Tuesday, July 30, 2019

When to call an Orthodontist for your Kids


Ever since specialties like Orthodontics, Oral Surgery, Periodontics and others were formed, there was a pattern established for dentists to refer patients to more specialized experts based on need and age.

Ideally, every family should have a single General Dentist (the “family dentist” or “cosmetic dentist”) that they see for routine care, cleanings, fillings, crowns, emergencies etc.  These dentists act as the trunk of a treatment “tree”.  General Dentists screen patients, provide general care and identify more complex problems that may be better treated by a “branch” of specialized dentistry, what we call a “Specialist”.  This describes a need-based referral.  Perhaps a bad tooth would require a difficult root canal, a procedure requiring specialized equipment and expertise from someone with significantly more focused training that only performs root canals day-in and day-out (in this case an “Endodontist”).  An impacted wisdom tooth requiring removal will likely be referred to a specialist, this time an “Oral Surgeon” while a nervous young child may be more comfortable seeing a children’s dentist or "Pedodontist".


Need Based Referrals

Need-based referrals to an Orthodontist (the specialist for aligning teeth with braces and/or aligners) are patients with crowding and rotated teeth, excessive overjet, poor bites or other “mal-occlusions” and even patients with jaw pain.  These patients could be pre-teens, teens or adults but the problems are obvious and evident to the general dentist making for an easy and logical referral.  

If a general dentist or dental office tries to sell everything “in-house”, you most likely are looking at more of a profit-driven practice as opposed to a patient-centered practice. We can all agree that there is a place for Wal-Marts, Targets and Walgreens.  But medical and dental offices are not that place.  When it comes to dentistry, I want the name brand product, not the generic version produced in some third world Country (like Invisalign aligners).  And I don’t know about everyone else, but when I go to a doctor; I want the professor, not the student or even the assistant.

“Need-based referrals to an Orthodontist (the specialist for aligning teeth with braces and/or aligners) are patients with crowding and rotated teeth, excessive overjet, poor bites or other “mal-occlusions” and even patients with jaw pain”


Need based referrals are still made by good family dentists and pedodontists (children’s dentists) that put their patients first though there are an alarming number of general dentists trying to offer braces and clear aligners based on a weekend course or internet training and u-tube videos.  And although there are simple cases that can be treated with less experience, identifying those cases as "simple" is not as easy and many difficult issues can be hidden to the untrained eye. 


What has changed across the board is the lack of referrals based on age.  To understand this, patients must understand that all “specialists” started as general dentists themselves.  Some, like me, may have practiced for years as family dentists and even practiced in other settings like a hospital.  These dentists then either became more adept at or grew to prefer a specific discipline and chose to give up general dentistry and enter into a full-time specialty program for an additional two to six years of training and education.  Once graduated, they became the experts of their chosen field and they would continue training and learning specific to that field for the remainder of their careers.


Orthodontists are trained in facial development, cellular and bone physiology, physics and applied materials; they are taught years of research on Orthodontics from the very creation of modern tooth movement to jaw function and occlusion and from simple braces and aligners to complex multi-disciplinary systems including implants and surgery.  In fact, Orthodontists are only chosen from the very top of the general dental field with only 2 to 7 positions available for every 400 or so applicants of dentists.  Specialty school is grueling and intensive taking 12h/day sometimes and 5 to 6 days per week.  It should be no surprise that specialists are the go-to doctors for complex treatments.  This of course stands to reason why weekend courses are completely insufficient for learning the complexities taught at 2 to 3 year orthodontic programs.


This teen was referred only after all permanent teeth erupted.  Under care of a general dentist since a child, this malocclusion was present at age 6 but left untreated.  Correction now is difficult and will require removal of a tooth and late expansion which is less stable.



After 26 months of treatment including palatal expansion and full braces (with removal of the unilateral blocked out bicuspid),the alignment and arch are corrected but this patient will forever be required to wear a retainer due to the severity of the crowding.  


This is why a good family dentist will refer need-based patients (with obvious crowding/ malocclusions) to the Orthodontist.  But what happens when the general dentist does not recognize a problem or does not see the early stages of what may become a serious malocclusion later?  Do you even see your actual general dentist at each appointment or are you primarily under care of the hygienist who screens you for the dentist during your cleanings?  In too many cases today, it isn’t even the dentist deciding on a need for early Orthodontics.

“a good family dentist will refer need-based patients to the Orthodontist.  But what happens when the general dentist does not recognize a problem or does not see the early stages of what may become a serious malocclusion later?


Age Based Referrals 

Age-based referrals are recommended by the American Dental Association as well as the American Association of Orthodontists and the American Board of Orthodontics; all of which recommend that EVERY child should see an Orthodontist by age 6.  Educators and dental societies as a whole recognize that a general dentist or pedodontist will not see every problem developing in a child.  Orthodontists are trained to recognize and investigate problems starting at age 6 (and even earlier in severe cases).  This is because the first permanent molars erupt at age 6 revealing the jaw position, size and relationship to opposing jaw; at a time when the patent’s growth can be manipulated and even altered.  Orthodontists are not only armed with much more knowledge and experience, but they also have special imaging machines that reveal growth problems and allow them to be quantified and monitored (or treated if necessary).  Early changes can prevent later braces, prevent removal of permanent teeth later for space or overjet, prevent impaction of teeth and even prevent surgery in MANY cases.  Early treatment, when warranted, will improve any later correction, improve function and wear of teeth, improve stability of any future alignment and can improve facial profile and lip support drastically improving facial esthetics. 

“Age-based referrals are recommended by the American Dental Association as well as the American Association of Orthodontists and the American Board of Orthodontics; all of which recommend that EVERY child should see an Orthodontist by age 6.”

So why should a general dentist refer EVERY child by age 6?  Because they are not trained as well to see early, developing malocclusions and will not recognize preventable (but serious) problems until they manifest later with the eruption of permanent teeth.  General dental offices and even Pedodontist offices also are set up for dental hygienists to monitor the patients instead of the actual dentist.  Because of this, some dentists will not refer any patient until all permanent teeth are erupted; as if growth means nothing and as if all teeth will always fully erupt even in severe crowding situations or narrow arches (which they will not as you will see below).  Every month I get a case that parents and/or dentists were waiting on teeth only to realize too late that the reason the teeth were not erupting is because they were blocked/impacted, sometimes destroying the roots of adjacent permanent teeth.  These are predictable, preventable and treatable at the right time and missing them is nothing short of a tragedy.  Consider the following patient:


Patient 1.

This 10 year 5mo old young lady may appear to an untrained eye as being normal, but experience tells the orthodontist that the upper jaw is narrow and there is constriction in both arches. This patient was seen because an older sibling was in treatment; she had been under a general dentist’s care for years. I recommended a quick X-Ray to check the un-erupted teeth.

My screening X-Ray taken to check development due to this slightly narrow upper jaw immediately revealed an impacted lower canine which had been present for years.  At this point, surgery and extensive braces were already necessary.  Treatment ended up requiring two surgical exposures of the impacted tooth and two phases of braces over 4 years (see below).

11y 3mo
11y 7mo
12y 11mo
13y 2mo
14y 3mo

Final picture of previously impacted lower left canine now fully erupted and in occlusion.  A long course of treatment that may have been prevented with earlier screening and removal of the lower baby canines early when the permanent canine started to show signs of erupting to the wrong place.


 Patient 2.

This 9 years old accompanied his older sibling to a routine adjustment appointment where again I noticed a narrow upper jaw with crowding and suspected impacted teeth.  The children’s dentist had been “monitoring” this patient for years and had recommended no treatment at several of the recent visits.  But I had a strong suspicion due to the arch form and ended up taking a screening X-Ray that day to assure myself and the patient there were no hidden problems.  

In the screening film, it is immediately obvious both upper canines are impacted and transposed with the adjacent teeth and have been for at least a year.  Unfortunately at this time, there was already damage occurring to the incisors as the impacted canines were superimposed over the developing roots.  Treatment was initiated immediately with expansion to restore the arch width but ultimately surgical exposure of teeth and removal of 4 bicuspids was required. 


“But my dentist takes X-Rays and never said anything”

If ever there were more famous last words.  Patients need to know that general dentists and even Pedodontists (children’s dentists) don’t always focus on the whole forest; they are looking at the trees.  And their hygienists are considerably less trained at identifying orthodontic problems even though they may be the ones doing most of the maintenance and oral hygiene.  Regular dental X-rays taken of the teeth (“bitewings”) don’t show anything from the middle of the root down and insurance only allows a full mouth panoramic X-Ray every 2 to 3 years.  It is impossible to see many of the serious skeletal dysplasias or developing malocclusions from bitewings and an occasional panoramic film.  Without the years of experience and added knowledge (and this DOES NOT include weekend courses), MANY cases are not treated at the opportune time and are therefore poorly treated, difficult to maintain and lead to un-necessary removal of permanent teeth and high relapse rates.  Not only can early crowding, impaction of teeth and jaw discrepancies be missed, but other pathologies can also be missed by not monitoring adequately.  Consider the following panoramic X-Ray.

This patient was the 10 year old (older) sister of another patient; I suggested a quick
screening x-ray to make sure there were no problems despite dad advising me that
her Pedodontist had seen her regularly for years.  Note the large tumor in the jaw that
went un-noticed for years; surgery was immediately scheduled due to the risk of
fracture and tooth loss from the expansive resorption of bone already present.


“Without the years of experience and added knowledge (and this DOES NOT include weekend courses), MANY cases are not treated at the opportune time and are therefore poorly treated, difficult to maintain and lead to high relapse rates”.


Patient 3.

Initial photo and panograph (9y 8mo) showing the impacted and transposed upper right cuspid (left on film); note the generalize crowding of upper teeth including the impacted canine on the opposite side which was present for at least 18mo prior to the patient calling to make an initial screening visit on their own (without referral from their dentist).
A Rapid Palatal Expander (RPE) was placed in the upper arch to restore arch width and open space for teeth while limited braces were placed to shift roots away from the impacted cuspids. Pano was taken at 10y 3mo (6mo into treatment).
Four months later (10y 7mo), we were able to start opening more space for cuspids; there was a risk of damage to adjacent roots however we had no choice but to move the lateral roots across the impacted cuspid to correct the transposition.
After another 4mo (11y 0mo) we have finally moved the upper right lateral incisor root away from the impacted cuspid.  On the other side, the previously impacted cuspid is now corrected.

One year later at 12y 0mo, you can see the cuspids continue to erupt into correct position and we can move the roots of the laterals back into position; root length is compromised from the previous impaction and movement

9 months after removal of the limited braces at age 13y 0mo, cuspids are now erupting into position with adequate space and we can re-evaluate for any Phase II braces as the remaining lower teeth erupt.


This is not to say Orthodontists are perfect or growth (or even good treatment) is 100% predictable.  I have watched cases myself only to see them grow out of control when, looking back, I could have helped earlier.  But most cases do follow patterns of growth and most problems are predictable by age 6 to 7.  If there is a question, patients can be monitored for years by an Orthodontist to confirm or disprove any growth prediction.  Braces can be reduced to an optional treatment or even prevented, removal of teeth can be avoided and surgery can absolutely be avoided in many, many cases. 

When a patient is referred AFTER teeth have become impacted, even if it is at a relatively early age, there can still be damage to roots which will eventually lead to early loss of teeth and eventual replacement by implants.  In fact, impaction can develop very quickly which is why the recommendation is to see an Orthodontist by age six.  Even by age 7 there can be significant problems already present (and easily visible) that could have been caught and treated at least a year earlier.  Consider the 7y 3mo patient (Patient 4) below:


Patient 4.

Age 7y 3mo, Note the shift in the lower jaw due to a Posterior Crossbite (the lower jaw wider than the upper jaw) and the severe early crowding.  The crossbite and crowding have been present for at least a year but now the X-Ray shows impacted upper teeth, blocked out and crossing over developing roots.  Treatment was immediately recommended to expand the maxilla and relieve pressure form the impacted teeth on the adjacent roots.


Age 9y 3mo after expansion to correct the crossbite and limited braces to align the front four teeth once adequate space was created.  Note the impacted canines are straighter but remain high and near the tips of the adjacent lateral incisor roots.


Now at age 9y 6mo,  at the end of the Phase I Early intervention, you can see roots of the developing teeth were shifted away from the un-erupted canines but the un-erupted 1st bicuspids continue to lean over the canine in the upper arch. The Baby molars over these tipped bicuspids were removed to expedite eruption of bicuspids away from the canines.


One year later, at age 10y 6mo,  despite the extra space created, eruption of bicuspids and shifting roots of the incisors away from the impacted canines, the canines shifted even more toward the midline and over the developing roots of adjacent incisors.  There was no room to surgically expose these canines yet and we could not remove permanent teeth or risk significant damage to the patient’s already weak profile so Phase II braces were planned immediately to open space for canines.


Age 11y 0mo and Phase II braces have been placed to open space over the impacted canines and to begin re-shifting incisors roots away from these impacted canines.


Eight months into full braces, age 11y 8mo, you can see the canine on the right side of the X-Ray (patient’s left) has come in straight while the right side remains impacted; space is now available to surgically expose the remaining impacted canine.

Twelve months following surgical exposure and traction of the impacted canine, age 12y 8mo, teeth are aligned but the damage is clear to the roots of the front teeth; inflammation from the impacted teeth not only resorbed bone around the crowns of the impacted teeth as is normal, but it also caused resorption of the permanent teeth roots.  Braces were removed a month later and retainers placed with the knowledge that it is likely we will be replacing at least one tooth with an implant by age 18 and the remaining incisors would be under close observation.  Patient’s profile was maintained and even improved but compromises remain that go back to the initial maxillary hypoplasia treated just a year late.  


This patient above (Patient 4) also illustrates how some patients need to be identified as early as possible; not just because a problem may be severe, but also because you don’t know when a patient may already be predisposed for root resorption.  In fact, there is no reliable way to predict who may be more susceptible to root resorption but we do know that some patients have more aggressive immune cells and/or similar identifying markers on root and bone cells making them more likely to experience shortened roots with any orthodontic movement or trauma to teeth.  In Patient 4 above, there was little to any movement performed on the front two teeth yet there is also root shortening on them suggesting that the loss of roots is not just from the impacted teeth but may have been drastically accelerated by the impactions and surgery required during treatment. 

Even knowing this has happened, the treatment would have still been required or more teeth could have been damaged. The only factor that may have reduced damage was to restore arch width earlier in the upper jaw before the canines turned in to the midline thereby preventing the impaction and eventual superimposition of canines. 

So what can early treatment, when referred at the recommended age, provide young patients?  Consider the next few patients as examples of what good Age-based Referrals can provide:


Patient 5.

This 8y 4mo patient presented with a Class III malocclusion, full underbite, and a severe midface deficiency.  As is usual in midface deficient patients, the maxilla is under-developed in all dimensions which creates a posterior crossbite as well.  There is a 2.0 mm lateral shift with a 1.0 mm anterior shift.

Treatment began with a rapid palatal expander (RPE) and Protraction (reverse pull) Headgear for 6 months.  The appliances were then removed and the teeth allowed to “settle” for 3 mo.

Now at 10y 1mo, after Traction, notice the full midface with upper lip support and
normalized profile.  Of course also notice the correction of the anterior crossbite (underbite)
as well as the posterior crossbite.  We then placed a removable orthopedic appliance
to enhance maxillary growth and reduce mandibular growth while guiding eruptions.

Once in the removable orthopedic appliance, growth will be controlled to assist facial esthetics and to minimize future treatment, completely eliminating the need for surgical assistance despite the Class III growth.

At age 12y 10mo, the patient has completed Early Orthopedic Therapy and all
permanent teeth have been guided into the respective arches.  We will now
monitor until baseline growth then re-evaluate for braces.


A good dentist will refer every patient at age 6 because they know what they don’t know.  And they want the best for their patients.  You can bet they have their kids seen on time, why wouldn’t they want the same for your family?  It is not conservative or cautious as some may think; it is not protecting the parents from hearing about sometimes costly treatments.  It is absolutely the opposite.  If there is no treatment needed, there will be no fees; even if monitoring is prescribed there is usually no fee; Orthodontists will take regular panoramic films for free and send them to your dentist for free until treatment may be recommended or a decision is made that no treatment is needed.  If treatment is recommended, it will most likely prevent more severe (and costly) problems, provide a better and more stable correction and even improve lip support and facial profile for the patient’s lifetime.

 “A good dentist will refer every patient at age 6 because they know what they don’t know.  And they want the best for their patients.”

Patient 6. 


This 7 year old patient presented with severe mandibular
retrusion and low self-esteem secondary to constant teasing
from her peers.  A removable Orthopedic appliance was
fabricated and worn full time for 22 months.  Progress
records were taken (see below) as we changed to night-time
wear to hold the correction.

The facial correction is very noticeable in profile but the real improvement is in
this patient’s self-esteem and newly discovered personality.  If no treatment was performed
during growth, surgery would have been necessary to attain this same correction.

When is professional neglect and bad advice malpractice?

No one ever wants to “rat out” a fellow dentist.  Either out of some misguided professional courtesy or just out of a desire not to get involved (dental review boards are notoriously slow and can cost everyone involved significant time and money just to appear and/or produce records); accusing colleagues of malpractice or even neglect can damage a specialty practice by scaring off other referrers or putting the patient between two doctors. This is understandably a real concern.  After all, we don’t know what someone else is thinking, we don’t know what a patient has been told or if one parent was told something different, and we can’t raise every patient like our own.  But a balance must be established.  We also may not have records from earlier periods that can confirm a problem was evident “within the standard of care”.  And after all, we aren’t miracle workers and neither are dentists or pedodontists; some issues simply will go unnoticed for a while and it’s no one’s fault.

Although a touchy subject, my own opinion is that if a general dentist does not refer a young patient to a specialist as recommended by the ADA, the AAO and the ABO, and the dentist is willfully ignoring skeletal problems that will predictably lead to surgery if not treated or if a patient has such severe crowding early on and there is obvious risk of impaction of teeth and/or damage to adjacent developing roots, then there is a case for complaint.  

Patient 7. 

This 7y 7mo female patient was referred for severe protrusion.
She was fitted for a Frankel II Orthopedic Appliance which
was used full time for roughly 30 months

At age 11y 8mo, the molars had been corrected to a solid Class I relationship with all
permanent teeth erupted.  A removable guidance appliance (positioner/pre-finisher) was then
employed to align the teeth and settle the bite.

12y 4mo, this patient’s bite has settled and the teeth aligned without braces (and of course without extractions).  The dramatic facial improvement and the beautiful arch development are all due to the patient’s natural growth process which was modified and enhanced during the pre-pubertal growth spurt and guided with Early Treatment Orthopedics.  Instead of headgear pushing the upper molars back to match the retruded lower molars, the lower jaw was brought forward, along with the molars, and the “bad” lower position was matched to the “good” upper position of teeth.  The positioner/pre-finisher was further used as a night-time retainer for 18 additional months to hold the correction through any latent growth.


If a general practice delegates almost all of their screening to dental hygienists and significant problems are ignored/missed for years only to lead to a more significant treatment later with loss of teeth or some other need that would have otherwise been predictably prevented, there is a case for complaint.

This is one of the most commonly missed situations of patient abuse; if a general dentist is treating with braces or aligners and cannot finish a case to the standards of the specialist, this is malpractice.  We are not licensed to experiment or gain experience from our patients without telling them there is a better treatment or doctor elsewhere.  Patients can potentially sign this away if they are advised the dentist is not a specialist and is treating with less knowledge and experience but even then, if treatment is not to the established standards and damage is introduced from the poor work, this can absolutely be malpractice.

“… if a general dentist is treating with braces or aligners and cannot finish a case to the standards of the specialist [Orthodontist], this is malpractice.”

Even if a trained Orthodontist does not give every reasonable option for treatment INCLUDING traditional braces when we all know they are better than aligners and the results fail to meet the established standards of care for traditional braces, then this can be malpractice.  Believe it or not, if a patient is not informed of what to expect if no treatment is performed at all, then this can also initiate a complaint. 
Is it worth legal remedy? In most cases probably not.  In some cases, maybe.  But is it worth changing to a different dentist?  Probably.  Dentists and Orthodontists that don’t take their profession serious enough when it comes to braces/early treatment or don’t place the patient’s needs first are probably not going to be good at other aspects of their profession.

“Even if a trained Orthodontist does not give every reasonable option for treatment INCLUDING traditional braces when we all know they are better than aligners and the results fail to meet the established standards of care for traditional braces, then this can be malpractice.”


What are Specialists doing to help educate the dentists and the public?

Orthodontists have recognized this trend of late referrals and will regularly discuss treatment rationale with their general dentist colleagues.  When a case comes in and there are obvious and predictable developmental or skeletal problems, an Orthodontist will usually contact the referring dentist and discuss timing of that specific treatment (and when it may be better treated).  We cannot make a general dental office refer every patient for screening but we do try to educate dentists on what to look for at particular ages if they are going to insist on their own screening process.  This is not ideal but a good (especially an experienced) dentist will catch a majority of the obvious problems and fair amount of the less obvious issues.  But the better doctor knows what they don’t know.  As an Orthodontist, I would never make the final decision about a crown, about a gingival graft or even what type of filing material is best; I have not kept up with current literature or standards on general dental care or restorative care.  I am not proficient in surgery or grafting even though I trained in a hospital at one time and have seen and read about certain procedures as they relate to Orthodontics.  I acknowledge that my patients would be better treated by the general dentist or other specialists in the field so I defer to them. 

The American Association of Orthodontists has also begun advertising direct to the public to educate people as to the need for children age 6 to see an actual Orthodontist without the need for a specific referral from a dentist or pedodontist.  In fact with products being pushed onto the public directly through questionable advertising from the likes of Invisalign, Smile Club Direct (owned by Invisalign) and their dental providers, dental societies are educating the public against DIY aligners and other ill-conceived treatments not based at all on function or physiology.  These products focus on nothing more but lining up a few front teeth with no thought or concern of the effects on the entire system or “forest” which consists of an entire functional occlusion able to feel the thinnest piece of paper between the teeth. The public is asked to ignore any problems or potential problems with TMJ joints, occlusion of back teeth, contact of roots or any other potential jackpot of problems possible.

These products even have disclaimers stating such and leaving it up to patients to decide if they need a real doctor (see below). 

“I further understand that my clear aligner therapy treatment will only address the alignment of my teeth and will not correct my existing bite condition. In order to correct the current condition of my bite, I will need to seek more comprehensive treatment via my local dental professional. Because I am choosing not to engage the in-patient services of a local dental professional, I understand and accept that my teeth will be straighter than they currently are but may still be compromised.


Remember that specialists are here for the public and for the general dentists/pedodontists; we exist as a specialty to provide better care for very complex treatments; and every time we move teeth and change the bite rest assured it is very complex, even if you or your general dentist/pedodontist don’t realize it.  The best way to assure you are preventing unnecessary work, reducing the most risks and providing the best/most stable correction for you or your family is to consult a trained Orthodontist as soon as you are considering treatment (this should be at age 6 for your kids).  Referrals are no longer necessary for any patient to discuss treatment with Orthodontists today and waiting for one can cost you or your kids thousands of dollars and potentially prevent achievement of a complete correction.

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.

Steiner Ranch Orthodontics, 4302 N. Quinlan Park, Austin, TX
North Central Office, 1814 W. 35th, Austin, TX

Dr. James R. Waters is a 1996 Summa Cum Laude graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Hospital Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics. He is a Diplomate of the American Board of Orthodontics and member of the College of Diplomates of the ABO.  Dr. Waters has been honored as one of “Texas Best” Orthodontists by his peers in the Texas Monthly magazine focusing on Texas healthcare providers for 14 years straight.  Dr. Waters and his wife of 23 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at www.BracesAustin.com .