The Justification for Orthodontic Treatment

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The Justification for Orthodontic Treatment

  1. 1. Advice for PCTs, LHBs and SHAsThe Justification forOrthodontic TreatmentThis document has been produced by the British Orthodontic Society
  2. 2. The Justification forOrthodontic TreatmentThis document has been produced by the ClinicalStandards Committee of the British OrthodonticSociety. It seeks to provide information forpurchasers and other interested parties about thespecialty of orthodontics. It is divided into eightsections covering modern orthodontic practice.1. What is Orthodontics? page 42. Prevalence of orthodontic page 4 problems3. Why do people need braces? page 54. Health gains from orthodontic page 7 treatment5. Risks of orthodontic treatment page 106. Demand for orthodontic page 11 treatment7. What is the best time to carry page 11 out orthodontic treatment?8. Providers of orthodontic care page 12 3
  3. 3. 1. What is Orthodontics?Orthodontics comes from the Greek words “orthos”,meaning correct or straight and “odontes”, meaningteeth. It is a specialised branch of dentistry concernedwith the development and management of deviationsfrom the normal position of the teeth, jaws and face(malocclusions). A malocclusion is not a disease butsimply a marked variation from what is considered to bethe normal position of teeth. Orthodontic treatment canimprove both the function and appearance of the mouthand face. Appliances (braces) can be fixed or removableand are used to straighten the teeth and encouragegrowth and development. The main aims of orthodonticcare are to produce a healthy, functional bite, creatinggreater resistance to disease and improving personalappearance. This contributes to the mental, as well as thephysical, well being of the individual.The photographs show how the treatment of dentalmalocclusions, often using fixed appliances, can greatlyimprove the aesthetics and function of an individual’sdentition. These dramatic improvements are known tohave significant psycho-social benefits to the patient.People with obviously unsightly teeth are very keen tohave them changed. Crowded teeth can be potentiallyunhealthy and often provoke teasing or ridicule. Oncestraightened, teeth are often less prone to being damagedand the improvement to facial appearance can bedramatic.2. Prevalence of orthodontic problemsThe 2003 Children’s Dental Health survey1 found thatapproximately one third of children would benefit greatlyfrom orthodontic treatment. Indicators of treatment needand outcome have been developed and validated by thewhole orthodontic profession to assess the efficacy andappropriateness of care. The most widely used are theIndex of Orthodontic Treatment Need (IOTN)2 and thePeer Assessment Rating (PAR)3.The IOTN is divided into two parts called the dentalhealth component (DHC) and the aesthetic index (AI). 4
  4. 4. The DHC is used to quantify the impact of a particular Dental Feature Prevalencemalocclusion upon the long-term dental health of an in Populationindividual whereas the AI provides an assessment of the (%)socio-psychological impact through appearance. They CLEFT LIP AND PALATE 0.3%are used to categorise malocclusion into five groupings IMPACTED TEETH 8.5%measured from 1 to 5 with the most severe being 5. It HYPODONTIA 1.8% (missing teeth)is generally accepted that IOTN groups 4 & 5 would REVERSE OVERJET 2.1%“greatly benefit” from orthodontic treatment as well as (lower teeth in front of upper teeth)some individuals from IOTN 3 when the AI is high at 6 or LARGE OVERJETS (top 8.8%more. The main flaw of this index system is that it fails to teeth stick out)evaluate the child’s perception of need. This may lead to CROSSBITE AND 3.0% DEVIATION OF JAWSthe denial of treatment of children with a genuine socio- ON CLOSINGdental need4. DEEP OVERBITE (lower teeth bite on 4.3% palate)Holmes5 found that 38.5% of 12 year olds would greatly SEVERE CROWDING OF TEETH 9.0%benefit from orthodontic treatment. The most common OPEN BITE (teeth do 0.7% not meet)severe problems in a normal population are detailed:3. Why do people need braces?Evidence suggests that correcting the following tooth/jaw anomalies with orthodontic appliances will benefit thepatient’s long-term dental health:-Crowding: Teeth may be poorly aligned becausethe teeth are too large for the mouth. Poor bitingrelationships and unsightly appearance may all result fromcrowding of the teeth. The upper canine teeth are one ofthe most frequent culprits.Deep (traumatic) overbite: Extreme (vertical) overlapof the top and bottom front teeth can lead to themcontacting the roof of the mouth causing significant tissuedamage and gum stripping. In some patients, this cancontribute to excessive tooth wear and early tooth loss inadulthood.Increased overjet: Upper front teeth that protrudebeyond normal contact with the lower teeth oftenindicate a poor bite of back teeth and can indicateunevenness in jaw growth. Thumb and finger suckinghabits can also cause prominence of the upper incisorteeth and increase the risk of trauma and permanent 5
  5. 5. damage to the front teeth. A systematic review of theavailable evidence on this topic found that individualswith an increased overjet had more than double the riskof injury6.Open Bite: An open bite results when the upper andlower front teeth do not touch when biting together. Thisleads to all the chewing pressures being placed on theback teeth, which may cause these teeth to wear downquicker. It may also make the patient’s biting less efficient,which may cause social problems especially at meal times.Spacing: If teeth have either not developed or aremissing, or smaller than average in size, unsightly spacesmay occur between the teeth. This is a less commonproblem though when compared with patients who havesignificant crowding of their teeth. Some malocclusionshave a greater adverse effect on quality of life than othertypes. Individuals with four or more missing teeth havebeen shown to have poorer “quality of life” scores7.Crossbite: This occurs when the upper front teeth biteinside the lower teeth i.e. towards the tongue. This canlead to one or more of the lower incisor teeth becomingmobile with early receding of the gums. It can also occuron the back teeth and is best corrected at an early agee.g. 8-10 years, due to biting and chewing difficulties as aresult of the deviated bite and associated displacement ofthe lower jaw.“Reverse” overjet or lower jaw protrusion:Approximately 3 - 5% of the population have a lowerjaw that is significantly longer than their upper jaw. Thiscauses them to bite their lower front teeth ahead of theupper front teeth thus creating a total crossbite of theteeth. It can also lead to significant wearing down of thetips of the upper front teeth. 6
  6. 6. 4. Health gains from orthodontic treatment Improved dental health and resistance to dental disease: Clinical experience suggests that poorly aligned teeth reduces the potential for natural tooth cleansing and increases the risk of tooth decay. Malocclusion could thereby contribute to both dental decay and periodontal disease, which would damage the long-term health of the teeth and gums as it makes it harder for the patient to take care of their teeth properly8. However, the evidence linking periodontal (gum) disease and crowding of the teeth is conflicting. Some studies have found no associations between crowded teeth and periodontal destruction9. Others have shown that mal-aligned teeth may have more plaque retention than straight teeth but socio- economic group, gender, tooth size and tooth surface have greater influences10. Studies seem to indicate that malocclusion has little impact on diseases of the teeth or supporting structures as the presence or absence of dental plaque is the major determinant of the health of the hard and soft tissues of the mouth. Straight teeth may be easier to clean than crooked ones but patient motivation and dental hygiene seems to be the over- riding influencing factor in preventing gum disease9. Having straighter teeth may help moderate tooth brushers to be more efficient with their oral care. Improvements in the overall function of the dentition: Teeth which do not bite together properly, can make eating difficult. Individuals who have a poor occlusion can find it difficult and embarrassing to eat because of their poor control of either biting through food or poor chewing ability on their back teeth. Adults with severe malocclusion often report difficulties in chewing, swallowing or speech. Studies have found no causative association between orthodontic treatment and jaw joint (TMJ) problems11, 12. In the main, speech is little affected by malocclusion. However, if a patient cannot attain contact between their front teeth, this may contribute to the production of a speech lisp. Prevention of trauma to prominent teeth: The risk of trauma/injury to upper incisors has been shown to increase to 45% for children with significantly 7
  7. 7. protruding upper front teeth13. These malocclusionsscore a Dental Health Component of 5, indicatinga “great need” for treatment. Such trauma to themouth of an untreated child can result in a fractureof the tooth and/or damage of the tooth’s nerve(pulp). Prominent upper front teeth are an importantand potentially harmful type of orthodontic problem.Providing early orthodontic treatment for youngchildren (aged 7-9 years) with prominent upper frontteeth is of questionable clinical significance. It may beprudent to delay treatment until early adolescence.However, important factors such as psychologicalimpact and the reduction of associated accidents(trauma) to the protruding front teeth need to beevaluated on an individual basis14.Treatment of impacted (buried, partiallyerupted) teeth: Unerupted teeth may causeresorption (dissolving) of the roots of adjacent teeth.Cyst formation can also occur around uneruptedwisdom or canine teeth. Extra (supernumerary) teethmay also give rise to problems and prevent the normaleruption of a permanent tooth. Unerupted or partiallyerupted wisdom teeth can often be left alone in themouth if they are not giving the patient any problems.Improvement in dental/facial aesthetics: Oftenresulting in improved self-esteem and other psycho-social aspects of the individual. Until recently, thisaspect has been harder to measure and quantify. Anumber of studies over the years have confirmed thata severe malocclusion can be a social handicap. Socialresponses, conditioned by appearance of the teeth,can severely affect an individual’s whole adaptationto life. This can lead to the concept of a patient’smalocclusion being “handicapping”.One of the most significant effects of a malocclusionis its psycho-social impact on the individual patient.There is little doubt that a poor dental appearancecan have a profound psycho-social effect on children.Shaw et al. (1980) found that children were teasedmore about their teeth than anything else e.g. clothes,weight, ears. A person’s dental appearance can have asignificant effect on how they feel about themselves15.Children and adolescents with poor teeth can often 8
  8. 8. become targets for teasing and harassment from otherchildren. This results in these patients being unsureof themselves in social interaction and having lowerself-esteem.Adolescents who complete orthodontic treatmentreport fewer oral health impacts on their daily lifeactivities than those who had never had treatment.Groups of children who need orthodontic treatmentexhibit significantly higher impacts on their emotionaland social well-being16. Malocclusion has a negativeimpact on the oral health related quality of life ofadolescents. Children aged between 11 and 14 yearsold with malocclusion demonstrate significantly more“impacts” i.e. worse quality of life, compared with aminimal malocclusion group based on the IOTN17.Johal et al. (2006) investigated the impact thata malocclusion has on a child’s quality of life byassessing the effect of an increased overjet (>6mm)or spaced front teeth. These groups of children alsohad more significant social and emotional issues thanchildren with well-aligned teeth18. Their research alsofound that both these occlusal traits had a significantnegative impact on the quality of life of their parentsand other family members.Shaw et al. (2007) carried out a major multi-disciplinary longitudinal study in Cardiff back in 1981of an initial sample of 1,018 11-12 year olds. A 20-yearfollow-up study looked at the dental and psycho-socialstatus of individuals who received, or did not receive,orthodontics as teenagers19. Unfortunately, only a third(n=337) of the original sample could be re-examinedin 2001 due to a 67% dropout rate. Those patientswith a prior need for orthodontic treatment, who hadtreatment completed as a child, demonstrated bettertooth alignment, better self-esteem and “satisfactionwith life” scores. However, orthodontics seemed tohave little positive effect on psychological healthand quality of life in adulthood. Unfortunately, thislong-term study suffered with problems of an archaictreatment regime (mainly removable appliances beingused), antique methodology and short retentionregime. Its relevance to 21st century orthodontics istherefore debatable. 9
  9. 9. In summary, it appears that both psycho-social andfunctional handicaps can produce a significant need fororthodontic treatment in addition to the dental healthbenefits described.The benefits of orthodontic treatment include animprovement in dental health, function, appearance andself-esteem. These perceived benefits are described inmore detail below. Prospective patients (and their parents)seem to be confident of the gains that they expect toachieve by undergoing a course of orthodontic treatment.The benefits of orthodontic treatment often go beyondimproving a person’s dental health. People may feel theylook better, which can contribute to self-esteem and one’soverall quality of life20.5. Risks of orthodontic treatmentIn the vast majority of well-planned cases, the benefitsof orthodontic treatment outweigh the possibledisadvantages. Patient education and the selection ofappropriate treatment plans for individuals reduce this riskconsiderably. The most important aspect of orthodonticcare is to have an extremely high standard of oral hygienebefore and during orthodontic treatment21.i. Early tooth decay: poor oral hygiene (toothbrushing) can lead to damage of the teeth aroundorthodontic braces. Early tooth decay (decalcification) willoccur when plaque accumulates around a fixed brace inthe presence of frequent sugar intake. Thorough dietaryadvice, excellent oral hygiene and the use of fluoridesupplements are used routinely by orthodontists tominimise this risk.ii. Root Resorption: mild loss of tooth root tissue(dissolving) is very commonly seen as a consequence oftooth movement but this does not cause any long-termproblems for the vast majority of patients.iii. Loss of Periodontal Support: if a patient’s oralhygiene is poor during treatment, orthodontics mayexacerbate gingival inflammation and susceptibility toperiodontal (gum) disease. Patients who have undergoneorthodontic treatment do not have any increased pre-disposition to developing periodontal disease22. 10
  10. 10. 6. Demand for orthodontic treatmentOrthodontics has played an increasing role in dentistryover recent years and this trend is likely to continue inthe future. Recent surveys of the long-term effects oforthodontic treatment reveal that the vast majority ofindividuals who have undergone orthodontic treatmentfeel that they benefited from the treatment and arepleased with the result. Many patients will demonstratedramatic changes in their dental and facial appearance.It is well known that not all patients with malocclusion,even those with extreme deviations from normal, seekorthodontic treatment. The perceived need for treatmentis influenced by both social and cultural factors andcurrently the demand for treatment greatly exceeds theresources available. There has been a marked increase indemand from both children and adults seeking treatmentsince the 1980s as a result of more dental awarenessby the public in conjunction with an increased socialacceptance of fixed braces.7. What is the best time to carry out orthodontic treatment?Each year, in excess of 130,000 patients (most of whomare children under the age of 18 years) have braces fittedunder the NHS in England & Wales. There is a wide rangeof opinion on the best time to start orthodontic treatmentbut the vast majority is carried out on children who havelost all their baby (deciduous) teeth and have most oftheir adult teeth (except for wisdom teeth) present inthe mouth. This means that the earliest the majorityof children commence their orthodontic treatment isbetween 11-12 years of age.Orthodontic treatment provided whilst many baby teethare still present in the mouth, i.e. at age 7-9 years, isregarded as early or interceptive treatment. A commonexample of this type of orthodontic treatment is incases with anterior and/or lateral crossbites with jawdisplacement on mouth closure23, 24. Simple expansionappliances (removable or fixed types) are usuallyemployed to deal with this clinical situation over a 11
  11. 11. few months. Another example of valid interceptiveorthodontic treatment is where the timely removal ofa baby tooth can enable the spontaneous (natural)correction of a dental centreline shift or allows an “off-track” (ectopic) adult tooth to erupt into its correctposition in the mouth without the need for braces.Most UK orthodontists do not favour early treatmentto correct increased overjets, deep overbites or severedental crowding and prefer to carry out this treatmentat the more “ideal” age of 10-12 years or later. Earlytreatment for increased overjets is commonplace inthe USA and mainland Europe. It is described as “twophase” treatment as it involves a period of early activetreatment with a functional or removable appliancefollowed by a second phase with fixed braces once allthe adult teeth are present in the mouth. This compareswith “one phase” treatment of adult teeth where thefunctional and fixed brace treatments are combinedthereby reducing the overall treatment time and possiblycost. The optimal timing for treatment of children withincreased overjets remains controversial25 and needs tobe based on individual indications for each child. Goodcommunication skills can identify specific children whosepsychological well being can be improved by earlytreatment26.8. Providers of orthodontic careIn the United Kingdom (UK), orthodontic care is providedwithin the state funded NHS at no direct cost to thepatient or their parents. All Specialist Orthodontists areDentists but only about 3% of Dentists are Orthodontists.An Orthodontist is a specialist in the diagnosis, preventionand treatment of dental irregularities and facial growthanomalies. An Orthodontic Specialist must completean initial 5-year dental undergraduate programme at aUniversity Dental School and then successfully completean additional 3-year post-graduate programme ofadvanced education in orthodontics. By the completionof their specialist training, trainees will have undertakena Masters Degree and the Membership in Orthodonticsfrom one of the Royal Colleges. Currently, hospital anduniversity trainees complete two years of additional 12
  12. 12. training before they can become eligible to apply forconsultant posts.At present, there are approximately 1200 orthodonticspecialists in the UK. These are made up of specialistpractitioners, hospital consultants and communityorthodontists. Compared with the rest of the developedworld, the UK is severely short of qualified orthodontists.The UK is 15th out of 17 European countries in terms oforthodontic provision with 1 orthodontist per 73,000population - only Spain and Turkey are worse off.Germany and Austria top the table with 1 per 30,000- the average is 1 in 55,000. Many other Europeancountries utilise orthodontic therapists to work alongside orthodontists as part of the orthodontic team. Thenumber of funded training places and the very recentintroduction of orthodontic therapists in the UK willinfluence the future availability of orthodontic care.There is a wealth of evidence to show that orthodontictreatment is more likely to achieve a pleasing, successfulresult if fixed appliances rather than removable appliancesare used27-30 and if the operator has had some post-graduate training in orthodontics31, 32. The likelihood thatorthodontic treatment will benefit a patient is increasedif a malocclusion is severe28 and if appliance therapy isplanned and carried out by an experienced orthodontist29.However, the likelihood of either a health or psycho-socialgain is reduced if the malocclusion is mild and treatmentis undertaken by an inexperienced operator33. 13
  13. 13. References1. Lader D, Chadwick B, Chestnutt I, Harker R. et al. Children’s dental health in the United Kingdom 2003.Summary Report Office for National Statistics: March 2005.2. Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. European Journal ofOrthodontics, 1989; 11: 309-320.3. Richmond S, Shaw WC, O’Brien KD, Buchanan IB. et al. The development of the PAR index: reliability andvalidity. European Journal of Orthodontics, 1992; 14: 125-139.4. De Oliveira CM, Sheiham A, Tsakos G and O’Brien KD. Oral health-related quality of life and the IOTNindex as predictors of children’s perceived needs and acceptance for orthodontic treatment. British DentalJournal, 2008; 204: E12.5. Holmes A. The Prevalence of Orthodontic Treatment Need. British Journal of Orthodontics, 1992; 19:177-182.6. Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A systematic review of the relationship betweenoverjet size and traumatic dental injuries. European Journal of Orthodontics, 1999; 21: 503-515.7. Wong AT, McMillan AS, McGrath C. Oral health-related quality of life and severe hypodontia. Journal ofOral Rehabilitation, 2006; 33: 869-873.8. Roberts-Harry D, Sandy J. Orthodontics. Part 1: Who needs orthodontics? British Dental Journal, 2003;195: 433-437.9. Geiger A, Wasserman B, Turgeon L. Relationship of occlusion and periodontal disease. Part 8:Relationship of crowding and spacing to periodontal destruction and gingival inflammation. Journal ofPeriodontology, 1974; 45: 43-49.10. Davies T, Shaw W, Worthing H. et al. The effect of orthodontic treatment on plaque and gingivitis.American Journal of Orthodontics & Dentofacial Orthopedics, 1988; 93: 423-428.11. Sadowsky C. Risk of orthodontic treatment for producing temporo-mandibular disorders: A literaturereview. American Journal of Orthodontics & Dentofacial Orthopedics, 1992; 101: 79-83.12. Luther F. Orthodontics and the TMJ: Where are we now? Angle Orthodontist, 1998; 68: 295-318.13. Todd J, Dodd T. Children’s dental health in the United Kingdom. London: Office of Population Censusand Surveys, 1985.14. Harrison JE, O’Brien KD, Worthington HV. Orthodontic treatment for prominent upper front teeth inchildren. Cochrane Database of Systematic Reviews, 2007; Issue 3.15. Shaw WC, Meek SC, Jones DS. Nicknames, teasing harassment and the salience of dental featuresamong school children. British Journal of Orthodontics, 1980; 7: 75-80.16. De Oliveira CM, Sheiham A. The relationship between normative orthodontic treatment need and oralhealth-related quality of life. Community Dentistry Oral Epidemiology, 2003; 31: 426-436.17. O’Brien C, Benson PE, Marshman Z. Evaluation of a quality of life measure for children withmaloccluson. Journal of Orthodontics, 2007; 34: 185-193. 14
  14. 14. 18. Johal A, Cheung MYH, Marcenes W. The impact of two different malocclusion traits on quality of life.British Dental Journal, 2007; 202: E6.19. Shaw WC, Richmond S, Kenealy PM, Kingdon A, Worthongton H. A 20-year cohort study of healthgain from orthodontic treatment: Psychological outcome. American Journal of Orthodontics & DentofacialOrthopedics, 2007; 132: 146-157.20. Turpin DL. Orthodontic treatment and self-esteem (Editorial)American Journal of Orthodontics & Dentofacial Orthopedics, 2007; 131: 571-572.21. Travess H, Robert-Harry D, Sandy J. Orthodontics. Part 6: Risks in orthodontic treatment. British DentalJournal, 2004; 196: 71-77.22. Sadowsky C, BeGole EA. Long term effects of orthodontic treatment on periodontal health. AmericanJournal of Orthodontics, 1981; 80: 156-172.23. Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database of SystematicReviews, 2001; Issue 1.24. Pietilä I, Pietilä T, Pirttiniemi P. et al. Orthodontists’ views on indications for and timing of orthodontictreatment in Finnish public oral care. European Journal of Orthodontics, 2008; 30: 46-51.25. Tulloch JFC, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class IItreatment. American Journal of Orthodontics & Dentofacial Orthopedics, 2004; 125: 657-667.26. O’Brien K. et al. Effectiveness of early orthodontic treatment with the Twin-Block appliance: a multi-center, randomized, controlled trial. Part 2: Psychosocial effects. American Journal of Orthodontics &Dentofacial Orthopedics, 2003; 124: 488-494.27. Jones ML. The Barry Project – a three-dimensional assessment of occlusal treatment change in aconsecutively referred sample: Crowding and arch dimensions. British Journal of Orthodontics, 1990; 17:269-285.28. Richmond S, Shaw WC, Stephens CD, Webb WG, Roberts CT, Andrews M. Orthodontic standards in theGeneral Dental Service of England and Wales: a critical appraisal of standards. British Dental Journal, 1993;174: 315-327.29. O’Brien KD, Shaw WC, Roberts CT. The use of occlusal indices in assessing the provision of orthodontictreatment by the hospital orthodontic services of England and Wales. British Journal of Orthodontics, 1993;20: 25-35.30. Turbill EA, Richmond, Wright JL. A closer look at General Dental Service orthodontics in England andWales I: Factors influencing effectiveness. British Dental Journal, 1999a: 187: 211-216.31. Fox NA, Richmond S, Wright JL, Daniels CP. Factors affecting the outcome of orthodontic treatmentwithin the General Dental Services. British Journal of Orthodontics, 1997; 24: 217-221.32. Turbill EA, Richmond, Wright JL. A closer look at General Dental Service orthodontics in England andWales II: What determines appliance selection? British Dental Journal, 1999b: 187: 271-274.33. Mitchell L. 2007 Chapter 1.6 ‘The effectiveness of treatment’, page 5, in ‘An Introduction toOrthodontics’ 3rd edition, Oxford University Press, England. 15
  15. 15. Produced by the Clinical Standards Committee of the British Orthodontic Society 2008 British Orthodontic Society 12 Bridewell Place London EC4V 6APEmail: ann.wright@bos.org.uk www.bos.org.uk Telephone: 020 7353 8680 Fax: 020 7353 8682 Registered Charity No: 1073464 CB 1 July 09

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