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Volume 1, Issue 2
Summer 2005:

Letter to the Editor: Response to Dr. Sobel's Letter

Shannon Brownlee

Cell 2 Soul. 2005 Summer; 1(2):a12

[This letter is in response to Dr. Richard Sobel's Letter to the Editor: Criticism. -Ed.]

Yes, I wrote in bitterness and frustration, and in doing so I apparently failed to convey the principal source of my anger, which is this: Had I known at the outset that I would end up needing six hours of surgery on both jaws, surgery that will cost me or my insurer the equivalent of a year's tuition at an Ivy League college, I don't think I would have begun the orthodontic treatment that I am now told leaves me with no option but surgery. I probably could have gotten along perfectly well with a splint at night.

As for Dr. Sobel's contention that there are indeed studies on orthognathic surgery, I don't know what he considers good evidence for efficacy, but I couldn't find it. A search on PubMed for "orthognathic surgery" and "outcome" produced 94 articles, dating back to 1976. There were a couple of prospective studies, unrandomized, fewer than half a dozen case controlled studies, and not a single randomized controlled trial.

Most curious, however, was the fact that a good number of the studies looked not at health outcomes, but rather at the psychological effect of orthognathic surgery. Specifically, they asked how the surgery affected the patient's self-image. That's the sort of question one asks when investigating cosmetic surgery, not a treatment that has been billed as essential for oral health.

And therein lies the deepest root of my bitterness with my surgeon and myself. He used language that portrayed this long, expensive, and potentially hazardous treatment as a matter of health, but in reality, he was selling what is ultimately an unproven, and at least partially cosmetic, procedure.

So yes, I'm angry. I'm also feeling sheepish about being taken in, and I'm afraid. Afraid of contracting a nosocomial infection, and of suffering cognitive impairment, even temporary, after such a long surgery, which might or might not actually help my physical complaints. I'm scared of nerve damage that might leave me with permanent loss of feeling in parts of my face, or worse, neuralgia. And I'm worried that my insurer won't cover it, and that my choices will be paying out of pocket for what I have come to see as necessary surgery that could have been avoided, or deciding against the surgery and not being able to chew properly for the rest of my life. And still having TMJ pain and gum loss.

Because in the end there's scarcely a shred of evidence that this surgery actually provides the therapeutic benefit that was promised by my physicians. I could find only a single study in my PubMed search that asked even one of the three critical questions about efficacy that I posed to my surgeon: Does surgery and orthodontic treatment reduce TMJ? The answer is, nobody knows because that one study simply asked 52 patients if they had more or less pain after the surgery. (Egermark, I. et al. Eur. J. Orthod. 2000 Oct.22 (5) 537-44). No control group. No standardized measure of pain. Not exactly what you'd call strong evidence.

Left entirely unasked were the other pertinent questions, Does the treatment reduce tooth grinding? Does the treatment reduce gum loss? When my surgeon, and orthodontist, and dentist, for that matter, all told me surgery would solve all three problems, TMJ, tooth grinding, gum loss, what were they using to back up their claims? The fact is, they don't have any evidence. Maybe the surgery does what's promised, and maybe it doesn't, but the student of medical history knows that much of medicine that seems to make perfect sense turns out to be useless or worse when put to the test. I'm thinking here of Eucainide and Flecainide, arthroscopic knee surgery for arthritis pain, high dose chemotherapy for breast cancer . . . the list goes on.

Having recently watched a major surgery, I can understand why a surgeon thinks that surgery can cure soo many ills. I marveled at the sureness of the doctors who were cutting into a living, breathing human being, sawing through bone and pulling aside nerves and organs in order to reach a remote spot inside the body. Just watching was exhilarating. There's a new show on American TV, "Grey's Anatomy," in which surgery is called "the game, " the implication being that of all the specialties, surgery requires the most brains, skill, and daring. Whether surgeons are any brainier than other doctors is open to debate, but the best surgeons I know simultaneously have both the sureness they need to hold a scalpel, and a deep humility about their work. They recognize the power they wield can harm as easily as it can heal.

The saddest part of my story is that my surgeon appears to be a few quarts low on humility. Without that, it's hard to trust him to act in my best interest, and without trust, there is no therapeutic relationship. Dr. Sobel is right about one thing, that every dispute between doctor and patient does indeed have two sides, but in this case it's my mouth and my pocketbook that are most at risk. I never complained to my surgeon. There would be no point. I don't want him to do the surgery as I no longer trust him, and I don't believe he is capable of acknowledging his own arrogance, no matter how diplomatically I might put it. To him, I would be just another disgruntled patient, easily replaced with the next man or woman who looks in the mirror and sees an imperfect face.

P.S. Having begged my orthodontist one last time to please find a way for me to avoid surgery, she has finally acknowledged that I can probably get by with a splint at night, which will simultaneously keep my jaw in place and prevent me from grinding away at my poor teeth. My chart will note that I understand this is not her "recommendation," that she does not see the splint as "optional." Optional. I wonder whether that word has any real meaning in medicine. She and the surgeon want to see a perfect bite, which in my case is only obtainable by rearranging the bottom half of my face. I just want a functional bite, teeth that won't fall out of my head by the time I am 65, and a working temporomandibular joint. Perhaps if they had outlined the risks more fully at the outset, and the uncertainly, we might have figured out what optional meant to me, the patient, a lot sooner.


Shannon Brownlee
Annapolis, Maryland

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