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Editorial

Remember When Orthodontics Was Fun?  Hold that Thought.

I am fearful when I see people substituting fear for reason.
- Klaatu
The Day The Earth Stood Still - 1951

Depending on one’s age, there are moments in time that define one’s generation.  I’m young enough to have been born after the shooting of President Kennedy, but vividly recall adults asking one another ‘Where were you when JFK was shot?’ Fully entrenched in my psyche, it was enough for me to convince my orthodontic classmate Lorne Kamelchuk to ditch the latter hours of the 1998 AAO and travel to The Texas School Book Depository atop the infamous Grassy Knoll.  Better hours were never spent, I assure you that.

There are other moments in history that define the last of the Baby Boomer generation; Woodstock, the shooting of John Lennon, Gulf Wars I and II.  Until recently, I used to think that the attack on the World Trade Center in Manhattan was the most poignant moment in our collective lifetimes.  ‘Where were you when you heard about the Twin Towers’?  Enough time has passed to make the deaths of 2,606 innocent souls the stuff of casual cocktail conversation. 

While the destruction of the Twin Towers was horrific, it was a singular, localized, controllable event. September 11, 2001 was the evil offspring of humanity’s hatred and intolerance of itself.   A finite number of people were directly and indirectly affected but in relatively short order, life got back to normal.  Soon after the reality of what had just occurred on American soil, then NYC mayor Rudy Giuliani vowed ‘ We’re not only going to rebuild, we’re going to come out of this stronger than we were before’.  And they did just that. 

Fast forward to the Ides of March, 2020, the day that the effects of coronavirus COVID-19 hit with full fury. International Borders were closed.  Organized sports, schools and any degree of familiar socialization were all locked down. The terms self-isolation, quarantine and physical distancing became part of the vernacular. The practice of dentistry was relegated to emergency care only, and then, only if providers were outfitted with previously unheard of levels of personal protective equipment.  It is past the middle of May and just now there is talk of judiciously lifting a select number of restrictions.  Dentistry, alas, is not on the list.

As bad as 9/11 was, COVID-19 is arguably worse. This global, indiscriminate virus has killed, at the time of this writing, 313,626 people worldwide.   It’s neither localized nor remote. It’s in our own backyard and one would have to travel pretty far to find someone unaffected by its wrath.   It will be impossible to ‘rebuild and come out stronger’ this time around.  This virus has and will change the way we live, work and play forever.  Corona literally means crown, and this pandemic is the king of historical events to mark a generation.

It has become clear that the practice of dentistry will never be the same. While regulations that affect how dentistry is delivered have been ramping up steadily for years, COVID-19 slammed regulation into hyperdrive in an effort to protect the public from potential life-threatening exposure. The new standard is not universal precaution, it’s ‘mini-hospital’ meaning enclosed operatories, negative pressure and unprecedented levels of disinfection between patients.   All well and good, sort of, for the implant dentist, but what has all this got to do with the relatively clean practice of orthodontics?   Wasn’t it our innate aversion to bodily fluids that drove us to the profession in the first place?

The reality is that the regulations that impact the profession of dentistry will centre on best practice precautionary principles that are based more in risk-management than in application of science. This practice is not new and the point here is not to criticize the regulators who find themselves in an impossibly difficult position.  The regulators are fulfilling their mandate to protect the public and we practitioners must abide by that mandate.   The problem in the case of COVID-19 is that the resultant regulations may have made the practice of orthodontics all but impossible to deliver. 

One doesn’t have to think too hard to recall instances when orthodontists have had to adapt to newly enacted dental regulations in short order. A mere twenty four months ago, dry heat sterilizers were deemed obsolete, instruments needed to be fully separated when in an autoclave and office manuals became something more than dusty old binders sitting on a shelf.   Looking back, the changes we had to make then seem like a walk in the park compared to what is coming down the pipe.

There are three challenges of which we are compelled to address, that being, personal protective equipment (PPEs), physical distancing within the office and the control of aerosols.   Of the three, physical distancing is the least worrisome; restrictions are bound to ease once some degree of immunity takes hold.   Similarly, while PPE supply, cost and application are all challenges that must be addressed, the answers will work themselves smoothly into everyday practice in relatively short order.  The biggie is the control of aerosols.   Most orthodontic practices are based in open concept design that precludes the use of a hand piece or an air water syringe.  To expect orthodontists to convert their open concept clinics into mini-hospitals at their expense in order to reopen may be just beyond the limits of accommodation.  There is no quick solution to this problem.  Accommodation of this magnitude involves time, money and a total revision in the manner in which orthodontic care is delivered.

It is abundantly clear that solid clinical research is the solution to effective and safe aerosol management for our patients, staff and families.  How far do aerosols travel?  How long does the virus live?  How truly transmissible is COVID-19 in the orthodontic office?  Only when there is indisputable accepted evidence available to reassure the regulators and the public that orthodontic practice is safe will any amendments to the regulations be made.   It will take a concerted effort but the answers will come in time.

But will they come too late?

Stay safe,
Jimmy P 

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