What does it mean to practice evidence-based medicine or orthodontics? Among other things, it means that we must document what we do and how well we do it. In his editorial in the October 2000 issue of The Angle Orthodontist, Editor Bob Isaacson makes some important and timelycomments on the standards of orthodontic care. He asks, "Should we passively allow the consumer to establish the standards of care for orthodontists?" and then answers, "It is important for us to document what we consider acceptable."
The American Association of Orthodontists (AAO) took some steps in this direction with the development and adoption of the Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics in 1996. Whereas this document does not establish standards of care, it does list treatment goals as "optimum dentofacial function, health, stabilityand esthetics," and then lists the following positiveoutcomes of treatment:
1. Satisfaction of the patient's chief complaint.
2. Well-aligned teeth.
3. Good or improved occlusal function.
4. Good or improved dental facial esthetics.
5. Good or improved environment for dentofacial development.
6. Desirable modification of the size, shape, and position of the jaws.
7. Stability of treatment results.
8. Good or improved dental and periodontal health.
The critical issue of how to measure these characteristicsis the next question. Many systems of measurement that use indices of malocclusion have been developed over the years, and the AAO Foundation did fund some studies in 1996 to evaluate some of these systems. Some of the methods such as the Peer Assessment Ratio (PAR) Index 1 and the Index of Orthodontic Treatment Need (IOTN)2 measure various aspects of dental alignment and occlusion, but many important parameters, such as facial esthetics and stability of results, are not covered. The American Board of Orthodontics 3 published a method of evaluating dental casts by using a very detailed system of measurement, although it does not cover facial esthetics or cephalometric values. Andrews 4 published another method of cast evaluation that included a detailed scoring system, but statistics on these studies have not been published. Any of these methods could also be used to evaluate stability if suitable long-term samples were available, but that has not happened yet. Many long-term evaluations were done primarily by using the Irregularity Index of Little,5 concentrating on lower incisor alignment.
A further step was the call for and subsequent funding by the AAO Foundation for studies on the outcomes of orthodontic treatment. Such studies require the very challenging task of gathering unbiased samples of treatment records from various treatment providers and applying appropriate measuring systems. This would not directly set the standards, but it could provide the basis for starting the process. One indication of the difficulty of this task is that the call was made in 1997, but by the end of 2000 nothing had appeared in the literature from these studies. The AAO Foundation does not plan to make additional special funding available for such studies at this time. If standards of orthodontic care are to be established, the AAO, the ABO, and the AAOF are in the best positions to take on the job. It is a difficult task, and some would say that it is impossible or even dangerous. Yet measuring what we do and letting the public know what we find is the way to provide evidence of our claims of providing excellent orthodontic care.