How to choose an orthodontist

Los Angeles Times

July 1, 2011

The do's and don'ts of choosing an orthodontist.

•Write down questions in advance. Bring up things that concern you.

•Visit websites such as braces.org for more information before your visit.

•If you've been referred to multiple orthodontists, visit their websites (if they have them). Learn a little about orthodontics beforehand. If you've heard a couple of different names of orthodontists, bounce them off your general dentist or your pediatric dentist. Ask questions such as "have you seen any of his or her work?" and "What do you think of it?"

•Always feel free to ask additional questions, and make sure you're comfortable with the answers you're getting. "Good doctors are good teachers," says Lee Graber, past president of the American Assn. of Orthodontics and an orthodontist in Vernon Hills, Ill. Orthodontists need to be able to explain why they're doing what they're doing, the expected result, and of course the consequences of not going ahead with the treatment, says Graber.

•If you still don't feel comfortable with the research you've done on your own and the questions you've asked, get a second opinion. It's important to have good rapport and communication with the orthodontist, because it can be a long-term relationship. Says Graber: "I might see a youngster at age 7, not treat them until age 11, but still follow them through with them until they're 18. So I've seen that youngster for 12 years."

•Be sure that the person you're seeing has his or her credentials and is a specialist.

•Don't hesitate to get second opinions, but beware of soliciting too many opinions. "There are a lot of roads to Mecca in orthodontics and a lot of different ways to do things and get good results," says Graber. "So you may hear things explained differently. While I as a healthcare professional might be able to differentiate that he's using different words but talking about the same thing that she was in this office, the consumer may get confused."

•If you find someone you like right off the bat, don't feel badly about picking that person. Most initial exams are done at minimal costs for patients to meet the doctor and find out the scope of treatment that might be needed.

— Amanda Mascarelli

The quest for the perfect smile

Studies back up many consumers' perception that looks matter.

By Amanda Mascarelli, HealthKeyLos Angeles Times

July 1, 2011

The job of an orthodontist has morphed over the years, says Dr. Mark Yanosky, an orthodontist inBirmingham, Ala., and an adjunct assistant professor of orthodontics at the University of Alabama at Birmingham. It used to be that people just wanted well-aligned teeth, he says.

"Now, people come in and want well-aligned, perfectly white teeth with beautiful digital contours; they want a beautiful smile, beautiful facial aesthetics," says Yanosky. He sums up the approach as "smile aesthetics."

The emphasis is perhaps unsurprising. Magazine ads promote an array of tooth-whitening products. Television commercials tout Invisalign, a widely used, removable brace. And Internet come-ons for prettier, better teeth abound.

Meanwhile, gobs of studies show that people who are perceived to be attractive — known as the "what is beautiful is good" concept — receive greater social benefits.

This physical stereotyping leads people to assume that "attractive" individuals are more intelligent, are more qualified in job interviews, and have happier marriages. A 1974 study in the Journal of Research Personality and a 2001 study in the Journal of Social Psychology found that physical appearance even influences the verdicts and sentencing of defendants on trial.

Some research has focused specifically on teeth, finding that people make negative judgments about individuals with rotten teeth. A soon-to-be-published study expands on that research.

"We knew that was true, but we didn't know how that applied to just having straight teeth or crooked teeth," says Dr. Steven Lindauer, professor and department chairman of orthodontics at Virginia Commonwealth University in Richmond.

To evaluate the psychological and social benefits of orthodontic treatments and the importance of teeth in the assessment of physical attractiveness, Lindauer and his colleagues selected teenage volunteers age 10 to 16 years old; they chose the teens by standing outside a movie theater and offering movie vouchers to participants.

The researchers took the teens' photos and digitally inserted straight or crooked teeth into the photos of each. They then showed the images to other study participants, so that one group saw a face with crooked teeth while the other group saw the same face with straight teeth. The reviewers were asked to rate what they thought about the faces based on popularity, sports ability, leadership, and intelligence.

In an upcoming report in the American Journal of Orthodontics & Dentofacial Orthopedics, the researchers say that those with straight teeth were rated 10% higher than the faces with crooked teeth in all of the categories except for smarts. In the intelligence category, the difference was not quite statistically significant, says Lindauer, but close. The results indicate a "modest social benefit" to having straight teeth, says Lindauer.

Dr. Lee Graber, an orthodontist in Vernon Hills, Ill., and past president of the American Assn. of Orthodontists, can vouch for the allure of perfect teeth.

He recently saw a patient — a physician — who didn't like the appearance of her teeth and the way her lips were sinking. "She's a pretty, smart physician — she shouldn't feel that way, but she does," says Graber.

"The data is there on the social science side that we live in a society where not looking abnormal, but looking good, is a valued commodity," says Graber. "You can say you're not supposed to judge a book by its cover, but we do it every day."

HealthKey@tribune.com

Copyright © 2011, Los Angeles Times

You have to get braces? Cool

The dental devices are lighter, more comfortable, less expensive and less noticeable than before, with kids and adults alike willing (and sometimes eager) to get them.

By Amanda Mascarelli, HealthKeyLos Angeles Times

July 1, 2011

Gone are the days when braces regularly provoked taunts of "tin grin" and "metal mouth." Nowadays, braces are not only more accepted than ever — for children and adults alike — they're often downright desirable.

"I think it's become a rite of passage in some way in this society," says Dr. Indru Punwani, professor and department head of pediatric dentistry at the University of Illinois at Chicago.

Between 1982 and 2008, the number of people getting braces in the U.S. leaped a whopping 99%, according to the American Assn. of Orthodontics. And adults are on the bandwagon. From 1989 to 2008, the number of adult patients getting braces rose by 24%.

"The stigma of being 'too old' for braces has diminished for the most part," says Dr. Stephen Tracey, an orthodontist in Upland, Calif. "It wasn't that long ago that adults considered orthodontic treatment 'just for kids.'"

Orthodontists cite a host of reasons for the acceptance of braces. They've become more affordable, with insurance often covering part of the cost. The devices are more comfortable and less noticeable than in the past. Treatment is shorter, requiring fewer visits to the orthodontist. Society overall is recognizing the importance of oral health. And, of course, there's an ever-increasing social pressure to look one's best.

Braces are "faster, they're sleeker, they're smaller, they're smoother, they're just far more comfortable," says Dr. Michael Rogers, president of the AAO. "I think from that standpoint, the public is just more willing to have the braces and more willing to go through the treatment."

Dr. Lee Graber, an orthodontist in Vernon Hills, Ill., and past president of the AAO, would agree. He's had orthodontic patients ranging from 3 to 88 years of age.

Not only are patients willing to start treatment well past adolescence, they're also willing to assess their children's need for treatment much earlier.

"We're seeing more youngsters because more and more people are recognizing that orthodontics is a component of an oral healthcare program," says Graber.

Braces, it seems, have no age limits.

Treating children

Orthodontic treatment for children sometimes occurs in two stages. Phase one, or early intervention orthodontics, begins around age 7 or 8 when children have gotten their first permanent teeth. Phase two begins when the permanent teeth are in, typically age 11-14; this is when the majority of kids get braces.

"Phase one is not so much to make the smile beautiful, it's more to get the problems intercepted so that the jaws grow better and things function better," says Rogers.

Reasons for early intervention include severe crowding of the teeth, pronounced overbite or underbite, jaw-growth discrepancies, and cross-bites, in which the upper teeth fail to overlap the lower teeth.

"Many times if you wait until the adult age to correct a cross-bite, it can involve a surgical procedure by an oral surgeon to free up the segments of bone, whereas if we correct them early, the bones are pliable, and it's corrected easily and non-surgically," says Rogers.

If children are not biting straight from an early age, orthodontia can alter their jaw development — another reason to begin in the 7 to 9 age range.

"Orthodontics can straighten the teeth up, but it can't realign that lower jaw," says Dr. Rhea Haugseth, a pediatric dentist in Marietta, Ga., and president of the American Academy of Pediatric Dentistry. "So you've got a skeletal discrepancy then. So if we see something skeletally wrong, we want to go ahead and fix it and try to get them into a more normal growth pattern."

Orthodontists say that the benefits of braces for both children and adults can affect the health of teeth for a lifetime. Teeth are easier to clean when not crowded, and they wear evenly when properly aligned. Further, the treatment helps teach patients how to take care of their teeth.

"There's an educational process that takes place at the same time that they're going through corrective therapy," says Graber.

Difficult decisions

In some cases, orthodontists must make close calls about putting braces on children, Graber says.

Occasionally he encounters moms who say that their daughter is embarrassed of her teeth and doesn't want to smile at school. "She'll say, 'You know, four of her friends are getting braces right now. She thinks her teeth look funny and her friends are getting it taken care of; isn't there anything you can do?'" says Graber. "You sometimes end up really having to talk to parents about what really is appropriate and normal."

But he acknowledges that in rare cases, if a child's self-image is hindering their development or causing them difficulties at school, it may be worth it to put braces on even if the treatment isn't essential. "Sometimes it may be a very short period of treatment, and the psychological benefit certainly is worth it," says Graber. "The mental is sometimes more important than the dental."

In other cases, says Graber, "I've had kids leave in tears. I tell them, 'You know, you really don't need braces — you might need them later, but you really don't need braces now.'"

"Usually when you tell them the reasons why you don't want to do it, they value that opinion," adds Graber.

Occasionally, orthodontists face pressure from kids or their parents to get braces. "I think there is pressure on parents from their kids and from parents to other parents, of the old 'keeping up with the Joneses' sort of thing," says Ray Stewart, executive director of the California Society of Pediatric Dentistry. "It's kind of a status symbol for kids to have braces now when they're in the second and third grade."

But Haugseth says that the number of cases of parents or kids thinking they need braces when they don't is an insignificant number. And she says the same pattern occurs in reverse: "Do I see just as many kids who are hoping that they never have to have [braces]? Yes."

"I practice in a more affluent area, so it might be more of a common misconception there that we're putting them on for perfection," says Haugseth. "I'm one that a little abnormality makes it look real. I'm OK with that completely."

Adults opt in

Adults, too, are making tough decisions for themselves about whether or not to invest in braces, which are usually covered only in part by insurance. Braces typically run from $4,000 to $8,000, depending upon the treatment.

Many are opting for the clear and removable braces, which often are barely noticeable. More adults are in treatment now, says Tracey, "because they're willing to go into orthodontics if they don't have to look like they're in junior high with headgear and crazy-looking braces."

And the trend is contagious. "I've got one company — I must be treating almost everybody in that company because one gets it and another gets it and they just feel like it's an acceptable thing to do," says Rogers.

David Sweeney, a 48-year-old pilot for United Airlines based in Libertyville, Ill., just had braces removed after wearing the clear, glue-on brackets for a little more than two years. "A lot of people didn't know I had braces," says Sweeney. "They were surprised when I told them." As Sweeney's overbite improved, which shifted his jaw line, people began commenting that they thought he had lost weight, he recalls. But his weight hasn't changed in five years, says Sweeney; rather, his improved bite had caused his face to appear slightly longer and thinner.

Even adults who had braces as children sometimes need to return for orthodontic treatment in midlife or later. Just as bone density decreases with age throughout our bodies, the bones in our mouths also lose density and shift with age. Many people do not wear their retainers as directed after treatment and find that their teeth eventually shift out of alignment.

"A retainer is to retain, to hold [the teeth] right where they are," says Haugseth. "Now we know that you've got to retain them the rest of their life. Even my teenagers ask me, 'Do I have to wear this forever?' and I say, 'Pretty much, if you don't want anything to move.'"

Teeth also shift because of wear and changing pressures in the mouth, says Tracey, another reason why adults may end up needing braces regardless of whether they had them in their youth.

Tracey sees other adults opting for braces in order to enhance their competitiveness in the tough job market or because they are re-entering the dating scene after a divorce. "A beautiful smile contributes greatly to a person's self-esteem," says Tracey.

It takes time

Ultimately, however, some things haven't changed in orthodontia. It's still a process.

Meredith Keller, a mother of two in Ellicott City, Md., chose to have braces put on her son when he was beginning second grade, around 7 1/2, because he had buckteeth. "At the time, I was happy about it," says Keller. "I thought, 'Oh good, we're getting this out of the way.' It seemed like a good idea." Her son wore the braces for just under a year.

But Keller says that she hadn't previously considered the challenges of maintaining the correction. Her son was fitted with a retainer at the beginning of third grade. "That's pretty young to be responsible for keeping track of one of these things," says Keller. "And there's a comfort issue, too." He also ended up needing gum surgery to remove excess tissue on the top teeth, which required anesthesia.

"All these things came up that made me think maybe I should have waited." All in all, Keller says she is happy with the results, but has been told that her son may need braces again in phase two.

healthkey@tribune.com

Copyright © 2011, Los Angeles Times

Specialist in Orthodontics Dr. Ted Rothstein Alerts to Rising Levels of Substandard Invisalign Treatment by Insufficiently Trained General Dentists

An orthodontist since 1976, Dr. Rothstein, has composed a list of "due diligence" hard-hitting questions for the would-be Invisalign patient to ask the dental professional--forewarned is forearmed.

Brooklyn, NY (PRWEB) July 12, 2011

Invisalign orthodontic treatment is becoming extremely popular. General dentists are competing fiercely with the specialists in orthodontics for their share of this market. Never mind that most of them are insufficiently trained and experienced in orthodontics, and lack the temperament to provide this service. Dr. Rothstein has compiled a list of questions that every consumer can use when deciding to undergo teeth straightening.

Invisalign is a type of orthodontic treatment that can be used in place of typical "train-track" braces, depending on the severity of the bite/smile problem. Keep in mind the dentist must first accurately diagnose in detail the problem(s) of the bite condition, decide how and which teeth are to be moved then send the lab rubber impressions of the teeth to make the "aligners" with exact instructions. Finally, the dentist places "attachments" on the teeth and dispenses the aligners to the patient who must wear them 22-hours each day for 2-3 week before changing to the next aligners in the treatment series.

AlignTech created this method of treatment specifically for orthodontists, but when general dentists sued for the right to provide the service, they won the case. In 2009 Invisalign mandated that generaldentist and orthodontists were henceforth required to take 10 continuing education units and submit ten cases as minimum requirements for being an Invisalign provider presumably to stem the tide of inferior treatment results. That mandate was rejected in 2010 after widespread objection from both groups (Leiszler DDS and Styger DDS v. Align Technology ,United States District Court for the Northern District of California Case No. 3:10-cv:2010-MMC)

At present a general dentist can become a provider by taking a one day eight-hour course.

Consider that there are 120,000 general dentists in the US while there are a mere 6,500 orthodontic specialists. These overwhelming odds insure that more and more consumers are choosing providers who lack sufficient training and experience to provide their patients quality results. Worse yet, the patients may never find out that the results are sub par.

Dr. Rothstein poses the key question: when preparing to embark on a once-in-a-lifetime trip that is going to take on average more than a year with as many stopovers (office visits): isn't the consumer better served by the orthodontic specialist even though having to pay a higher fee? Indeed when the consumer pays more to engage the services of the specialist isn't he receiving more in the way of experience and wisdom that far outweighs the additional fees the consumer may have to pay?

Remember the general dentist is a professional who practices "general” dentistry; this means their training and expertise lies in his ability to do a variety of dental procedures well, unlike the orthodontist who may often take as many as 15-25 office visits devoted to your one smile/bite problem, sometimes making delicate and tiny adjustments, and sometimes simply to effectuate the movement of a single tooth toward its correct position. The specialist has only one art--moving teeth. The generalist is therefore less temperamentally suited to this often tedious long drawn-out kind of bite correction.

Dr. Rothstein reports that he is seeing in recent years a growing number of patients on consultation in treatment with Invisalign by the generalist who simply lacked an understanding of the limitations of the Invisalign appliance.

General dentists are not fully trained to recognize the many nuances associated with effective treatment, or even foresee the potential problems lying in wait as they proceed. Training and experience really do make a difference.

There are also cases in mid-course where the general dentist had no idea how to handle the problem that the patient was encountering. and cases where the end result of the Invisalign treatment were so lacking that the only recourse was to finish the case with fixed braces.

Due diligence questions to ask when choosing an Invisalign provider:

Are you certified specialist in orthodontics besides being a general dentist?

Do you have an orthodontist to whom you regularly refer other cases?

Do you do the train-track braces also?

When did you begin providing Invisalign?

How many Invisalign patients do you have under treatment?

How many Invisalign patients have you completed?

Are you certain my case can be completed with Invisalign?

How many months will I be in treatment (typically two aligners/month)

Is the fee you are quoting all-inclusive?

Can you provide me with the contact information of two of your completed Invisalign patients?

Does the doctor himself personally provide my treatment?

What are some of the typical problems you have seen since you are providing Invisalign?

Dr. Rothstein's final word of advice is always seek a second opinion with a provider who is a specialist, and let them know exactly what the general dentist recommended. It's worth the additional fee (many orthodontists offer a free second opinion). Indeed, Dr. Rothstein readily maintains that when he is in a quandary related to treatment of his own patients he encourages them to obtain a second opinion.

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Ted Rothstein
Dr. Ted Rothstein