| Questions in Clinton









Since orthodontics is a specialty why do some general dentists and pediatric dentists also provide orthodontic treatment?

The Mississippi State Dental Practice Act is the law governing the practice of dentistry, and it's purpose is to protect patients from incompetent and unethical dental providers and to prevent unqualified non-dentists, such as dental technicians, from practicing dentistry. General dentists may legally provide services in all areas of dentistry if they believe they are competent to do so. Pediatric dentists are specialists in treating children and therefore may provide any dental services for children if they believe they are competent to do so. Although these dentists may legally provide orthodontic care for their patients, they are prohibited from misleading patients to believe they are specialists in orthodontics. They are not allowed to identify themselves as orthodontists.

All dentists are expected to abide by the American Dental Association's Principles of Ethics for the Practice of Dentistry, so they should not provide services to patients unless they are adequately educated and competent to do so. Most dentists are ethical and strive to provide excellent dental care for their patients. If they do not feel competent with more difficult cases, they usually refer them to the various dental specialists. A dentist is expected to make that decision before starting any  procedure. The problem with orthodontic treatment is that many cases which initially appear to be quite simple can quickly become complicated, and some mistakes cannot be satisfactorily resolved later, even by an orthodontist. Specialists are expected to recognize potential problems in the beginning so that complications can be minimized. Even orthodontists sometimes encounter unexpected problems which prevent them from achieving the excellent results expected.


Why do some orthodontists start braces or removable appliances for very young patients?

Early treatment is discussed in the Children section, but some orthodontists do treat more very young patients than others. There are reasons why early treatment can be appropriate, but treatment can be postponed in most cases. Dr. Rushing prefers to postpone active treatment of problems which can be corrected  later without causing complications. As discussed in the Children section there are some cases which definitly should be treated early. However most patients can be treated in one phase starting around twelve years of age. It is important to have the first evaluation by an orthodontist before the last four baby molars are lost, as this allows treatment to be done without extractions in more cases.


Why can one orthodontist treat a patient without extracting teeth when another says teeth must be extracted?

There are  two primary reasons why orthodontists choose to extract teeth.  First, if the teeth are significantly crowded, some teeth are removed so the remaining teeth can be straightened. Secondly, if the front teeth protrude and need to be retracted, some teeth may have to be removed to provide the necessary space. Almost any patient can be treated without extractions by any orthodontist, but to do so may violate well-established treatment parameters. The proper question for each individual patient is not "Can treatment be done without extractions?", but should it be?" Be assurred that when permanent teeth are removed the spaces are completely closed with the braces.

Since we claim that orthodontists are highly trained specialists, how can there be a strong disagreement about such a serious issue as extracting teeth? In the early years of the orthodontic specialty all patients were treated without extracting teeth. Some orthodontists continued to see their treated cases collapsing and started extracting premolars, and this did reduce the problem of relapse. When it became obvious that better results were obtained by extracting teeth, it became a common practice. This then led to the problem of orthodontists indiscriminately extracting teeth in too many patients. The pendulum then slowly moved back to the center, and there was a healthy balance between extraction and non-extraction treatment. Today the pendulum has moved back toward non-extraction again. We now must answer the question "Why are highly educated orthodontists now choosing  to treat patients in a way that was proven to be unsuccessful in the past?" There is no scientific evidence to justify this change.

The extraction vs. non-extraction issue should not be controversial if the goal for orthodontists is to do what is best for patients. This issue has been thoroughly studied and debated by orthodontic researchers and educators, and many scientific studies have clearly shown that extractions should be done for many orthodontic patients. The degree of crowding can vary from very mild to very severe, and the treatment method can vary for each situation. The crowding can be resolved by extracting teeth, by reducing the widths of teeth, or by expanding the teeth forward or laterally. Orthodontists have known for years that expanding the teeth does not increase the bone supporting the teeth, and that over-expanded teeth are not stable. The supporting bone and gum tissue around the teeth tend to recede when teeth are over-expanded, and this is a very unhealthy problem.

Research studies and many years of experience have taught orthodontists that expansion of the teeth should be avoided in most cases. Surprisingly there are now orthodontists claiming that they are using special braces which cause the bone to grow as the teeth are expanded, and they claim that the teeth will be stable. These claims are not supported by good scientific studies. From a scientific and biological standpoint it seems rather absurd to think that the bone cells will react differently because a particular bracket design is being used.

The extraction issue is an emotional one with parents and patients. They would always prefer to hear that teeth will not be extracted. Patients with knee injuries would always prefer hearing that they do not need surgery, but orthopedic surgeons have to tell them what they need. Likewise, if a better orthodontic result can be achieved by extractions, it is the duty of the orthodontist to honestly advise the patient and parents what is needed. Many orthodontists are focused on marketing and gaining new patients, so they lean strongly toward non-extraction treatment in order to gain the favor of potential patients. They will often agree to start the treatment without extractions to appease the patients and parents, and then after a few months they will recommend extractions. This may be a savy marketing technique, but there is certainly an element of dishonesty involved. It is unwise to choose an orthodontist simply because he or she agrees to treat the patient without extractions. One of the worst mistakes an orthodontist can make is to treat a patient without extractions when the patient really does need to have extractions.

Dr. Rushing believes it is his professional and moral duty to treat all patients honestly and to the highest standards possible based upon the scientific evidence available.Therefore he develops an individualized treatment plan that is most appropriate for each patient. He then has a consultation appointment to explain the treatment plan and to answer any questions before any treatment is started. Our goal is to treat our patients as we would expect to be treated ourselves.


Why are headgears used by some orthodontists and not by others?

The simplest answer is that orthodontists who use headgears are extremely concerned about quality results, while others may be more concerned about marketing themselves. They  believe they will gain more patients if they do not ask them to wear headgears, and this is probably true. Parents could let their children skip school when they don't want to go, but they send them because they know it is necessary for good grades. Dr. Rushing asks patients to wear headgears when it is best for them, because he knows it is an orthodontist's professional duty to provide the very best treatment possible, using the best tools available. He spends the time necessary to educate patients and their parents about his recommendations, and they generally comply satisfactorily. Some patients are not cooperative, and  their orthodontic results can be far from ideal. However, when orthodontists totally abandon the use of headgears, many of their patients will have compromised results, and that is professionally unacceptable.

A headgear, also called a night brace, is an orthodontic device that is worn at night while sleeping. It fits around the back of the head or neck and usually attaches to the upper molar teeth. Two basic reasons for wearing a headgear are discussed below:

1. When the upper front teeth protrude and need to be retracted, an orthodontist applies a force to them with rubber bands, elastic chains, springs, etc. to pull them back. These also place forces on the back teeth and tend to move them forward. A headgear is often used to hold the back teeth in place while the front teeth are pulled back. There  is  a tug-of-war between the front teeth and the back teeth, and the headgear helps keep the back teeth in place.

2. When a child has a protruding upper jaw or a receding lower jaw, a headgear is used to pull back on  the upper teeth and jaw. This force is very effective in slowing the forward growth of the upper jaw, and this allows the lower jaw to catch up. A great improvement of the facial profile can be achieved.

Patients who are willing to wear headgears while sleeping definitely have a greater potential for excellent, stable orthodontic results. Many other devices are used for this purpose, but all of them produce a negative side effect by moving the lower teeth forward. The headgear is the only device commonly used for this purpose that does not also advance the lower teeth. However, temporary anchorage screws (TADS) placed in the bone can be used in some cases to prevent unwanted tooth movements.


Does Invisalign Work?

Note that Invisalign appliances are not the only clear aligners available. Various other companies offer clear aligners for orthodontic treatment. Aligners certainly can straighten teeth but are not as effective as conventional braces for most types of tooth movements. With conventional braces, individual  brackets placed on the teeth allow the teeth and their roots to be moved efficently in all directions with wires, elastics, springs, etc. Root alignment is a very important aspect of good quality orthodontic treatment and should not be neglected. Dr. Rushing believes that aligners are appropriate only in the very few cases which have minor crowding or spacing. Dr. Rushing can treat these minor cases with removable appliances or braces for lower fees than he can treat them with Invisalign appliances. Dr. Rushing has re-treated patients with conventional braces after they were treated with Invisalign appliances, because significant orthodontic problems were not corrected by the aligners. Unfortunately, these patients had to pay twice for their treatment. Patients can avoid this scenario by choosing orthodontists for their orthodontic treatment. Align technology aggressively advertises Invisalign to general dentists and entices them to treat orthodontic patients without having proper training in diagnosis and treatment of orthodontic problems.


What are Six Months Braces?

Be assured that only those patients with very minor orthodontic problems can be treated in six months to the high standards expected by the dental profession. However, all patients can have some of their teeth aligned in a few months if quality is not a priority. When the front teeth are very crowded they can be trimmed in widths and pushed forward enough to straighten them, but this may actually make the upper and lower teeth fit together worse than before. 

Some general dentists are advertising six months braces for adults, enticing them to forego comprehensive orthodontic treatment, which typically requires much more time. Most adults with orthodontic problems have discrepancies which cannot be properly corrected in such a short time. Orthodontic treatment which ignores these issues is penny-wise and pound-foolish, because  the cost is substantial, especially for a compromised result. In many cases veneers and crowns are also required, making the final cost very expensive.

Advocates of "Six Months Braces" say they are offering patients what they want, and that is probably true. However, all dentists have a responsibility to advise patients of what is really best for them, and all dentists are required to do no harm with the treatments they provide. Treatment which can be done may be very different from what should be done.

Anyone interested in braces should have an evaluation by an orthodontist before consenting to any type of treatment. All treatment options will be discussed, and If there is a reasonable option which can be done in a short period of time, the orthodontist will be the best person to provide that treatment.

Clinton Dentist | Questions. Evertt Rushing is a Clinton Dentist.

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