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Do-it-yourself impressions and clear retainers: A fairy tale

2016; Elsevier BV; Volume: 150; Issue: 2 Linguagem: Inglês

10.1016/j.ajodo.2016.06.010

1097-6752

Rolf G. Behrents,

Dental Education, Practice, Research

A tremendous amount of information available to the public suggests that do-it-yourself (DIY) dentistry is something to be considered. In general terms, this includes DIY extractions, partial and full dentures, crowns, and bridges; with regard to orthodontics in particular, there are DIY aligners, gap bands, and clear retainers. All that is required is a consumer who is a DIY enthusiast and who is willing to pay a fee and then put something in his or her mouth and hope for the best. By definition, these DIY products and services are not provided by licensed dentists or specialists and are not considered consistent with the dental practice acts of all 50 states. Most of all, they do not generally consider the safety, effectiveness, and true costs of the procedures. Recently, much has appeared in the popular media about the accomplishments of Amos Dudley.1Dudley A. Orthoprint, or how I open-sourced my face.2016http://amosdudley.com/weblog/OrthoGoogle Scholar Mr Dudley is a young college student studying digital design at the New Jersey Institute of Technology. Unhappy with the arrangement of his teeth, he developed a rather ingenious DIY system for straightening his maxillary teeth. He took his own impressions and then used available technology and software to produce a series of clear aligners. In doing so, he had access to a high-quality laser scanner, a 3-dimensional printer, and a thermoplastic vacuum-forming machine, along with computer-aided design and animation software. He found that his DIY treatment was successful, and he spent only about $60 for the materials to construct the devices. Reflecting on his experience, he admitted that he did not have the knowledge and skills of a trained orthodontist nor was he interested in making aligners for other people. He also indicated that people should not attempt the same procedure themselves. Narrowing this discussion to clear retainers, the DIY opportunity is simple. A consumer contacts a company that supplies an at-home impression kit, usually containing impression material, plastic trays, and instructions; a Web site is often available for video instructions. The consumer takes his own impressions and sends them off to the company, eventually receiving the clear retainers and a plastic storage case; the cost is generally about $100 to $150 for a set (maxillary and mandibular) of clear retainers. This all seems fairly simple, but simple things are not always easy. For example, it is a simple matter to quit smoking; you just stop. But it is not easy to do so. In the case of treatments that involve taking DIY impressions, the question to be raised is whether DIY enthusiasts can take impressions with sufficient quality for producing retainers. Anecdotal evidence argues that most cannot. On the basis of educational experience, one thing students learn during 4 years of dental school is how to take dental impressions of reasonable quality for the intended purpose. In the 2 to 3 years of orthodontic training, students learn to produce higher-quality impressions for display and appliance construction. It is difficult to believe that novices can perform at the same level, no matter their level of enthusiasm for doing so. Also, reports are starting to emerge demonstrating that the DIY impression experience does not always produce the desired appliance. In the example shown here, a young patient was treated successfully and was given clear retainers for retention. Later, the patient reported that “the dog ate the retainers”; he called his practitioner's office and was told that the cost of replacement would be $195. The patient decided to seek a DIY alternative on the Internet. Subsequently, he paid a $125 fee and took his own impressions, and the company provided a new set of clear retainers (Fig). Although the maxillary retainer fit the teeth fairly well, it did not extend to the second molars; this would allow those teeth to supererupt and affect the occlusion. The mandibular retainer did not fit well at all (Fig, B). The patient tried unsuccessfully to bite it into place, but that made his teeth hurt, so he discontinued wearing it altogether. Defects in the retainers were most likely the result of a lack of extension of the maxillary impression and distortion of the mandibular impression (movement of the tray during the setting of the impression material, removing the impression before the material was set, pulling the impression material out of the tray during withdrawal, and so on). Realizing that the DIY clear retainers would not be adequate to retain his teeth, the patient finally contacted the original orthodontist for replacements. New retainers were made, and they are now being worn appropriately—and being kept away from the family dog when not in use. The moral of this story is that good treatment costs money, and bad treatment costs money, but bad treatment will cost even more if it must be redone. Patients and society cannot afford bad treatment. There is not much information in the literature about the quality of DIY impressions. There is a small amount of literature about the success of DIY ear-mold impressions to be used in fabricating custom hearing protection devices or audio earbuds; the general conclusion of this body of work is that the DIY impressions are inadequate when compared with those made by professionals. In orthodontics, I am aware of only 1 study that relates to the same question. An article by Abel et al2Abel Y. Nelson S. Amberman B.D. Hans M.G. Comparing orthodontic treatment outcomes between orthodontists and general dentists with the ABO index.Am J Orthod Dentofacial Orthop. 2004; 126: 544-548Abstract Full Text Full Text PDF Scopus (27) Google Scholar published in 2004 described a DIY impression process used to collect a sample. The investigators provided impression materials and instructions to 255 tenth graders in Cuyahoga County, Ohio. Impressions were made, and a total of 196 impressions were judged to be useful in the study. The intention of the study was to measure various aspects of malocclusions; the impressions would not be used for appliance construction. In the latter case, the quality of the impressions would be very important, more so than in the former. Because of the dearth of evidence substantiating that DIY impressions are good enough to produce high-quality retainers, at this point it might be concluded that the DIY impression and retainer experience is merely a standard gamble. Fortunately, the amount of the gamble is relatively small; in the case above, the amount of the gamble was $70 ($195 – $125), but the odds of success were not known at the time. Were the odds of obtaining a usable impression 10% or 90%? That might make a difference for those shopping for the best opportunity at the lowest risk. So for now, the DIY experience for clear retainers can only be considered a fairy tale, and although it is true that “fairy tales can come true, it can happen to you…”—on the other hand, maybe not. In the future, we will know more; studies are currently underway. The possibilities and probabilities of success will be qualified and quantified, and that will be important for DIY enthusiasts to consider. For now, the public should adopt a more skeptical approach instead of demonstrating a willingness to believe in something or someone without reasonable evidence or knowledge (ie, credulity). And, certainly the most gullible DIY enthusiasts (the young) need some assistance and guidance in making the DIY decision. In addition to the possibility of a DIY impression experience being a waste of money and time, are there other harms to be considered? The answer is easily found in the dental literature but seldom described in DIY informational disclosures. With regard to taking impressions, various unpleasant things can occur, including gagging, vomiting, sweating, panic, and crying. Less common but more serious problems include ingesting or inhaling the impression material. Swallowing a small amount of impression material is usually not a problem; the material passes through the esophagus into the stomach and out through the intestines without significant problems, usually within a week. A large amount of the material, however, might become lodged in the intestines and require surgery to be removed. If inhaled, small pieces of the impression material could lodge anywhere from the trachea to the smaller bronchi and contribute to pulmonary abscesses and pneumonia—or even death if the blockage is large. If the impression material is not set when it is inhaled, it can become lodged in the bronchial tree, forming an impression of the area involved. Signs and symptoms of foreign body aspiration can include choking, gagging, coughing, labored breathing, signs of distress, high-pitched wheezing upon inspiration (stridor), reduction or absence of the air entry, and asymmetrical chest movements. According to the literature, all aspirated foreign materials and some types of ingested items require the patient to be immediately referred to a physician for assessment; the persons need to be escorted and may be hospitalized, depending on the situation. Aspiration could require bronchoscopy and surgery. One final consideration. This type of DIY opportunity is particularly disturbing to bona fide professionals. They have invested the time, effort, and expense to learn how to take impressions and make clear retainers, and they are losing a benefit that would traditionally be theirs. But they are also concerned about the needs of patients. They place great value on the quality of their treatment results, they do not want their work to relapse, and they do not want their patients to resort to a DIY retainer experience. So, what to do? It is common practice to charge patients for replacement of clear retainers; this of course is meant to cover costs as well as to encourage patients to properly care for their retainers. Some practitioners also offer retainer insurance. How do patients view these practices? Based on experience, it is my opinion that patients view charging for replacement retainers in a negative light: as a self-serving way for clinicians to extract more money from them. Worse, in some cases, when a replacement is necessary and must be paid for, a patient otherwise happy with the treatment result and with the doctor after treatment could develop a sour attitude about the practitioner and the specialty over time. Under this light, it might not come as a surprise that some former patients would consider a DIY substitute instead of returning to the doctor. Is there any solution to this situation? Perhaps there is, and perhaps we should once again consider the thoughts of Amos Dudley. He treated himself with aligners, and he said he was going to make his own clear retainers, not just 1 set of retainers. He was going to make a “bunch of retainers… which I can use till I die.” He is a smart young man; he is planning ahead, and he wants to be permanently happy with the arrangement of his teeth. Subsequently, I found out that 1 of our instructors does something like this already, and he is a smart guy, too. When he concludes treatment and removes the appliances, he gives the patients 2 sets of clear retainers instead of 1 and explains that “1 is for now and 1 is for later.” The patients and parents seem quite happy and remain so for quite some time. If they are motivated patients and need a third set, where do they seek care? They come back to see their hero rather than roll the dice on the Internet.“Well,” cried the Marionette, angrily this time, “may I know, Mr. Parrot, what amuses you so?”“I am laughing at those simpletons who believe everything they hear and who allow themselves to be caught so easily in the traps set for them.”“Do you, perhaps, mean me?”“I certainly do mean you, poor Pinocchio—you who are such a little silly as to believe that gold can be sown in a field just like beans or squash. I, too, believed that once, and today I am very sorry for it. Today (but too late!) I have reached the conclusion that, in order to come by money honestly, one must work and know how to earn it with hand or brain.”“I don't know what you are talking about,” said the Marionette, who was beginning to tremble with fear.“Too bad! I'll explain myself better,” said the Parrot. “While you were away in the city, the Fox and the Cat returned here in a great hurry. They took the four gold pieces which you have buried and ran away as fast as the wind. If you can catch them, you're a brave one!”Pinocchio's mouth opened wide. He would not believe the Parrot's words and began to dig away furiously at the earth. He dug and he dug till the hole was as big as himself, but no money was there. Every penny was gone.From Le Avventure di Pinocchio, a novel published in 1883 for children by Italian author Carlo Collodi (translated by Carol Della Chiesa in 1926)