Tuesday, October 23, 2018

Braces v. Fake-Orthodontics (Invisalign); 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. 


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