Thursday, November 15, 2018

Bad Breathe and Palatal Expansion


How does Palatal Expansion RPE affect Halitosis (Bad Breathe)?




Halitosis can be a significant problem in teens and young adults; there are entire industries built on covering up bad breathe or providing products to improve oral hygiene. 
 
 


One of the many companies that focus product development for halitosis
 
 

Of course not brushing or flossing will lead to chronic bad breathe but did you know bad breathe can also be the result of certain combinations of malocclusion, poor airways and/or chronic inflammation of the nasal soft-tissue.  One of the more important factors in children can be a narrow maxilla.

 


These boys demonstrate a typical narrow maxilla with airway obstruction and chronic “mouth-breathing”.  Note the lip posture at rest being open, allowing the oral cavity to remain dry and preventing the natural cleaning from the saliva.
 

The reason the maxilla would be narrow can be from over-active musculature around the mouth and cheeks (thumb sucking, late pacifier), diseases and syndromes that affect growth, adverse tongue activity or obstructed airways causing a patient to breathe through their mouth instead of their nose.

 

This patient may seem to be the classic appearance of a character dreaming of sugar plums dancing through her head but in reality, this young lady presents with a serious malocclusion including skeletal dysplasia and a high, narrow maxilla which can and will lead to severe crowding, possible TMD and, yes, halitosis.


This child is demonstrating mouth breathing during sleep; not the decay visible on front teeth from having a constantly dry mouth.  Halitosis can start very early in development which s why children should see an accredited Orthodontist by age 6 to 7.
 
 
 
No matter the cause, the result can be chronic bad breathe (halitosis).  At a chemical level, Halitosis is caused by volatile sulfur compounds (VSC’s) which are formed by the proteolysis of sulfur-containing amino acids (cysteine, methionine) and proteins by the bacteria found in the oral cavity.  When someone has specific bacteria (gram-negative), acidic saliva, decreased saliva or basic gingivitis, the conditions are ripe for proteolysis.    


An illustration of the bacteria present in the oral cavity, bacteria that can turn proteins and amino acids into volatile sulfur compounds (VSC’s) which cause chronic halitosis.



So with patients experiencing bad breathe as adolescents and pre-adolescents, what does the Orthodontist look for and what can they do to help rid these young patients of this offensive and embarrassing infliction?


Your Orthodontist will evaluate your child’s upper jaw (maxilla) to see if the arch is narrow and constricted; they will assess the airways and determine whether expansion is appropriate and needed.  Expanders are generally used on pre-adolescents and early adolescents to restore narrow upper (maxillary) arches to their ideal widths.  Of course this increases space for teeth and helps to alleviate crowding but it also widens the floor of the nasal cavity and increases air flow.

 
 
 
In fact, according to a recent study published in the Journal of American Association of Orthodontists (Erhamza and Ozdiler, Am J Orthod Dentofacial Orthop 2018 ; 154:702-7), Rapid Palatal Expansion has been shown to significantly reduce Halitosis (measured by halimeter and organoleptic values) in patients following successful expansion at age 11 to 15.
 
 
“… according to a recent study published in the Journal of American Association of Orthodontists … Rapid Palatal Expansion has been shown to significantly reduce Halitosis”
 
Unfortunately DURING treatment, this may be a different story if the expander itself is not kept clean and the gum tissue massaged regularly around the appliance.  I use a bonded expander which protects the molars and provides a splint-like overlay for the jaw to shift on and settle to its natural position during expansion however this appliance certainly can cause temporary halitosis if oral hygiene instructions are not followed.  And certainly wearing appliances can led to difficulty cleaning the teeth and short-term bad breathe.  Regardless, even if the patient is not a great brusher during treatment, they still will benefit in the long run from expansion.
 

Several of the different sized brushes that are available to help with cleaning an expander.
 
 
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.
 
Central Austin Location, 1814 W. 35th
 

Steiner Ranch Location, 4302 N. Quinlan Park Rd. in Steiner Ranch
 
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced 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 and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 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 BracesAustin.com. 

 

Tuesday, October 30, 2018

Alzheimer's and Periodontial Disease


Chronic Periodontitis (gum disease) may have connection to Alzheimer’s disease

  

There is an unsettling trend to view dentistry as a simple cosmetic procedure with little to no focus on the well-established link of dental health to overall systemic health of the body and mind.  Social media, commercialization of dentistry, overstressing new technologies and a general erosion of ethics may all be somewhat to blame.  I don’t recall seeing anything on my Facebook come up on the dangers of Chronic Periodontitis or its relationship to life altering diseases but I certainly see many ads about Invisalign and tooth whitening.  However now and then there is a study that really is worthy of informing the public, even if it is very preliminary.

 

So how can dental health affect your body?

 

Already researchers have linked Chronic Periodontitis (Gum disease) to Cardiovascular Disease (CVD), Chronic Obstructive Pulmonary Disease (COPD) and recently to Rheumatoid Arthritis (RA), the later by promoting the onset and even the severity of RA.  In particular, bacteria that causes gum disease actually increases the severity of RA with increased bone and cartilage destruction.
 
P. gingivalis attacking bone in Rheumatoid Arthritis


But a new study recently published in the peer-reviewed journal of the Pubic Library of Science (PLOS One*, Oct. 3, 2018) was designed to investigate if there is a correlation between bacteria normally seen in periodontal disease (Porphyromonas gingivalis or P. gingivalis for short) and that same bacteria seen sometimes in the brain tissue of Alzheimer’s patients. 
 

P. gingivalis


This bacteria, P. gingivalis, is a known pathogen in the oral cavity associated with Chronic Periodontitis (the very same bacteria linked to CVD, COPD and RA), the chronic infection of gum tissue that causes people to lose alveolar bone and eventually teeth. The article was presented by Keiko Watanabe, DDS, PhD, a Periodontology professor at the University of Illinois at Chicago who focuses her research on systemic effects of specific oral bacteria known to cause Chronic Periodontal Disease in humans.

 


 


Dr. Watanabe’s prospective study took 20 mice and injected half with regular doses of the bacteria P. gingivalis while the other half received a saline injection.  After 22 weeks, the mice were sacrificed and the brain tissues compared.  As expected, the mice that received the saline injections had normal brain tissue however the mice receiving the bacterial suspension revealed brains with signs of degeneration, inflammation and senile plaque typically characteristic of Alzheimer’s disease in humans.  Dr. Watanabe points out that it is the chronic nature of the infection that related to the changes in the brain tissue, the same chronic exposure any patient would be receiving from years of chronic periodontitis.      


Brain tissue showing degeneration with plaques


It is possible there is a direct effect from the bacteria on increasing beta amyloid production (a major constituent of senile plaque and widely believed to cause Alzheimer’s) or, as Dr. Watanabe postulates, it may be an effect of neuroinflammation caused by the chronic presence of the bacteria. 
 

 
No matter the direct causation/mechanism, the study definitely suggests there is a link and there needs to be more research on chronic bacterial infections as they relate to Alzheimer’s.  Periodontal disease is a common ailment for humans even in the developed world making this potentially a landmark study.  And any advancement in the understanding and/or treatment of Alzheimer’s disease is certainly of unmeasurable value to society as a whole.  I am always quick to point out to patients the multi-faceted nature of diseases; that there can be many factors and/or triggers for what we perceive as a single disease or ailment.  Sometimes just reducing these factors is enough to keep the disease at bay or prevent expression of certain symptoms.  This is why I feel strongly that anytime you can reduce the risks, you should make that effort (and of course good oral health is in itself its own reward).
 
 
Most people reading this will have been touched one way or another with the terrible effects of Alzheimer’s disease; and Periodontitis will affect many more of us if left untreated.  This study demonstrates how even preliminary research can be employed to possibly reduce risks of potentially severe diseases simply by strengthening our individual resolves to maintain something we should already be maintaining.

 


Health as a game of Chess?
 
 




I believe we should view our individual health like a chess game (as opposed to a single faceted approach like checkers) visualizing cause and effect many moves ahead.  The sooner we realize we are in the game, the better we will fare many moves later.  Therefore I would be amiss not to point out that dental crowding is a factor in chronic Adult Periodontitis due to difficulty cleaning, approximation of roots and plaque accumulation.  Which is another reason for this article in my Blog as a Board Certified Orthodontist; just as we chase down every known factor correlating to Alzheimer’s, it is wise to also look at the predisposing factors for known antagonists.  By straightening teeth, we reduce the risk of Periodontitis which then reduces the risk (or possibly severity) of such diseases as CVD (the leading cause of death in men AND women in the US making up some 25% of all deaths each year; not including the many diseases CVD may also lead to such as stroke and heart disease.), COPD (irreversible chronic disease that ultimately leads to death), and RA (can lead to lung disease, nerve damage and osteoporosis).  And now, another piece of the puzzle, Alzheimer’s disease for which there is currently little treatment and no cure. 

 

“I think we should view our individual health like a chess game ... so I would be amiss not to point out that dental crowding is a factor in chronic Adult Periodontitis due to difficulty cleaning, approximation of roots and plaque accumulation.”

  

*PLOS One is a peer-reviewed open access scientific journal published by the Public Library of Science since 2006. The journal covers primary research from any discipline within science and medicine. The Public Library of Science began in 2000 with an online petition initiative by Nobel Prize winner Harold Varmus, formerly director of the National Institutes of Health and at that time director of Memorial Sloan–Kettering Cancer Center; Patrick O. Brown, a biochemist at Stanford University...


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.

 

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced 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 and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 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 BracesAustin.com. 

 
 

 
 


Thursday, October 25, 2018

Cost (Value) of Braces


Costs Comparable to Braces

(Cost v. Value)



Every so often I have a patient that vents their frustration concerning the cost of braces for little Johnny.  Normally I try to explain the value of Orthodontics, the improved self-image and the life-long improvement of function and oral hygiene.  In truth, Orthodontics can be justified ten times over in most cases of malocclusion and will ultimately save money in the long run while the improvement in self-image/esteem and the sheer beautiful smile is incomparable.  In fact even as an adult, a beautiful smile has been shown to improve job opportunities and lead to an increased starting pay. 

 

But I would also point out that, as far as expenses go, the cost of Orthodontics/Braces is quite reasonable and affordable for almost every family.   To look at the COST of braces, we have to look at the basic economics of a practice.

 

As a sole practitioner for over 20 years, I routinely evaluate year-end overhead versus collections to determine profit and decide on pricing for the next year.  Sometimes this means there are no price increases, rarely (though it has happened in the past), we may even drop prices due to something affecting overall overhead such as taxes.  In fact, most Orthodontic office run about 65% to 70% overhead (which is a little better than our General Dental colleagues).  I try to stay at the 65% level so that I don’t have to nickel and dime for everything we do (I do not charge for broken brackets or extended treatments from missed time).  In fact, once I set a fee, that fee remains solid for the duration of treatment.  I also allow payment plans for all patients with no interest and minimal down payments.  If overhead is too high, the fees the following year may increase to reflect such.

 


But I really cannot go into that kind of detail when a parent is staring me down for some kind of discount.  And the initial fee can give sticker shock to those who have never paid for braces before.  So first, let’s consider the history of costs for a full set of adolescent braces (adult braces have always run @$1000 more) going back to the 1990’s:

 



1995   Adolescent Braces for 18 to 24mo $3800 to $4000
2000   Adolescent Braces for 18 to 24mo $4200 to $4500
2005   Adolescent Braces for 18 to 24mo $4400 to $4800
2010   Adolescent Braces for 18 to 24mo $5200 to $5400
2015   Adolescent Braces for 18 to 24mo $5600 to $5800
2018   Adolescent Braces for 18 to 24mo $6000 to $6500

 
Orthodontics have increased steadily but reasonably over the last 23 years with a total increase from a low of $3800 to a high of $6500 or 58% total increase, 2.5% per year on average (my medical insurance alone has increased 60% over the last two years!).
 
Other prices from 1995:
Median Household Income $34,076
Gasoline was @$1.00/gallon
Average Home: $158,700
Cost of base F-150 Truck $17,000
Full porcelain Crown $300
Dow Jones 5200
 



Compared to same numbers in 2018:

 
Median Household Income $62,450
Gasoline $2.49
Average Home: $188,900
Cost of base F-150 Truck $27,700
Full Porcelain Crown $1200
Dow Jones 26,000

 

On a more recent comparative note, I just received two quotes for repairs at my house; bids to replace my 6 year old water heater from a low of $4000 to a high of $6500 and replacement of a timing chain on my 6 year old car for $5500 (plus anything else they see while in there).  In both cases, more than half was for the labor, each for 1 day’s work!  And I don’t believe they have the same education or debt.    

 

So understanding that an Orthodontist will be correcting all of the teeth into ideal esthetics and function, setting jaw relationships and improving lip support and facial profile for life, it really is a good value for the money.  I would ask anyone questioning their Orthodontist about a $6000 fee what another specialist in medicine would charge you to treat anything else for 2 solid years (and follow up for another 2 years of retention) including any supplies and overhead he/she may spend along the way for your treatment.   And most Orthodontists will allow you to pay over the treatment time with little to no interest at all making the cost of braces no more than a family’s monthly cell phone bill (if not less).


Real Orthodontics is a tremendous value compared to other dentistry and medicine; probably the cheapest comprehensive correction you can make on an otherwise healthy patient.  The changes can affect behavior, self-esteem, self-confidence along with providing a healthy bite to prevent future jaw pain/headaches, excessive wear on teeth or even fracture of teeth requiring significant life-long restorative work.  It is also a very complicated specialty of dentistry and should not be performed by amateurs or weekend-trained dentists looking to increase their collections at your expense.  When you pay for Orthodontics, you are paying for a very specialized dental and sometimes medical treatment that will change the bite and function of the teeth FOREVER. 

 

What professional does a typical fee for Orthodontics include?  The “Standard reasonable cost” is based on an expert doctor, a specialist in Orthodontics.  Orthodontists have completed dental school at the top of their respective classes and all have pursued another 2 to 3 full years training in an accredited Specialty school for Orthodontics and you are paying for that post-doctorate education and experience.

 

 

“The Standard reasonable cost [Orthodontic fee] is based on an expert doctor, a specialist in Orthodontics.”

 
 

In Specialty programs, Orthodontic residents (already dentists) may have treated over 100 patients under the tutoring and guidance of other very experienced Board Certified Orthodontists while taking a full load of post-doctorate classes to understand development, bone physiology, physics, anatomy and biochemistry.  Contrary to current marketing and attempts to dumb down Orthodontics as a equivalent to a trip to the local spa, moving teeth is very complex and wrought with risks and long-term effects.



Remember that every Orthodontist started as dentists but they are far more than dentists after specializing (and their education was far more costly).  Good Orthodontists will explain things and simplify things to basic understanding but there is a world of science, art, knowledge and experience they rely on with every case they treat; knowledge and experience deficient from General Dentists and certainly from companies with direct-to-public schemes or fake-orthodontics/aligners. 

 

 

“Paying a General Dentist even 50% of the normal Orthodontic fee is akin to paying the hygienist full price for surgical removal of teeth or paying your school janitor full tuition to teach your child math simply because he can add & subtract and has seen it on the chalk board before.”

 

 

There is simply no General Dentist with the knowledge of a Board Certified Orthodontist because the knowledge is only available with a two to three year specialty program, programs that are steeped in 100+ years of research and experience.  If you do not understand the complete mechanisms of tooth movement, you are really just a technician relying on the product/lab technicians making the appliances (i.e. Invisalign, general dentist provides of traditional braces, smile club, etc.).  Paying a General Dentist even 50% of the normal Orthodontic fee is akin to paying the hygienist full price for surgical removal of teeth or paying your school janitor full tuition to teach your child math simply because he can add & subtract and has seen it taught before.   And even that is not proper unless they fully inform you they are not educated as an orthodontist.   Paying a non-dental company (smile direct club, etc.) is more akin to straight out malpractice and practicing without a license.  Might as well get your “Orthodontics” at the local swap meet on Saturday.






As a specialty, we as Orthodontists have been complacent in allowing companies and untrained providers to advertise and market directly to the public without providing accurate information and allowing them to compare their services to real Orthodontists, advertising fake-orthodontics as the real thing and even charging the same fees when they have no expertise.  We are finally awaking to this though it is a bit late. 




Unfortunately, Orthodontics has been terribly simplified in the eyes of the public due to a campaign of misinformation, omission of facts and sometimes outright false advertising and false claims.  Costs of Orthodontics may not vary much between untrained providers and real Orthodontists but you certainly are not getting what you are paying for in many cases.

 

Orthodontics is a huge responsibility for the both your family and the doctor you choose; so choose carefully by selecting a Board Certified Orthodontist who can properly diagnose, treat and retain your family’s teeth for a beautiful smile that lasts a lifetime.  You will find that the cost is no different and the experience will be much smoother.


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.

 

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced 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 and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 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 BracesAustin.com. 

 


 

Tuesday, October 23, 2018

Braces v. Fake-Orthodontics; Public left to educate themselves about Orthodontics


Public left to educate themselves about Orthodontics;

Braces v. Fake-Orthodontics

I have written about the public’s perception of Orthodontics (see my Blog article entitled “Public Perception of Orthodontics”) as well as advertising/propaganda by social media and even by various companies and other non-Orthodontists offering lesser forms of Orthodontics or what I would term “fake-Orthodontics” such as Invisalign, etc. for many years.  However I feel I must re-visit this subject with a focus on Public self-education.



To understand what changes have occurred in marketing and advertising, we must first go back to a time when Braces were only used by experts.  As recent as 5 to 10 years ago, General Dentists performed routine dental care, root canals, fillings, restorative work (crowns, bridges, partials) and hygiene care.  And they did these very well.  At the same time, almost every General Dentist would follow the American Dental Association and American Association of Orthodontists guidelines to have every child see an accredited Orthodontist by age 6 to see if there were any early developing problems.  Teens and adults with crowding would be referred to the Orthodontist for alignment with braces. 

 

Why General Dentists referred patients to Orthodontists:

 

1.     They knew their education was limited on Orthodontics and that only the experts would be able to identify some problems early; they knew diagnosis was perhaps as important as the treatment.

2.     They cared about the long-term health of their family of patients; they knew they would be responsible in the future if something was missed early; they knew crowded teeth led to more cavities and could cause low esteem in kids and they trusted the Orthodontist to fix any problems.

3.     They wanted to offer complete service with the best options for all patients as a practice builder; they worked in a dental “community”; within a circle of professionals that were all masters of their field.

4.     There was a defined and established “Standard of care” from the ADA, AAO and every other governing boards of Orthodontics that mandated a specific proficiency and accredited education level to perform Orthodontics and General Dentists respected this ethical obligation.

5.     They knew a “Jack of all Trades” was a Master of None.  The whole idea for specialists was that there is too much information to be an expert in every field, this is why specialists also do not perform General Dentist procedures because in becoming an expert in Orthodontists, they could not also be an expert General Dentist.  Good dentists work as a team with their colleagues.

 

 

So what has changed, why are untrained General Dentists pushing “fake Orthodontics” or Invisalign/Clear aligners?

 

First of all, every point made above should be absolutely valid today.  Unfortunately, professional ethics in advertising and practice are not the same they used to be and there is so little oversight that the public is really left to the mercy of the dentist they happen to end up with (location, insurances accepted, costs, personal ethics).

 

I would argue one large problem in more populated areas has been a flood of General Dentists with a lack of restorative work to keep them busy and the rapid turn-over of practices, doctors and patients causing a move away from comprehensive general dentistry.  The trend today is to treat everything as fast as possible, do it all “in-house”, and then dismiss the patient.    

 

Insurance also has been a factor. Consider that a good, quality family dentist has to pay more for better staff, pay for an independent building or lease, buy his/her own equipment and maintain a pool of many patients over long periods of time for routine cleanings and monitoring.  A good family dentist is going to be around for many years; he/she will have to answer for any problems that may show years after treatments.   A dental company that employs dentists can share equipment, rent, and have limited to no long-term responsibility to patients.  Dentists come and go almost yearly and they have no personal responsibility for long-term dental care; companies can change dentists at an alarming rate and the company owns the records, not the employee dentist or Orthodontist. 

 

Companies can provide cheap service with less quality and can therefor accept lower reimbursement from insurances.  The more of these “dental factories” in a community, the harder it is for an independent dentist to succeed and the worse off patients are for comprehensive care. 

 

A new report last month in Dental Economics revealed an average overhead of 78% for sole dental practitioners.  Therefore, profit is only 22%.  Insurances ROUTINELY will offer HMO or PPO plans where the dentist must agree to accept lower fees in exchange for being an “exclusive provider”.  What is the discounted fee? Usually they require a full 20% discount of usual fees.  That’s right, nearly all of the profit of an independent office. 

 

 

“to accept this insurance [HMO’s and PPO’s], a dentist or Orthodontist is essentially only working to pay his/her overhead, staff and keep around 2% for profit”

 

In this environment, General Dentists start looking to increase profits by offering other services, even when they are not proficient or qualified.  They become “in-house” labs and “we do everything” clinics.  Little by little, as they introduce “fake Orthodontics” into their practice, they erode the standards of care and the entire field of Orthodontics suffers.



“General Dentists [offering Orthodontic treatment] erode the standards of care and the entire specialty of Orthodontics suffers.”

 

 

I had always been told by older Orthodontists in the previous generation that great quality will always beat out mediocre treatment but I am afraid this just is not the case in general; for one, the public goes for the cheaper route first (including insurance plans).  Secondly, it is very difficult for a patient to know what quality really is when they are bombarded by misleading advertising from Social Media, paid false testimonials, un-ethical General Dentists, Dental Factories and even Dental supply companies that present aligner trays (Invisalign, Clear Correct, Smile Club, etc., etc.) as equal to traditional braces.  It is equally difficult for an Orthodontist to advertise his/her quality to a public drowning in propaganda and social media hyperbole.  And it is uncertain whether a dentist providing “fake Orthodontics” will critique their own work if it is limited at best and more often quite deficient.  You can bet that no dentist would place restorations with the same poor occlusion they leave many times after Invisalign. 

 

 

“… no dentist would place restorations with the same poor occlusion they leave many times after Invisalign”

 

Advertisers, marketers and dental companies know every bit what patients want to hear and they exploit that routinely.  They also know they can bury the truth behind five pages of junk marketing and false claims on Google.  Just search braces or Orthodontists or even Invisalign directly and look at all of the paid advertisements; it’s impossible to find a real article about the efficacy or (in)effectiveness of Invisalign.  And don’t forget about the “art of omission” which is when a provider just says “I can straighten those teeth, let’s get an impression for Invisalign” with no mention of anything else or specialty care/standards.

 

“ …the “art of omission”… is when providers [general dentists] just says “I can straighten those teeth, let’s get an impression for Invisalign” with no mention of anything else or specialty care/standards.”

 

 

Unfortunately, as more General Dentists have been pushing the “fake Orthodontics” or Invisalign over the last 5 to 10 years, more real Orthodontists are seeing their referrals dry up and their practices losing patients unless they also provide Invisalign which is exactly the strategy of these companies; to give the other providers credibility once the specialists are also using their product.  It has become a giant game of dominos.

 




 
Something also more common in the last 10 years is that there are many more adults realizing the benefits of Orthodontics but they are more likely to resist braces; this has led to more patients treating but with inferior products such as Invisalign.  At first many of us figured some treatment was better than nothing for adults that would refuse braces.  But in the long run this has proven to create a monster of a problem as more teen are now being offered “fake Orthodontics” with aligners to try and attract them to one office over another (to tell them what THEY want to hear so they choose an office over another). This is all too common in Austin currently and is leading to rather poor treatments with low overall standards of care and many re-treats.
 
“At first many of us [Orthodontists] figured some treatment [clear aligner therapy] was better than nothing for adults that would refuse braces.  But in the long run this has proven to create a monster of a problem as more teens are now being offered fake Orthodontics with aligners to try and attract them to one office over another”
 
 
As a side note, there is also a population of dentists that will sell very large and expensive “instant correction” schemes to people instead of offering alignment by Braces.  Why? Because porcelain, ceramic, and now zirconia look better than previous generations and can cover small defects and discolorations as well as change the shape of teeth to make them appear straighter in some cases.  In the past, this would be frowned on by the dental profession as providing unnecessary dental work that damaged teeth (see the teeth being prepped for typical crowns below) and created a life-long dependence on replacement and future restorations (of otherwise healthy teeth).




I once even heard the president of the Capital Area Dental Society in Austin speak about his “Pearls of Wisdom” in a meeting with over 200 dental professionals; his “Pearl”? Shave crooked upper front teeth down and place porcelain crowns/veneers with straight front surfaces so the teeth would now be straight instantly.  Cost? $8,000 for the front six teeth.  Result? Six bulky front teeth that looked like Chiclets (yes that square, white chewing gum); opaque and monochromatic, with excessive overjet (buck teeth) due to the still-crowded inside surfaces contacting lower teeth.  Even if the front of the top teeth are made to look good (see below) the gums get squeezed out in areas and remain inflamed in many cases which can lead to periodontitis, recession and eventual replacement; opposing teeth will become severely worn and more dental problems will be created for the future.  Lower teeth can no longer be aligned because they would not fit the back of the upper teeth.

 

 
So what should the Public know?
 
“Orthodontics” is the science and practice of correcting malocclusions, not just making teeth pretty in the front.  It is a fallacy to call Invisalign a form of Orthodontics and certainly “Invisible braces” (I am sure they would disagree as would dentists that are heavily invested in Invisalign).  The facts show in almost every research study not paid for by Invisalign, and even some that are funded by Align technologies (their parent company), that traditional braces are far superior in every aspect of movement (refer to evidence presented in my Blog entitled “New 2017 Study shows Invisalign only 50% effective v. Braces” and “Does Invisalign work? (And should I believe all the Advertising)” with evidence and studies taken directly from clinical research studies published in the Journal of the American Association of Orthodontics & Dentofacial Orthopedics which sets the standards for modern orthodontics).  
 
 
“Orthodontics” is the science and practice of correcting malocclusions, not just making teeth pretty in the front.
 
In every AJODO study comparing Braces to Invisalign that I have read (and I believe I have read them all), Traditional (real) Braces are faster, more efficient, can move teeth farther with true root movements; they can be adjusted month to month as jaws shift changing the relationship and function of the occlusion and they are not compliance based.  In short, Traditional Braces provide Orthodontic corrections (ideal esthetics with ideal function and stability) while Invisalign and other clear aligners tip teeth to appear straighter without the ability to fully move teeth in all dimensions and leaves the occlusion worse off in many cases (again refer to articles presented in my Blog directly from the AJODO) and almost never equivalent to traditional braces.
 
“Braces are faster, more efficient, can move teeth farther with true root movement and can be adjusted month to month as jaws shift changing the relationship and function of the occlusion [v. Invisalign].”
 
So why doesn’t the public know this?
 
Unfortunately, technology has out-pacing regulations and dentistry.  Social media advertising has become the driving force in many direct-to-the-public campaigns and there have been no regulations and no oversight on social media, no rules or penalties for false advertising, no proof required to pass on propaganda (just look at recent elections). Companies learned this was a path for selling directly to the public instead of having to sell their product to a dental professional who then would “use” their product when it seemed appropriate or as the AJODO defined.  As a public company (no different than Coca-Cola or Hershey’s), Invisalign was run by business people, not doctors. 
 

 
They tested the public and learned exactly what the public wanted to hear, these companies then incorporated this into their social media campaign.  They also went directly to General Dentists to sell their product as a replacement for braces because Orthodontists were not accepting Invisalign as a good product for most patients.  Companies instead pushed General Dentists to provide Invisalign themselves and to profit from them without referring patients out to a specialist.  After enough years of this, and especially due to new generation of dentists that were “trained” by Invisalign marketers, almost every dentist now offers this “fake-Orthodontics” and most never refer a case out to the specialist.  Either through omission, ignorance, false claims or maybe just purely profit, it seems rare that patients are even informed of better treatment by these dentists that offer “fake Orthodontics” or Invisalign. (Refer to the Blog entitles “How Facebook is Dumbing Down Orthodontics” and “Orthodontics and Social Media”)
 
This has led to a reduced standard of care and an altogether attitude of “give the patients what they [think] they want.  As more orthodontists just give up, the future of true Orthodontics is quite literally in jeopardy.  That means true Orthodontic care to restore function, protect against TMD (jaw pain/joint disorders), provide a life-long functional occlusion and preserve natural teeth will be harder to find and more expensive.  It also means, as I have seen over and over, many cases will have been incorrectly, incompletely or poorly treated and require now require re-treatment altogether (you can see some of these cases in my other blogs titled  Braces ,,, For than just a smile” and “Braces are Better ! (and here’s why)”.
 
 
So how can patients wade through the propaganda and marketing to make sure they are paying for true Orthodontics and not a sub-par treatment?
 
First, find a good General Dentist that doesn’t try to do everything “in house”; look for someone that works his specialist colleagues to provide the very best for his patients and look for someone who is going to take time to formulate short-term and long-term treatment goals.  Talk to friends and neighbors to find a dentist that continues to follow up with patients and talk to the hygienist about the office you are seeing.
 
When it comes to any Orthodontic questions, get a consult with a true Orthodontist, preferably a Board certified Orthodontist if there is one nearby.  These are generally free of charge and very informative.  Once you are in the consult and if treatment is recommended, ask the Orthodontist for the best treatment option and have him/her provide benefits v. disadvantages of braces v. Clear Aligners if aligners are immediately recommended (I would ask them if they feel braces are faster & more reliable and can aligners move the teeth the same as braces).
 
Next, ask for similar cases already treated to see that this Orthodontist can do what they say with other cases.  All certified Orthodontists will take a full set of records on every patient (models, X-Rays and Photographs) and should have plenty of these cases to share with you.   
 
Finally, be sure and tell the Orthodontist you are expecting a successful and stable outcome; if the treatment with aligners fails, do you still have to pay for braces to finish (and who decides the results are failing)?
 
If you have a treatment with a General Dentist, you really have to have a certified Orthodontist check the results to see if your occlusion is acceptable after treatment; I have found it highly unlikely for dentists using “fake Orthodontics” to actually critique their work when complete and fewer accept issue with the bite thereafter.  If back teeth are not in contact after treatment, then you should demand this be corrected.  See my Blog “Does Invisalign work? (And should I believe all the Advertising)” to see some of the more common and obvious problems seen with Invisalign treatments.
 
Should you completely avoid clear aligners?
 
Even though Braces are superior in every way except esthetics during treatment (obviously the clear aligners are the least visible), that doesn’t mean you shouldn’t consider clear aligners for simple cases in adults.  Most people will not be able to distinguish a perfect bite from braces versus a good bite with aligners.  The problem for the public is that unless your doctor is an Orthodontist and offers both braces and aligners, you are probably not going to get an honest answer for the best treatment without some probing (and even then you may not). 
 
Orthodontists are held to a higher standard and will be more knowledgeable on when not to recommend aligners or when their inherent limitations are going to affect function after treatment. 
 
 
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.
 
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced 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 and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 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 BracesAustin.com.