December 13, 2003
Orthodontic Jaw Wiring is a service I provide.  Providers of the OJW service are rare, be they orthodontists,
                        dentists or oral surgeons. Never before now has anyone established/created  a protocol for providing
                        this service. Naturally, would-be providers are concerned with legal and liability issues.  In addition
                        some studies would be useful such as the  short and long term effects of limiting the motion of the
                        jaw joints (the "TMJ").  I have had a few OJW patients say that they were first wired by an oral surgeon
                        because of trauma and it was then that they realized the potential of this method to control their weight.
                        The responses I have received from grateful patients reinforces for me that, overall, OJW is a beneficial
                        service although its detractors are rife. Recently, I encouraged a dentist in Colorado  to provide the
                        service to his patient, Jay Freeman, instead of having him come to New York and having me do it. The 
                        patient wrote the following:
                        (See The Second Forum on the Pros and Cons of OJW: responses to the letter of 9/22/03).
                        The chart entry for a recent patient of my own, AF illustrates the OJW approach. The accompanying
                        photo  documentation illustrates succinctly how OJW is done.

September 22, 2003

Orthodontic Jaw wiring for weight loss (OJW): A primer and protocol for orthodontists updated.

Dear Orthodontic Colleagues and Interested Others:

Almost two years have gone by since I sent my first correspondence to you regarding orthodontic jaw wiring (OJW) for the control of spiraling overweight. My thesis is that orthodontists are uniquely positioned and well-suited to provide this service
, much in the same way that they provide their services for patients who come to them for such problems as TMJ and sleep apnea.

You will note that the nationwide epidemic that is obesity is being brought to our attention by the media over and over again. You have only to look at your email each day and count the promotions that proliferate for weight loss products to understand the extent of the problem for the severely overweight who are seeking help to discipline their eating habits.

In addition, the demand for bariatric surgery is soaring in spite of the fact that the mortality rate is one in one-thousand.  I have no doubt that the mortality rate from bariatric surgery (four-hundred deaths last year) will continue to rise as more and more less-than-competent and non-certified surgeons enter the field to fill the ever-growing demands of the "morbidly" obese patient population. We have an opportunity, if not a mandate, to help some of these people before they reach the point of being morbidly obese.

Today it is even more urgent that we as orthodontists examine our role in providing this service to those who meet the criteria.  "We must do what we conceive to be the right thing and not bother our heads or burden our souls with whether we will be successful. Because if we don't do the right thing, we will be doing the wrong thing and we will just be a part of the disease and not a part of the cure." 
-- E. F. Schumacher 

I intend to promote and offer this service until my experiences tell me the service is either unwanted, harmful or ineffective, all of which are contrary to my extensive personal experience in providing this much sought-after service.

The question I posed in my previous letter was should we or should we not make our expertise and this service available, and provide a treatment modality which for some might be the treatment modality of last resort; where other treatment methods have resulted in failure or ended with death? I have answered that question for myself as result of years of experience providing this service. It is high time that the men and woman of good conscience in our field withdraw their heads from the proverbial sand and glimpse reality.

It is my conviction that orthodontists can and should make their skills available to those who are hopelessly out of control with their eating, and give them the right to choose from other methods including OJW. Toward that end I have developed a strict protocol for your consideration to help those who seek a modicum of control over their compulsive need to overeat, even if only for a short duration, and even if they tend to regain the weight. Bariatric surgery patients have a 20% failure rate among their numbers and a host of frightening side-effects,  yet it is still quite a popular choice and becoming more so. It is my contention that If OJW were more well known and more widely offered,
the overweight population would choose it as a treatment option.

The letter I sent to you resulted in an array of responses some of which were simple and forthright and addressed the desirability of the service in very simple terms. Other responses were totally unbalanced, and even some quite hostile to the idea as you can read in the Pros and Cons page that I posted. The "Pros and Cons" page is revealing in that colleagues who had the most objections seem to be the least knowledgeable and were the most opinionated.

With passing time, and the knowledge acquired from delivering patient-care in terms of OJW, I have gained some insights which I share with you now. Perhaps this retrospective will persuade others like me that OJW is a service they can offer with pride and dignity.

Herein, I will update you on some of the advances in the protocol I developed for delivering OJW for the control of compulsive overeating.

So to begin I direct your attention to the directory of all the pages on my website pertinent to OJW, a service I provide for
carefully selected candidates. Orthodontic Jaw wiring for weight loss.

The literature references at present:  Celia Giltinian, chief librarian at the American Association of Orthodontist's headquarters in St. Louis, was kind enough to compile a list of literature references that are related or pertinent to the subject.  This list is posted at: wiring for weight loss literature references.htm.

Improvements in providing the OJW service:
1. The Informed Consent (IC):  Note the information requested immediately prior to the IC text, which gives an immediate sense of everything you might want to know about the nature of their chief complaint. The patient is asked to initial it in three significant locations and the part regarding the danger of regurgitation has been highlighted in yellow.  The IC would be your first notice that treatment is desired. I make contact with the patient only when this document has reached my desk. Also new is the request for their dentist's and physician's name and contact number.

2. How to proceed once you have chosen OJW:  In this document I have specifically answered  questions regarding the details of what they will experience during and after the procedure.  The information permits the patient to become thoroughly familiar with procedure they will undergo, consequently, they tend to be much less apprehensive.   You may feel the need to examine your patients prior to the OJW visit. My experience indicates that by completing due diligence it is not necessary, especially since most of the patients come from long distances.

3. The
OJW "telephone" consultation memo. This  memo covers all the points that I would want my OJW patient to be aware of before their arrival at the office. Indeed, it is required that they forward it back to me by email to insure that they are aware of its contents. The memo assures me that the patient and I are on the same page so-to-speak. Indeed, it is required that they read it and sign it again in the office the day of their OJW.

4. In addition, the FAQ's of Orthodontic Jaw wiring will be helpful.

In retrospect it was impractical to think that a patient could actually
reapply a detached bracket themselves even if you gave them very explicit instructions and the supplies to do so. I am now confident that my colleagues anywhere in the country can be called upon to reattach a bracket. Furthermore, perfecting the method of bonding the brackets has resulted in virtually no detached brackets, not even on teeth with porcelain faces.

At present I encourage OJW patients to bring a significant other who will reapply the wiring which takes me two minutes to accomplish. The patient and the significant other are both shown how to do it. Staff members provide the training which is reviewed again by me when I place the wiring.  

When a patient comes alone from a distant city in another state, I  know that it is unlikely he or she will find another provider. Consequently, care must be given to train them how to properly place the wiring to bring the jaws together, in the same way that we orthodontists carefully train them to place elastics and power chain.

You can see the "TYPICAL FIRST VISIT" medical chart entry for an OJW patient. [GO TO IT].

I reserve Thursday 1:00pm after my last orthodontic patient to provide patient-care for OJW patients, however, the patients are asked to arrive two hours before their appointment to become comfortable in the office and review their documentation.

Once again I invite Dr. Jerrold, our profession's foremost legal commentator and orthodontist, and Jim Bowlin, legal counsel of the American Association of Orthodontists, as well as all others who received this note, to share their views on issues of liability and other pertinent matters of concern. Current and recent ortho graduate students, and indeed, all who receive this letter are cordially invited to share their views, comments or questions.  All responses will be posted to protocol report responses. Please indicate if you desire anonymity.
Please send me your name if you would be a provider of the OJW service.


Ted Rothstein, DDS, Ph.D.
NYU Post Grad Ortho Class of  1973.

"The gates of the Future are patrolled by a thousand guardians of the Past"  --Anon.


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