LW: Dr. Ricketts, how do you view orthodontics as a contributor to health, well being and longevity of patients?

RR: This is an underlying focus pertaining to our father, the field of dentistry, and its father, the field of medicine. Dental medicine needs to be viewed in a new light. Dr. White, as you know, due to requests from colleagues, I have been teaching advanced seminars since 1963. We start our courses out by considering the entire patient and not just a set of teeth. In fact I have agreed to conduct another seminar from May 18-28, 2003 if enough people are interested in our theories, science, mechanics and art.

In order to better understand this kind of perspective, perhaps your readers should know something about my background. Prior to my graduate studies starting in 1947, I had already performed some orthodontics. I was also a dentist in the Navy which was a rich experience. My duty, after indoctrination, was in a boot camp at Williamsburg, VA at Camp Perry. I saw young men who had never seen a dentist or used a toothbrush. We extracted many teeth with deep caries including first molars. This bothered me greatly. My next duty was at Camp Sheldon, a separation center, where I saw men being discharged after duty in the WW II. I charted about 300 men each day and used the opportunity to view thousands of occlusions. Ideal occlusions were very rare indeed.

I finished my service duty as the only dentist at the submarine base at Key West. I worked on members of President Truman’s secret service. That complete two years afforded me with a good overview of the human dental condition, especially in men.

Research:

Even before my graduation studies began, with the help of Dr. Allen Brader, we developed a technique for oriented laminagraphy. This provided beautiful body sections of the joint at prescribed planes. Through this, I again was provided a broad contact with dentistry and medicine. At the university level, I studied patients receiving full artificial dentures with Dr. Howard Kubachi. I also worked with Dr. Stanley Tillman in crown and bridge and full mouth rehabilitation. Further, I worked with Dr. Bernard Sarnat in oral and maxillofacial surgery and craniofacial anomalies on a cleft palate team.

Due to the brilliant x-ray images with the techniques, I was afforded the broadest kind of conditions of the head and neck. These came from the dental school and the medical school. One half of my master’s degree was in medical radiology. I also consulted with the department of physical medicine.

During my five years as a research fellow, I was interested in biology, rheumatology, genetics, endocrinology and medical orthopedics. This was all in addition to the studies of growth and development and the effects of orthodontics. In the medical school, I studied with Bennett and Braur in the department of pathology. From my interest in arthritis, I started communicating with Dr. Hans Selye with regard to the biologic effects of stress (or distress) and general health and the immune system. I wanted to know why joints were breaking down in a 5 to 1 ratio in women compared to men.

Research redirected:

In my original protocol, I had designed a study of the joint in order to determine the effects of orthodontic modalities on the growth behavior or changes in the joint. Very soon however, I became buried under an avalanche of "temporomandibular problems". I had to figure things out on my own because no one was available in the dental orthopedic field for help. It was obvious that there was some kind of an association between missing teeth and certain kinds of problems in patients with certain malocclusions. Research in many of these aspects has continued up to the present – more than one-half century

Longevity in our Population:

In the 1950’s as president of our dental society, I stated that my life ambition was two fold. First, it was to have my patients live past 100 years and die with their natural teeth in their mouth. My second desire was to change dental education as it was being taught. Now without an earth catastrophe, the children being born may expect to live beyond 100 years if they avail themselves of the knowledge we foresee. If the teeth do not contribute to longevity, they most certainly support the quality of life.

I look upon the loss of teeth as a failure in dentistry. If we look deeper; it is also a failure in preventive medicine. I look upon malocclusion as a compromise in the mental, social and physical welfare of a person.

There is an obvious lesson that we can appreciate. Why is it that so many people after having become edentulous are so willing to pay vast sums for implants and reconstruction, when they complain so loudly about ordinary dental and orthodontic fees. I still say superbly finished orthodontic service is the best bargain in the whole medical arena. The value that people ultimately place on teeth, for eating, speaking and having a physical and social well being, is manifested in the desire to be restored.

Even further, there is growing evidence that cardiovascular problems are associated with periodontal disease. This is not just because smoking is linked to both conditions. ‘The question has arisen: can the prevention or cure of periodontal disease be related to health of the heart?

Broad Perspective:

From the forgoing, it would be evident that orthodontist’ interests should extend beyond the teeth. It includes the jaws, the head and neck and involves the patient in totality.

Holism is a process by which all the parts working together make a greater contribution than the parts working alone. It is the same idea as that of synergy. If the teeth are a part of the body then occlusion is a foundation. Again, patients fail often to appreciate teeth until problems are encountered. Like fresh water and clear air, all is taken for granted only to be respected when they become scarce.

You know, Larry, we do not think of teeth in the sense of mind, body and soul. Yet if the smile does not reflect spirit – what does? Orthodontics is not just moving teeth into a straight alignment.

In considering the whole patient a question arises. "At what age of the patient can the orthodontist do the most profound good and at the least expense and maximum benefit for all concerned?"

LW: There seems to be a renewed interest in early treatment. Do you feel this is justified and how will patients benefit from much earlier therapy?

RR: I have prepared a series of four books on early treatment. We are trying to self publish but advertising takes money I do not have.

Probably my fix on early treatment started with correction of segments in cleft palate babies and treatment of already constricted post surgical maxillary components by age three years. I saw remarkable orthopedic results with the "W" appliance – the forerunner of the quad helix.

During that tenure at the University of Illinois I visited Dr. Silas Kloehn in 1950 in his office and conducted research on his patients. This was prior to the advent of cephalometric and laminagraphy. I then treated patients with the face bow and monitored them with head and joint x-rays. Although the few patients analyzed were anecdotal, they certainly demonstrated possibility. Honestly, however, I did not know how to interpret the findings in 1951 and 1952 because we were so steeped in the conclusion that all behavior was genetic. Gradually I had to take a strong stand that the whole mid face could be altered.

The answer regarding justification and benefits could be very large indeed. In fact, we listed forty benefits. Let me say this, it is high time that the specialty of orthdontics assume its rightful responsibility for the care of young children in the deciduous dentition on or before the age of six.

It is a well known truth that the first permanent molars take their positions upon eruption directly proximal to the position of the second deciduous molars. Ectopic eruptions are the exception. This is for Class I, Class II and Class III. It is also remarkable that buccolingual (first molar positions) are taken following the position of the second deciduous molars such as seen in developing cross bites both buccal and lingual. In fact, the deciduous second molars are guided in turn by the erupted positions of the first deciduous molars at age one year. It is also at this time that the level or the occlusal plane is established.

It is evident that the oral environment can play a large role in that development. But also genetic type is associated. Skeletal convexity, which is higher from birth to age three years particularly in Caucasian children, can be a component for Class II. Maxillary restriction is a component in about two thirds of Class III.

Thus the stage for malocclusions is not set at the permanent dentition or even the mixed dentition but very early.

Now the real issue is possibility! But underlying that is knowledge, training and skill of management of tots at the age of four and five years.

Orthodontic teaching has been negative to very early treatment, which we call preventative. It is preventive in the achieving of normal first premolars and overbite and overjet or crossbites of the incisors by the time the mixed dentition forms.

A part of the present debate is based on experiences of clinians more than a half century ago and do not apply to present day findings with the use of current modalities. These are primarily extraoral traction, the guad helix and utility arch therapy.

Objections are dictated by the clinicians belief in possibility. Is maxillary orthopedics a reality and can a functional import be rendered in the mandible? These are the questions we will try to answer in this series. My goal is communication.

In essence, the first priority is to achieve a normal congruity of the maxillomandibular relationship. This involves first attention to skeletal alignment. From this achievement the second priority is the acquisition of normal nasal and oral functional unity. When the basal jaw structures are corrected, this occurs most often quite naturally before age seven. The third priority is to set in motion nature’s forces of development such as eruption and incline plane action. The final priority is the promotion and utilization of normal growth processes.

The benefit is now to prevent premolar extractions to the 93% level and almost totally eliminate the need for maxillofacial surgery. I think that is justification enough. The amount of correction and time and effort goes up as the patient ages.

LW: What are some orthodontists currently seeing with patients treated early?

RR: All though my career I saw patients who had worn appliance for three to six years and nothing was accomplished. It could not have been a relapse when no effective treatment was rendered, and still a fee was collected. This is an issue of morals and ethics.

It should be recognized that this is not the fault of early treatment, but a manifestation of inept and undisciplined clinicians. We have had poor schooling in the methods and possibilities of early care and this present situation proves it. Just giving the patient an appliance or placing some bands or brackets is not treatment. For that matter, I also saw many patients started in the permanent dentition, which were embarrassing also. It doesn't seem to arouse an outcry when adult patients start orthodontic treatment and are subsequently sent to surgery, but if that treatment were started in the mixed dentition the sebsequent surgery would be considered a large error. Are we now in a cover-up mode?

Continue with Part 2