James R. Waters, DDS, MSD, PA: February 2018

Thursday, February 22, 2018

Debunking the Myth of Superior Oral Hygiene with Invisalign

Debunking the Myth of Superior Oral Hygiene with Invisalign.

With the advent of direct advertising to the public, one item that has continuously been claimed is that Clear Aligners such as Invisalign, Clear Correct, ClearPath or a dozen other brands provide better oral hygiene for orthodontic patients. This mantra has been echoed by dentists working to compete against their specialist colleagues offering true traditional orthodontics with braces and other appliances. But is this based in truth or just another hollow advertising promise by the companies and dentists providing these other products? Let’s look at one such ad from an aligner company:

First, no one is doubting the esthetics of clear aligners; and they can move teeth into better alignment, just not as quickly, not as efficient and certainly not to the same degree in many, many cases. Additionally the idea/myth of minimal appointments and few visits should be a red flag pointing to the fact that they are used as a mail-order type of appliance with little oversight by dental assistants (often trained in a few minutes to place aligners) and even less from the doctors themselves.

And teeth, believe it or not, will not move faster because of an aligner, ever. That is because aligners are removable and they get loose from function in the mouth and constant removal and replacement. In fact, there are many studies that debunk much of the advertising concerning aligners (see previous Blog article Does Invisalign work?) so these companies have skipped the Orthodontists and advertise directly to General Dentists and the public through TV ads and radio.

Putting that aside, I want to focus on the advertisement claim of “No Effect on Oral Hygiene” and the most current research to address this myth.

In the February 2018 issue of the American Journal of Orthodontics and Dentofacial Orthopedics (AJODO), this very question has been answered with a prospective, randomized clinical trial comparing not only clear aligners with traditional braces, but also traditional braces with self-ligating braces (also a company that has claimed better oral hygiene). (1)

“No evidence of differences in oral hygiene levels among clear aligners, self-ligating brackets, and traditional elastomeric ligated brackets after 18 months of active orthodontic treatment.”(1)

“The observations made in this study contradict popular beliefs that removable appliances have a minimal effect on periodontal health”

This study was set up using 71 patients (41 boys, 30 girls with a mean age of 15.6 years old). 27 patients were treated with Invisalign aligners, 22 patients were treated with self-ligating braces and the last 22 patients were treated with traditional braces.

Oral hygiene was studied before treatment, at 9mo into treatment, and 18mo after treatment.

Results revealed “No evidence of differences in oral hygiene levels among clear aligners, self-ligating brackets, and traditional elastomeric ligated brackets after 18 months of active orthodontic treatment.”

In fact, the researches point out that “The observations made in this study contradict popular beliefs that removable appliances have a minimal effect on periodontal health”

In discussion, the authors point out that this confirms previous research that covering the teeth with aligners prevents self-cleaning effects of tongue and saliva (below).

“The continuous coverage of all surfaces of the teeth including 1 to 2 mm of gingiva by aligners has been shown to prevent the flushing effect of saliva on dental tissues” (2)

It is also mentioned from other previous studies that, “insufficient saliva secretion reduces the self-cleansing mechanisms of the oral cavity and limits the antimicrobial effects of the residual saliva.37Med Oral Patol Oral Cir Bucal. 2010; 15: e924–e92938Am J Orthod Dentofacial Orthop. 2012; 141: 598–603 This can potentially lead to greater accumulation of dental plaque. Furthermore, the margins of aligners are almost never perfectly smooth. This can irritate the marginal gingiva.” (3, 4)

So once again, even though you may hear it and see it in advertisements, online resources or even word of mouth, true research shows that oral hygiene concerns should not be a factor in choosing aligners v. traditional true Orthodontics (i.e. Braces).

* https://doi.org/10.1016/j.ajodo.2017.10.009

1. Aditya Chhibber,a Sachin Agarwal,b Sumit Yadav,c Chia-Ling Kuo,d and Madhur Upadhyayc

Norwalk, Ohio, Melbourne, Australia, and Farmington, Conn, Which orthodontic appliance is best for oral hygiene? A randomized clinical trial, (Am J Orthod Dentofacial Orthop 2018;153:175-83)

2. Addy, M., Shaw, W.C., Hansford, P., and Hopkins, M. The effect of orthodontic appliances on the distribution of Candida and plaque in adolescents. Br J Orthod. 1982; 9: 158–163

3. Lara-Carrillo, E., Montiel-Bastida, N.M., Sánchez-Pérez, L., and Alanís-Tavira, J. Effect of orthodontic treatment on saliva, plaque and the levels of Streptococcus mutans and Lactobacillus. Med Oral Patol Oral Cir Bucal. 2010; 15: e924–e929

4. Türköz, C., Canigür Bavbek, N., Kale Varlik, S., and Akça, G. Influence of thermoplastic retainers on Streptococcus mutans and Lactobacillus adhesion. Am J Orthod Dentofacial Orthop. 2012; 141: 598–603

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 35^th 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 20 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.

Wednesday, February 21, 2018

Orthodontics and Social Media

Rating an Orthodontist by their online footprint?

As we move more and more into the technological age and the age of social media, we relay more and more on the word of others including Facebook, Twitter, Snapchat, Blogs, etc. etc. This often includes semi-anonymous ratings on various online search engines and listings such as yelp, Google and others. We even have neighborhood “service orientated” groups that offer advice and recommendations from neighbors with the assumption that reviews are objective and honest (and accurate). But how honest and relevant are these reviews? Who are we allowing to make medical decisions for ourselves and our families?

Recently we had an election for President of the US, I am sure you have all heard of Russian interferences through Social Media platforms and false accounts. Essentially, it turns out that foreign nations such as Russia have learned how social media can influence behavior and actions by driving certain conversations and providing false information in what may seem like an honest presentation; once provided in a well-known platform like Facebook, the normal person may be misled and act out accordingly.

And here is another beauty:

Advertisers for certain Orthodontic treatments (among many services and products) have learned these same tricks to a much more effective degree. There is an entire industry of tech-savvy young “professionals” that provide social media driven advertising including fake recommendations and “likes”, fake followers and gimmicky ads that pop up on our phones or computers as if providing a service out of the niceness of their little hearts.

Professionals like Orthodontists that practice in competitive markets (such as here in Austin or any other decently sized city) have in turn realized that without an online footprint they are at a disadvantage.

Typical consultant advertisement for doctors.

Additionally, companies that would normally provide data and research to doctors for review have learned to skip the doctors/experts and advertise their products straight to the consumers as if orthodontics is a small appliance or box of candy for consumption. Some companies have even changed the landscape of the profession as a whole by telling patients exactly what they want to hear and making promises beyond belief, ultimately becoming so large that they simply out-advertise and out maneuver all of their competition including the doctors themselves. Invisalign comes to mind but there are many similar products that over-promise and under deliver.

So What is the Solution?

So now I would probably go into the answer for the problem; a solution following great thought and much deliberation however, like so many others in practice, I really do not have a good answer to simple human nature. In truth, we just have a hard time dismissing something or questioning something that is presented in a professional and well placed venue. It used to be a joke that “I heard it on the Internet so it must be true” however this is simply not a joke anymore. People as a whole do believe what they hear and advertisers know this; they use it to push one product over another and one practice over another.

Believe it or not, false reviews are actually accepted in business today as a necessity; just look at the following articles:

We have to remember that even though there is a long history of ethics in medicine, the lines of business and medicine blur as more companies buy medical and dental offices and commercial (and un-regulated) social media becomes more a of a driving force for referrals. Many succumb to the age-old adage “if you can’t beat them, join them”.

What can you do to assure you are seeing an expert Specialist in Orthodontics?

If you are looking for a great Orthodontist what can you do to make sure you are at the right office? The time-tested simple way to know you are choosing a great doctor is the same it has always been:

1. You can talk to friends that have had treatment at the office.

2. You can review that Orthodontists online information and check their experience, confirm they are a true Orthodontist/specialist, see how long they have been in practice.

3. You can check to see if they are Board Certified and a Diplomate of the American Board of Orthodontics and member of the American Association of Orthodontists (these are the two ONLY organizations for true specialists).

4. You can set an appointment and meet them in person (this is always a free visit); at this visit you should get an idea of what that Orthodontist would do, if there is a problem and when any problem should be treated. They should be able to show you some of their previous work with similar patients. If you or your child is ready for treatment, they will likely recommend records (pictures, impressions and a couple X-rays).

5. A good Orthodontist will not start treatment without providing a written treatment plan and copies of the records to you at a consult. There may be treatment options but a good Orthodotist will ultimately tell you what is possible with different appliances/aligners/braces and which is best (and why).

Other things to look for are a nice, clean office independent of other doctors and with friendly staff. Orthodontic offices are generally more open so you will likely see the office “in motion” and can see how the doctor and staff interact with the patients already in treatment.

So do online activity and/or reviews matter when choosing your Orthodontist?

Clearly if you are reading this Blog, you will know that I do try to educate my patients and the public through the Internet though it is only a small part of my practice and really meant more of a reference for people that may ask questions when I am out and about or for referring doctors looking to educate themselves for their own practice. But I am in no way a great doctor because I have a Blog or have good reviews on the various social media and search engines. I do not pay to be placed anywhere (and therefore I am probably on page 4 of Google which is essentially oblivion) and I do not hire professional reviewers or tech teams that push my online presence. So online, I may be more difficult to find, I may not have 10000+ followers or 500 reviews.

What I do have is a good reputation with local doctors, patients and neighbors and I work very hard at that. I will miss the casual patient who decides he/she should get teeth straightened because of a pop-up ad on their phone; I will miss the patients that are referred by Invisalign to their “favorite” doctors (which are usually general dentists and Orthodontists that may not even see the patient themselves for more than a brief minute to collect money). I will probably never see the patient that lives and dies by online reviews since I will not pay for my own. In truth, a great Orthodontist that places his/her patients first will never have the time to base their practice on such advertising and we would rather put our dollars into the comfort and care of our existing patients (or even keep our costs down for our patients) then pay monthly to have people tell others how great I am.

As a consumer and prospective patient, you should take the time to do your own leg work and meet your local Orthodontist; if you have a choice (and most people do), then meet several. Talk to them and get comfortable before committing your time and money. Treatments can take 2 years; what you don’t want is a constantly revolving set of doctors or a careless doctor that never seems to see you or your family at each visit. And once you do find a good Orthodontist, trust them and let them do their work; they will give you updates and make the process an easy one while providing a great service that can last a lifetime.

Wednesday, February 14, 2018

Why would I need Braces for relatively straight teeth?

My teeth look straight, why do I need braces?

The trend in current general dentistry seems to be not to send patients to the Orthodontist unless their teeth are incredibly crooked or unsightly. Unfortunately for patients, severe crowding is only a symptom of some other problem that was evident much earlier and may have been correctible (preventing crowding) much earlier and with less effort and certainly with more stable results. Even worse, teeth in poor function sometimes can look very normal to the untrained eyes and yet be very detrimental to teeth. Even straight teeth may need braces but unless a trained Orthodontist evaluates your bite, you may not know until it is too late. And dentists just are not trained to the same level as specialists when it comes to functional development of the bite a as whole. General dental offices are focused on the trees, not the forest as a whole. Hygienists are trained even less; they are experts at cleaning the teeth but are not trained in facial development or early dental development to the level as a doctor or Orthodontist yet many times this may be the only professional that sees you at the check up for more than a minute. Without a referral to an Orthodontic specialist, you may never know what they also cannot see.

“Even straight teeth may need braces but unless a trained Orthodontist evaluates your bite, you may not know until it is too late.”

For the purpose of brevity I will focus on one main type of a malocclusion Orthodontists see regularly that requires braces despite have teeth that appear straight: what we term the Class II Division II malocclusion. This malocclusion is characterized by upper front teeth leaning backward blocking the lower teeth back. This leads to crowding in the lower arch, a deepbite (where the lower teeth deflect off the upper teeth and keep erupting up toward (and sometimes into) the palate, heavy occlusion on front teeth and sometimes a retruded lower jaw. An example of the Class II Division II malocclusion is shown below:

Note the backward tipped upper incisors and their effect on the lower teeth. From age 6 to 12, these patient’s will grow into ideal overjet if we simply round out the upper arch and upright the incisors. Without treatment, the bite continues to deepen and the lower jaw is dislocated distally (backward).

Since the lower jaw cannot come forward, these patients function backward into “Class II” malocclusion (the lines in the above photo should line up with each other but the lower jaw is pushed backward). This leads to severe wear on front teeth as it dislocates the condyles to the back of the joint space increasing the chance of eventual chronic TMD/headaches.

Class II can be worse on one side; again the lines above should be coincident but as you can see the lower jaw is pushed backward not allowing the jaw to occlude or bite forward.

When the patient does bring her lower jaw forward into the center of her joint space (aligning the lines drawn in the two earlier pictures), the front teeth occlude too ealry (holding the back teeth apart) causing the lower jaw to push backward (Class II); this hinders the actual growth of the mandible leaving patinet with a retruded chin (see below).

So the next question is:

What can this “Class II Division II malocclusion” lead to if left un-corrected?

Below you will see examples of patients with this malocclusion that were never treated and now have come to have their respective teeth corrected.

Case 1.

This patient is in his mid-forties and after a lifetime of heavy contact due to backward tip of upper front teeth and over-eruption of lower teeth, he has experienced severe wear which has worn down through the enamel and well into his dentin. It may take 10 to 20 years to get through the enamel, but once the opposing teeth reach the softer inner dentin of the tooth, the wear becomes very rapid sometimes reducing the tooth all the way to the gumline. As is the case with this patient, we must restore the position of teeth to the correct angles and levels in preparation for full porcelain veneers. At the current positions, there is no room to place veneers; they would simply break apart within the first week.

After 14mo in braces, the teeth have been “leveled” to the correct position and upper teeth have been uprighted outward to the correct angles. Space is now available for porcelain restoration.

After braces and porcelain veneers; total treatment time 18mo.

Case 2.

Patient presents with severe long-term wear, through his enamel, due to lingual (backward) tipped upper incisors and a lifetime of functioning on his front teeth. Note the “scrunched” face from a persistently decreasing vertical facial height.

Braces were used to re-open his bite, increase lower facial height and provide space for restorations. The upper incisors were also uprighted to their correct angle (v. leaning backward into the bite).

Braces have been removed and restorations placed by his general dentist. Occlusion is now restored with improved esthetics however the greater change is in the increase facial height making this patient look years younger even after nearly two years of treatment.

Now returning to the younger patient first pictured in profile at the beginning of this article, we can see that early correction of the backward tipped upper incisors allows the lower jaw to grow forward and the teeth to erupt into ideal function for a lifetime of normal occlusion:

Initial Photos with Class II occlusion and severe mandibular hypoplasia (note retruded mandible). Early treatment was performed around age 8 to upright backward tipping (erupting) upper incisors and to expand the upper jaw to prevent constriction backward of the lower jaw.

Following early treatment to enhance mandibular growth and open space for permanent teeth and final alignment. Note the marked improvement of the lower jaw years after the correction and the ideal fit of the teeth.

How can you tell your child may need braces despite having relatively straight teeth?

1. See an Orthodontic Specialist; initial exams are almost always free and a specialist will be able to tell you very quickly whether treatment is recommended, why and most importantly, when to begin for the best outcome.

2. Don’t just look straight at the teeth, look at your child’s profile when they are not paying attention to you; if the lower jaw is recessed significantly, you should see an Orthodontist (even if your dentist has not said anything; remember it is the Orthodontist that is trained to identify and correct the developing malocclusion. Waiting can lead to more severe problems, possible loss of permanent teeth due to crowding, wear of teeth and even TMD/joint pain later in life.

3. Look at your child’s teeth, if the upper front teeth are leaning back, your child needs to be seen by an Orthodontist. You will also likely see crowding of the lower teeth and, as the your child gets older, the lower teeth will grow up and contact the palate behind the front teeth.

4. If your child’s lower teeth are in front of the upper teeth you can figure treatment is needed and needed early; you should see the Orthodontist to discuss timing and options.

Remember that in these days of corporate advertising, false promises from clear aligners and television campaigns that stress looks without even mentioning function (that is a whole different article in itself!), function is far more important in the long run and teeth that are in ideal function always produce a great smile; unfortunately a “good looking smile” does not equate to ideal function. Only a trained Orthodontist is going to have the years of experience and knowledge to give you a consistently great treatment plan and provide the most ideal outcome every time.

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.