TED ROTHSTEIN, ORTHODONTIST ’73 AND OJW SERVICE PROVIDER and Founder of the the DPOJW
Round table participant Jay Freeman is the kind of pit-bull advocate any defendant would welcome on his legal team. He is a lawyer practicing in Colorado who found me through my website, http://www.drted.com/.
Like many other OJW patients it was no big deal that he would choose to come from such a distance, as I am the only practitioner in the country who has developed a unique protocol and Informed Consent, none of which heretofore existed, and offers the service with confidence. Consequently, Jay was set to come to Brooklyn to have his OJW.
In the course of completing due diligence I called Jay’s dentist, Ivan Naiman, who I eventually persuaded to do the OJW under my long-distance tutelage; the procedure went as planned and Jay is completing OJW with Dr. Naiman.
Jay is convinced that his needs are being addressed with OJW because his overeating has been temporarily brought under control. He considered and tried many other approaches and chose OJW, which he advocates because of his positive experience. I’m inviting Jay to join me at the Greater NY Dental meeting, November 28 – December 1, 2004,* when I present my table clinic on “The Dentist’s Role in the Treatment of Compulsive Overeating, OJW: A New Protocol.”
Jay’s experience is quite different from Pat’s, described below, whose circumstance comfortably fit into the framework described by Dr. Larry Jerrold, preeminent, well respected member of the orthodontic community, legal advisor and fellow OJW round table participant.
Jay’s story and Pat’s story are decidedly atypical. Let me tell you about the typical OJW patient before I tell you about Pat.
Seventy-five percent of OJW patients are female between the ages of 25 and 35. They eat compulsively and are unhappy about their inability to control their appetites. They are overweight to an alarming extent, generally 45-90 pounds beyond the healthy range for their height and body type, often meeting the clinical definition of obese; i.e., a body mass index (BMI) above 30 as would occur, for example, in a woman who is 5’5” and weighs more than 180 pounds, or a 6-foot man weighing more than 221 pounds. However, they are searching for a solution to relieve the anxiety and guilt each time they feel compelled to satisfy their need for oral fulfillment.
The need/compulsion/craving to eat when one is not hungry stands at the opposite end of the spectrum of eating disorders, which begin with anorexia (typically accompanied by bulimia), the eating disorder characterized by the "compulsion to not to eat". Both conditions present profound psychological and physiological significance for those who must bear them.
It is peculiar that as dentists we are cautioned in our text books and journals to be alert to the anorexic condition and to act to correct its ravages on the teeth. With OJW we have an opportunity to help compulsive overeaters overcome their problem, if only for the short term and sometimes even forever.
The gravest issues compulsive overeaters face are not social rejection and discrimination in the job market. Rather, the most serious consequences of compulsive overeating, and the ones most relevant to physicians, are soaring mortality from diabetes, hypertension, coronary heart disease and depression.
It is not surprising that many who suffer from this condition them are already under the care of both a physician and a psychotherapist by the time they find me. Further, it comes as no surprise that they have tried many of the extant diet and pharmaceutical regimes before considering OJW. One thing is certain: they dread of surgery of any kind.
They have contacted other dentists, orthodontists and oral surgeons who live closer to them, only to find that this group, by and large, is unwilling or unable to provide the OJW service I provide. I believe that is because no professional has devised a protocol for delivering the OJW service. Moreover, they have deep concerns with regard to insurance and liability issues.
I have become a "safe harbor" for some overweight people, even though they may have to incur additional travel and lodging expenses to visit my office and undergo the procedure. As standard practice, I complete comprehensive due diligence, and if a patient fits the profile, I accept them for OJW treatment and provide the service. The majority of them cannot, unfortunately, return to be examined and rewired, and since OJW has not as yet gained broad acceptance as a clinical treatment for obesity, and dentists are reluctant to assume responsibility for rewiring these patients, I must teach them how to rewire themselves in the same way I must teach my orthodontic patients to carry out even more complex maneuvers at home.
I encourage patients to follow the protocol I have outlined, viz., five weeks wired and five days unwired for exercises to prevent TMJ stiffening. I encourage them to email me and apprise me of their progress and challenges. Some, like Jay, write prolifically; others not at all. All patients have my home telephone number and can contact me at any time. To date, all who have written are glowing in their thanks and appreciation of the service I provided them. I am gratified by the warmth and genuine affection shown by these grateful patients.
I tell Pat's story, because it fits Dr. Jerrold's framework for accepting patients for OJW, i.e., when they are referred by a "primary" health care provider. Perhaps the “arch-tyranofoes” of OJW might agree.
Pat Wilson vanished off my radar three years ago after losing 70 pounds in eight months with OJW I had provided. When she contacted me in July 2004 she had regained all the weight plus an additional 20 pounds. She was depressed. Moreover, now she was experiencing hip and knee pain and was having difficulty walking, a side effect found in roughly 25% of obese patients.
"Pat, I think OJW is not aggressive enough for your present weight," I said, and suggested she visit George Ferzli, a specialist in bariatric surgery at Lutheran Medical Center in Brooklyn, New York. He was keen on promoting laparoscopic surgery (less invasive, and Medicaid reimbursed at $17,000) for morbid obesity as a credible alternative to full bariatric surgery. He referred her back to me, indicating that he would accept her if she lost thirty pounds prior to the lap band surgery. I agreed to rewire her.
I had her sign the Informed Consent - http://drted.com/index.html.bak2/Jaw%20wiring%20Informed%20Cconsent.htm, which indicates, among other things, that it is critical for her to understand OJW’s risks and drawbacks (among which is aspiration of vomitus); that I will evaluate the health of her gums, teeth and TMJ each time she returns at five-week intervals; and that success is fully achievable only with the help of a team of professionals, including her physician, her general dentist, a registered dietitian and possibly a psychotherapist to help her regain control over her compulsive eating.
I am comfortable providing OJW, because I have taken every medical and legal precaution a concerned and caring provider would take - i.e., appropriate selection and screening of patient's medical and dental history; appropriate examination and records; the giving and executing of an informed consent; contact with patient's other health care providers when indicated; instructions regarding care of appliance and 24-hour availability if problems should arise; and finally, follow-up care at specified intervals identical to the frequency with which I see all my orthodontic patients.
To me OJW is a powerful and elegantly simple procedure. Dr. Elliot Moscowitz would have to admit that the whole process of OJW bears a striking similarity to the delivery of orthodontic treatment. I am certain that the dental community has only to make it known to their patients that they offer the OJW service, and they will be surprised to see how favorably their patients respond. Such is the case of Brendon Batson an 18 year-old orthodontic patient coming to the end of his orthodontic treatment, who asked me to provide the service to him. It is his case that I will present at the GNYDM.
I never cease to be concerned about the issues that Larry Jerrold outlines: e.g., doing harm to Pat, my liability – (should harm come to her), and whether the Informed Consent she gave me was reasonably understood by her.
As he points out, I must be concerned about being perceived as "practicing within the scope of NY State's Dental Practice Act.” Larry concerns are valid, but I am bound by a greater contract, which is: to uphold the ideals of the Hippocratic Oath and the first dictate of all healthcare providers: first do no harm ("primum non nocere”), which has always been my primary focus and guiding principle.
Consequently, as I believe I adhere to these dictates, I continue to provide OJW service as I have the past ten years. No official of any agency has notified me that by providing OJW I have breached the scope of the NY Dental Practice Act. Indeed, the renewal of my dental license has never been challenged.
Moreover, I believe it is my duty and obligation to offer OJW because it is a treatment modality for obesity that has been neglected and has a rightful place in the spectrum of weight control options. All these factors act in concert to provide me a firm foundation for patient-care of the overweight using OJW.
Consequently, never for a moment have I ever believed that I was practicing outside the scope of my field, so the question remains: am I in fact and law practicing outside the scope? Perhaps someone wiser would like to answer that question.
My firm belief is that wiring a jaw is well within the scope of “dental practice,” in that it is done in a manner consistent with general dental and orthodontic skills, with the understanding that I am providing only the mechanical means to assist the patient’s goal without actually “treating the problem.” I am one component of the patient's health care team.
In no way do I believe that I am treating obesity, which as Dr. Moscowitz points out is a multifactorial problem. I have become part of the team that that is helping her to control her multifactorially caused overweight problem under control. I do believe strongly that I am compassionately and competently providing overweight patients like Pat and others like her a service for which they are grateful and willing to pay, and above all, which will make them healthier. Pat chose the procedure because she had not been as successful with the weight-loss procedures she had tried.
I chose to provide OJW for Pat because she fit the medical and dental criteria that I use when accepting a patient for OJW to control compulsive overeating. If the reader(s) will go to the website (http://drted.com/index.html.bak2/jaw_wiring.htm) they can see for themselves that the screening of patients is done with great care in order to address the other issues that Larry Jerrold raises.
Insurers need to recognize that OJW is not going away and it behooves them to assess risk and change the umbrella of coverage so that would-be providers are not unduly reluctant to provide the service.
To that end extensive efforts are being made to address the legal and liability issues related to the provision of OJW by “would-be OJW service provider(s)”. Liability issues should above all be addressed by the legal and insurance departments of the American Association of Orthodontists and the American Dental Association who provide coverage to many orthodontists and dentists.
Since 1996 my personal experience in providing the service has brought me an additional measure of professional satisfaction over and above that which I gratefully receive on a daily basis from the patients I treat for orthodontic and related problems.
The basis for this satisfaction comes principally from my feeling that the OJW service offers patients a "half-way house," so to speak, from a relentless foe (their appetite), which is literally killing them. In other words, these patients have or will acquire real physiological problems, unlike most of my orthodontic patients, whose predominant goals are to address the need to conform to society's handsome smile stereotype.
I am certain that if the protocol for providing the service is adhered to, the risk of doing harm is sufficiently low not to deter a prudent DDS or DMD from offering the service with proper attention to completing the due diligence that must be done whenever we as orthodontists accept any patient for treatment.
I am comforted in knowing that each time a new area of endeavor is pioneered, controversy is rife and should be welcomed and valued. As Anatole France once wrote, “When you hear the cannons run toward them.”
In a recent survey I conducted, I spoke with 15 oral surgeons comprising a total of 275 years practicing experience to inquire what their experience was in wiring jaws as a modality of treatment for patients with broken jaws and other pathologies. Not one of them could recount any morbidity/mortality related to the experience other than typical problems that accompany wiring. Death from aspiration of vomitus was unheard of among the group I sampled. Consequently, I believe that OJW is relatively safe when the strict protocol I have created for OJW is followed.
The issue of effectiveness of OJW is another major controversial issue, and one question is how to define success. Obese people want to look thinner. But academic obesity programs, said Dr. Gary Foster, the clinical director of the Weight and Eating Disorder program at the University of Pennsylvania, defines success as losing 5 to 10 percent of your weight. That, he says, is the amount of weight loss needed to improve blood pressure, blood glucose levels and cholesterol levels. People may still be fat, but healthier.
Others, like Dr. Jules Hirsch, an obesity researcher at Rockefeller University in New York, say there is another definition of success - getting rid of the weight problem for good. "At the end of the treatment, are they now like all kinds of other people who never had the problem of obesity?" Dr. Hirsch said. "By that definition, there has been nothing that works." **
If Medicare expands coverage to weight-loss modalities beyond bariatric surgery which now costs $30,000, it is going to need to know which procedures are effective and what those terms mean when it come to treating obesity: "... treatments, short of surgery, are not effective for long, obesity researchers indicate. Diet programs in academic centers - which are most likely to report results - find that most people lose 5 percent of their weight in six months, Dr. Foster said. A year later, a third of them regain the weight. And within five years, 80 to 100 percent gain back any weight they have lost, Dr. Foster said.
But most academic programs remain small and within academia, and most commercial programs do not conduct rigorous studies of their results, Dr. Foster said.
What would help would be large clinical trials asking how well weight loss programs do. It remains to be seen which methods will end up being reimbursed by Medicare. The article acknowledges the need for continued medical research, which the government will support financially since it has a vested interest in a solution. The implication for other insurers is meaningful since they tend to follow in Medicaid’s footsteps.
I believe doctors like Elliot Moscowitz, my erudite colleague and fellow alumni, who is well positioned in the Department of Orthodontics, should be alert to the possibilities of obtaining for the NYU dental facility, Medicaid funding for research on a potentially valuable treatment modality, for selected candidates aspiring to control their compulsive overeating by OJW, a treatment method that orthodontists are preeminently well-suited to provide. Weight control is now under sharp scrutiny because being overweight has become a national health epidemic and as of last year a 55 billion dollar industry receiving more attention with each passing day.
I also suggest to Elliot that he apply for federal research funding to run some controlled research projects and use the "null hypothesis" that OJW has no place in the gamut of treatment modalities now available to help compulsive overeaters restructure their lives.
Dr. Moscowitz seems aghast at the prospect that orthodontists might be part of a team that provides services to a segment of the overweight population, which is growing at the rate of 1% annually in the United States. Underlying his abhorrence of OJW, it seems to me, is the idea that it tarnishes the image of the "profession of orthodontics.”
I believe otherwise, and will continue to do my part to influence other members of the dental community to do the same. Indeed, interested readers who desire to become charter members of the DPOJW (Dentist Provider of Orthodontic Jaw Wiring) will receive free the online course I am preparing to present in January with certificate upon completion.***
Finally, I would like my colleagues to remember that 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”.
In conclusion, in the same way we discard archaic notions that guide how we deliver orthodontic treatment, and replace them with evidenced based facts, we must do no less for OJW.
Ps. To Jay Freeman, Dr. Larry Jerrold and esteemed colleague Elliot (who I admire and praise for his hard work on behalf of the NYU Post Graduate Orthodontic Department), my sincerest thanks for your frank and thoughtful comments and criticism. Please drop by my table clinic at the GNYDM entitled, “The Dentist’s Role in the Treatment of Compulsive Overeating, OJW: A New Protocol.”
*Specifically: Monday, November 29th, 2:00-4:00 Pm. Exhibit F rear,
3200 aisle, #9.
**NY Times, July 18, 2004, Weight Loss Field Awaits Change in Medicare Policy.
*** This offer is limited to the first 25 dentists who provide their name, telephone, office and email address.