in New York State. Before you consider joining their rank, beware, and understand the limits of the New York State Dental Practice Act. Otherwise, in helping your patients to lose weight, you could be jeopardizing your dental license and facing serious liability risks.
In New York State, the practice of dentistry is defined in Education Law § 6601 as follows:
The practice of the profession of dentistry is defined as diagnosing, treating, operating, or prescribing for any disease, pain, injury, deformity, or physical condition of the oral and maxillofacial area related to restoring and maintaining dental health. The practice of dentistry includes the prescribing and fabrication of dental prostheses and appliances. The practice of dentistry may include performing physical evaluations in conjunction with the provision of dental treatment.”
The state dental practice does not give dentists unfettered license to treat all physical maladies and conditions; whatever you are doing must relate to restoring and maintaining dental health.
In recent months there have been articles in several dental journals warning dentists that if they do offer this service or device to their patients, it may be considered outside the practice of dentistry in the particular state and, therefore, may not be covered by malpractice insurance.
Since the purpose of these new devices is solely for weight loss, NYSDA is of the opinion that they are not within the scope of the practice of dentistry as set forth in Education Law § 6601. If the patient’s medical condition is properly diagnosed by s physician and an appropriate plan of treatment is provided, including a prescription for an oral appliance, a dentist could fit and fabricate the appliance. The danger is in the dentist diagnosing, treating and monitoring the medical condition of obesity or other weight-related condition. The treatment of any weight condition could result in many adverse consequences beyond dental health, which may not be covered by a dentist’s malpractice insurance.
NYSDA requested that the New York State Education Department issue clear guidance regarding the issue. The department confirmed the Association’s opinion and issued a letter stating the following:
“If the purpose of the dental appliance is solely to treat a diet or weight loss condition, it would appear that this would not be within the scope of practice of dentistry as defined in New York. Nonetheless, if the condition is properly diagnosed and a lawful treatment plan is prescribed by a professional authorized to do so, the fitting and attaching of the appliance could very well have dental health implications, and a dentist may be involved in those services.”
Coincidentally, the Georgia State Dental Board has issued a similar ruling under its dental practice act stating: “making impressions for the fabrication of the appliance, and evaluating the interaction of the appliance with the oral cavity [is within the scope of a dentist’s practice, but] evaluating whether a patient is a suitable candidate for the appliance, or monitoring the overall health of a patient fitted with the appliance is not within a dentist’s scope of practice.” (Action: The Journal of the Georgia Dental Association, October 2004:1)
There are other methods for weight loss that are being marketed by dentists to which the same rationale would apply, for instance, orthodontic jaw wiring. As with the retainer-like appliance, jaw wiring involves the oral-maxillofacial area. But when the method is used for the purpose of weight loss, it would appear to fall outside the scope of the practice of dentistry.
There is no debate about dentistry’s role in the overall health of patients. The issue is finding the dentist’s role within the scope of the dental practice act. Certainly, educating your patient’s about the benefits of good nutrition is part of that role. Treating obesity with an oral device, however, opens up potential liability for the well-intentioned dentist.
Consider, for example, the possible consequences and civil liability that might result from prescribing such a device to an individual with an eating disorder, like anorexia. That is the exact scenario presented to a dentist “certified” to prescribe this oral device in a television interview. Of course, the dentist said the device would never be made for an individual with anorexia, but, therein, lies the danger. That is a diagnosis that must be made by a physician, and any treatment for the disorder needs to be closely monitored.
Weight loss is an issue that involves a multitude of factors—behavioral, psychological, physiological—that dentists are not adequately trained to monitor. Another issue that dentists must be mindful of in this respect is the use of any certification from a company. This could be misleading to the public, as it may lead someone to believe, erroneously, that such certification is sanctioned by the state.
Dentists must not overreach the scope of practice and risk losing their license in an attempt to help patients lose weight. Although the practice of dentistry is constantly evolving, with new products and procedures aimed at improving patients’ dental overall health, dental professionals must always be cognizant of the limits and scope of the profession. The material contained in this article in informational only and does not constitute legal advice.