By Keith Isaacson
The arresting title "Evidence and Orthodontics: Does your child really need braces?" headed an interesting and well researched paper (1) from Isobel Whitcomb, a brilliant investigative journalist in the online magazine “Undark” which circulates widely in the USA and is published by Massachusetts Institute of Technology.
The article questions the purported medical benefits of traditional orthodontics. In the USA Orthodontics is considered a medical speciality and the medical benefits are promoted. The American Association of Orthodontists suggests that a child should have an orthodontic consultation by the age of seven as “lack of treatment leads to dental decay, gum disease, broken front teeth and loss of bone tissue”. Persistent jaw pain and headaches are threatened if orthodontic treatment is not undertaken.
Many international researchers have failed to find any evidence to substantiate such claims. Dr Peter Vig, who is featured in the article, is a former colleague of mine who emigrated to work in the USA, and caused outrage in the American journals for criticising the claims of medical benefit. Despite his efforts, unsubstantiated claims continue to be made. He maintains there is a lack of scientific integrity in orthodontics.
Whereas all orthodontic treatment in the US is private, most treatment for UK children and teenagers is carried out within the NHS. A well-established 'Index of Treatment Need' based on specific clinical factors, determines whether NHS treatment is clinically justified. This eliminates patients with minor irregularities. Adults seeking orthodontic treatment to enhance their appearance are treated privately.
Whilst much orthodontic research is ongoing, trials can only compare different methods of treatment. It is not possible to initiate a trial comparing patients who have treatment with those who do not. Of the many claims made by the American Orthodontists, the only significant one is that prominent upper front teeth are at risk of being fractured. Orthodontic treatment can reduce this risk. Professor Kevin O’Brien of Manchester University has looked at the evidence for this.(2)
The question remains: Is orthodontics a medical speciality? I cannot give you any evidence, my response is purely anecdotal. Most of my career was spent as a Consultant Orthodontist in a large district NHS hospital where the patients included children with complex and handicapping malocclusions often needing jaw surgery and patients with cleft palates.
Significant prominence of the upper front incisors can be very disturbing for a young child especially as they change to a senior school. Orthodontic treatment for such children is not just for the sake of appearance.
Working with cleft lip and palate patients from birth to late teenage years is very specialised and requires liaising closely with plastic surgeons, ear nose and throat surgeons, and speech therapists.
We aimed to see all cleft palate patients with their parents as soon after birth as possible. It was often necessary to make feeding plates to cover the cleft so that the baby could swallow safely. Taking a dental mould on a premature baby was difficult and a potentially risky procedure. At an older age, bone grafting of the cleft usually required preliminary orthodontic treatment.
Most patients were treated with conventional orthodontic techniques. I will illustrate significant psychological enhancement in a few of them.
All NHS patients attending the hospital were categorised according to the severity of need for treatment. Those accepted were in the “worst” category. Children with less severe malocclusions were referred back to their general practitioner or to a specialist orthodontist for private treatment.
Treatment of the more severe cases frequently requires extraction of permanent teeth. This can be contentious if it involves extracting healthy teeth. Patients in the pubertal growth spurt can be treated using ‘functional’ appliances. These hold the lower jaw in a protruded position. They are not easy to wear but if successful can give dramatic results and often avoid the extraction of permanent teeth.
Significant prominence of the upper front incisors can be very disturbing for a young child especially as they change to a senior school. Orthodontic treatment for such children is not just for the sake of appearance. I received a letter from a patient that I treated over 40 years ago - her name is Tansy Summers (she asked me to quote from her letter and to give her name).
"You may not remember me but back in 1975 we first met. I was 12 years old, you were a young Consultant, I was a very shy, unsure, introverted rather troubled individual undergoing a large amount of bullying and harassment at school due in the main to the state of my teeth. I was in a mess: a very upset young girl. After your initial examination, I had teeth removed, a fixed brace fitted complete with complex headgear. This remained in place until the treatment was finished. I came to see you on a monthly basis for the necessary adjustments for about 3 years followed by a retainer. I was determined to see it all through and on my 16th birthday the braces were removed and I started my first employment. The ugly duckling had turned into a Swan.
“In all I've embraced life with vigour and fortitude and you enabled me to do so. And I thank you for that profusely. I procrastinated for 30 years but better late than never, hence my writing to you to say a sincere thank you for your past treatment of me Keith, I cannot thank you enough. Without you my life would have taken a very different course. You changed that: well done."
In some patients the discrepancy of size between the jaws is such that it cannot be corrected by orthodontics alone. A combination of orthodontics and surgery is the only answer to improve function and appearance. This work requires close collaboration with the maxillo-facial surgeons at each stage of the process. Once the patient has had the procedures explained and is prepared to have the necessary surgery (as with any surgical operation, this carries a risk). The planning of the process is frequently carried out by the orthodontist using specialised radiographs - and demonstrating to the patient the predicted change in both X-Rays and photographs. These are discussed with the patient and their parents at a multidisciplinary clinic with the orthodontist, maxillo-facial surgeons and (at my hospital) a consultant psychiatrist to assess whether the patient showed any evidence of being psychologically unsuitable for the treatment.
Prior to surgery orthodontic treatment is performed to arrange the teeth in the correct position and angulation prior to the surgical re-positioning of the jaws. During the operation, fixed braces are used to locate the new positions of the jaws (I would normally be present to assist in this).
And finally, another patient whom I shall call Paula. I had seen her when she was about 13 years old, when she had a short lower jaw and prominent teeth. Treatment with a functional appliance was unsuccessful as she did not cooperate with it, so she was discharged. When five years later she was referred back to the hospital, it was for jaw surgery to advance her lower jaw. By then, Paula had become rather introverted and, although the surgical planning was straightforward, she was interviewed by the psychiatrist to ensure she could cope with the surgery. I explained that I had failed to get a result by orthodontics alone. Coincidentally, as a teenager Paula had been a patient of the same psychiatrist. Knowing her family background, he understood why she had not cooperated with functional appliance treatment. He determined that now she could cope with the combined orthodontic and surgical treatment.
About two years later, an attractive, bright and personable young lady came into our multidisciplinary clinic, having completed treatment a year previously. While the surgeons were examining her, I was checking the dental models to see how her occlusion had been improved. I turned to the notes and showed them to the psychiatrist who was standing beside me. “It’s Paula!” I exclaimed. Neither of us had recognised her and we could not believe that this was the same patient who we had been treating whilst a troubled teenager.
Cases such as these made my career in the hospital service so rewarding.
Keith Isaacson, Emeritus Consultant Orthodontist
(1) Whitcomb I. Evidence and Orthodontics: Does Your Child Really Need Braces? Undark, 7 July 2020. https://undark.org/2020/07/20/does-your-child-really-need-braces/
(2) O'Brien K. Orthodontic treatment and dental health: chasing rainbows? Kevin O'Brien's Orthodontics Blog, 15 Jun3 2020. https://kevinobrienorthoblog.com/orthodontic-treatment-and-dental-health/