What I'm telling the GP

Before I begin treatment, I write a letter to the dentist (GP, general practitioner) to explain what I'm going to do. The letter I wrote today was exemplary enough (as in: a perfect example), that I thought I might share it with you.   You may use it yourself....(p.s.: I'm using a fictitious name....)...

"Dear George,  Hi. It's Barry Raphael, orthodontist for Stephanie.   Below is a summary of my treatment plan for Stephanie and attached are copies of records.  Please review and consult with Stephanie's father and mother with your opinion.

First some background.  Before I move teeth, I like to look at the cause of the problem.  Orthodontics has long been plagued by trying to treat and maintain teeth when the etiology has not been rectified.  I particularly look at muscular habits,  especially during breathing, swallowing and sleeping.  Mouthbreathing and tongues not positioned on the palate are, I feel, responsible for many of the malocclusions we see, Stephanie included.  

Her narrow palate, posterior crossbite and anterior openbite are typical of such issues.  As such, my preliminary treatment is aimed at eliminating the harmful habits.  Once reduced, straightening the teeth become much simpler.  More importantly, however, these habits and the poor growth patterns that ensue are associated with the sleep disorders that adults are now often struggling with.  No matter the orthodontic protocol I choose, she will be predisposed to sleep disorders if the habits are not corrected.

Correcting harmful habits, unfortunately, is like giving dance lessons - many will participate but only those that are motivated and work at it will succeed, and even then to varying degrees.  Without Stephanie's and her parent's understanding and participation, the results will diminish, and she will be likely be subject to typical orthodontic regimines like extractions and retractive mechanics - something I try to avoid whenever possible.

Stephanie's treatment will begin with a removable (by her choice) expander to widen the palate and establish room for the tongue.  Then myofunctional training to 1) keep the lips closed, 2) keep the tongue on the palate, and 3) breath through the nose, especially at night, will begin.  Again, her cooperation with these exercises is paramount to success.

Should she have difficulty with the exercises I proscribe, a referral to an Oral Myologist will be made for a more specific and individualized therapy.

Finally, when she is on the way out of the mixed dentition (estimated age 11-12), I will re-evaluate for fixed appliance therapy.  If the myofunctional work is effective, only alignment will be needed.  If it is not, then more complex treatment will have to be considered.

If you are not familiar with the above approach, or would like to learn more about it out of curiosity, I will be happy to forward some links to more information. You can start here.

Sincerely,  Dr. Barry Raphael "

Is Early Treatment Necessary? An ongoing battle....

I know that in orthodontics there is a move away from early treatment.  Tulloch and similar studies have been used to vilify early treatment since the results of two-phase and one-phase treatments seem to be the same. And since two-phase treatment is less economical to both the patient and the orthodontist, then why do it?  Reasonable argument.  Especially since new approaches to fixed appliances have resulted in better arch development, better facial appearance and less extractions. 
However, the AJODO (the most revered juried journal in the field) recently published a systematic review(1) on the efficacy of functional appliances.  In summary, the review found statistical significance but little clinical significance to the way functionals could make a mandible grow.  And it also concluded that the data supports “that 2-phase treatment has no advantages over 1-phase treatment.”

But wait.  It concludes: “several benefits must be attributed to the early treatment …”

1. prevention of trauma to maxillary incisors associated with a large overjet, (ed: every one agrees with this one)
2. psychosocial advantages for the child during an important formative period of life,(ed. kids and mothers,  especially, appreciate this)
3. interception of the development of dysfunction, (which is why teeth get crooked in the first place)
4. stable dentoalveolar correction (ed. stability: the holy grail of orthodontics)
5. improved prognosis and shorter duration of treatment with fixed appliances.(ed. Better Faces: Less Braces!

So given those five reasons, why wouldn’t you want to do early treatment for our children??? Since when is money and efficiency more important that the health of our children?

(1) Marsico,E, et.al. Effectiveness of orthodontic treatment with functional appliances on mandibular growth in the short term, AJODO,  2011, 139:1, 24-36.

The way I want to change the world.

I am thinking about orthodontics as a health service, not only an esthetic service...

Up until recently, I’ve felt that ortho was mainly an esthetic service, and that just few people really NEED it. Crooked teeth don't hurt. No one ever dies of a bad bite. But they WANT it.  And there are many benefits from a pleasing smile in our culture.  Better self-esteem.  More confidence smiling and speaking.  Pride in accomplishment.  Improved dental awareness and care.  All good things.  But like plastic surgery, it is a discretionary service, maybe even a luxury.  

From my new point of view, however, orthodontics, if and when it broadens its scope, can be a health oriented service that IS NEEDED by thousands of children.  When you look at alignment of teeth as merely a product of, a symptom of, or a solution to, a larger ailment that has health consequences well beyond just those of a pretty smile, then orthodontics takes on a greater significance.  

If crooked teeth are a symptom of early feeding and nutrition, then it is a health related matter.  If crooked teeth are a symptom of imbalanced musculo-skeletal alignment which contains vertebral subluxations and cranial strains, then it is a health related matter.  If crooked teeth are a symptom of suboptimal respiration where oxygen is not being processed efficiently and tissues are not being nourished as they should, then it is a health related matter.  If crooked teeth are related to mouth breathing, snoring, airway restriction, asthma, allergies, frequent upper respiratory infections, and sleep disorders, just to name a few, than orthodontics is certainly a health related matter.

What I am suggesting is that there is the possibility of a whole new line of concentration within our specialty.  One that is crying out for our attention. One that provides us with tremendous opportunity for improving the health of our children, now and into their future.  

Of course, we should still concentrate on the esthetic benefits of a beautiful smile.  But I also suggest that it is time to forgo esthetic goals when they are accomplished at the expense of health. Or when they are performed in ignorance of the health ramifications to our children. Ideally, our children have the right to enjoy both enhanced esthetics and enhanced health.

And that what I want to see happen in my lifetime.