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Advice for PCTs, LHBs and SHAs

The Justication for Orthodontic Treatment

This document has been produced by the British Orthodontic Society

The Justication for Orthodontic Treatment


This document has been produced by the Clinical Standards Committee of the British Orthodontic Society. It seeks to provide information for purchasers and other interested parties about the specialty of orthodontics. It is divided into eight sections covering modern orthodontic practice.
1. What is Orthodontics? 2. Prevalence of orthodontic problems 3. Why do people need braces? 4. Health gains from orthodontic treatment 5. Risks of orthodontic treatment 6. Demand for orthodontic treatment 7. What is the best time to carry out orthodontic treatment? 8. Providers of orthodontic care page 12 page 11 page 10 page 11 page 5 page 7 page 4 page 4

1. What is Orthodontics? Orthodontics comes from the Greek words orthos, meaning correct or straight and odontes, meaning teeth. It is a specialised branch of dentistry concerned with the development and management of deviations from the normal position of the teeth, jaws and face (malocclusions). A malocclusion is not a disease but simply a marked variation from what is considered to be the normal position of teeth. Orthodontic treatment can improve both the function and appearance of the mouth and face. Appliances (braces) can be xed or removable and are used to straighten the teeth and encourage growth and development. The main aims of orthodontic care are to produce a healthy, functional bite, creating greater resistance to disease and improving personal appearance. This contributes to the mental, as well as the physical, well being of the individual. The photographs show how the treatment of dental malocclusions, often using xed appliances, can greatly improve the aesthetics and function of an individuals dentition. These dramatic improvements are known to have signicant psycho-social benets to the patient. People with obviously unsightly teeth are very keen to have them changed. Crowded teeth can be potentially unhealthy and often provoke teasing or ridicule. Once straightened, teeth are often less prone to being damaged and the improvement to facial appearance can be dramatic.

2. Prevalence of orthodontic problems The 2003 Childrens Dental Health survey1 found that approximately one third of children would benet greatly from orthodontic treatment. Indicators of treatment need and outcome have been developed and validated by the whole orthodontic profession to assess the efcacy and appropriateness of care. The most widely used are the Index of Orthodontic Treatment Need (IOTN)2 and the Peer Assessment Rating (PAR)3. The IOTN is divided into two parts called the dental health component (DHC) and the aesthetic index (AI).
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The DHC is used to quantify the impact of a particular malocclusion upon the long-term dental health of an individual whereas the AI provides an assessment of the socio-psychological impact through appearance. They are used to categorise malocclusion into ve groupings measured from 1 to 5 with the most severe being 5. It is generally accepted that IOTN groups 4 & 5 would greatly benet from orthodontic treatment as well as some individuals from IOTN 3 when the AI is high at 6 or more. The main aw of this index system is that it fails to evaluate the childs perception of need. This may lead to the denial of treatment of children with a genuine sociodental need4. Holmes5 found that 38.5% of 12 year olds would greatly benet from orthodontic treatment. The most common severe problems in a normal population are detailed:

Dental Feature

Prevalence in Population (%) 0.3%

CLEFT LIP AND PALATE IMPACTED TEETH HYPODONTIA (missing teeth) REVERSE OVERJET (lower teeth in front of upper teeth) LARGE OVERJETS (top teeth stick out) CROSSBITE AND DEVIATION OF JAWS ON CLOSING DEEP OVERBITE (lower teeth bite on palate) SEVERE CROWDING OF TEETH OPEN BITE (teeth do not meet)

8.5% 1.8%

2.1%

8.8%

3.0%

4.3%

9.0%

0.7%

3. Why do people need braces? Evidence suggests that correcting the following tooth/ jaw anomalies with orthodontic appliances will benet the patients long-term dental health:Crowding: Teeth may be poorly aligned because the teeth are too large for the mouth. Poor biting relationships and unsightly appearance may all result from crowding of the teeth. The upper canine teeth are one of the most frequent culprits. Deep (traumatic) overbite: Extreme (vertical) overlap of the top and bottom front teeth can lead to them contacting the roof of the mouth causing signicant tissue damage and gum stripping. In some patients, this can contribute to excessive tooth wear and early tooth loss in adulthood. Increased overjet: Upper front teeth that protrude beyond normal contact with the lower teeth often indicate a poor bite of back teeth and can indicate unevenness in jaw growth. Thumb and nger sucking habits can also cause prominence of the upper incisor teeth and increase the risk of trauma and permanent

damage to the front teeth. A systematic review of the available evidence on this topic found that individuals with an increased overjet had more than double the risk of injury6. Open Bite: An open bite results when the upper and lower front teeth do not touch when biting together. This leads to all the chewing pressures being placed on the back teeth, which may cause these teeth to wear down quicker. It may also make the patients biting less efcient, which may cause social problems especially at meal times. Spacing: If teeth have either not developed or are missing, or smaller than average in size, unsightly spaces may occur between the teeth. This is a less common problem though when compared with patients who have signicant crowding of their teeth. Some malocclusions have a greater adverse effect on quality of life than other types. Individuals with four or more missing teeth have been shown to have poorer quality of life scores7. Crossbite: This occurs when the upper front teeth bite inside the lower teeth i.e. towards the tongue. This can lead to one or more of the lower incisor teeth becoming mobile with early receding of the gums. It can also occur on the back teeth and is best corrected at an early age e.g. 8-10 years, due to biting and chewing difculties as a result of the deviated bite and associated displacement of the lower jaw. Reverse overjet or lower jaw protrusion: Approximately 3 - 5% of the population have a lower jaw that is signicantly longer than their upper jaw. This causes them to bite their lower front teeth ahead of the upper front teeth thus creating a total crossbite of the teeth. It can also lead to signicant wearing down of the tips of the upper front teeth.

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 conicting. 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 socioeconomic group, gender, tooth size and tooth surface have greater inuences10. 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 overriding inuencing factor in preventing gum disease9. Having straighter teeth may help moderate tooth brushers to be more efcient with their oral care. Improvements in the overall function of the dentition: Teeth which do not bite together properly, can make eating difcult. Individuals who have a poor occlusion can nd it difcult 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 difculties 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 signicantly
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protruding upper front teeth13. These malocclusions score a Dental Health Component of 5, indicating a great need for treatment. Such trauma to the mouth of an untreated child can result in a fracture of the tooth and/or damage of the tooths nerve (pulp). Prominent upper front teeth are an important and potentially harmful type of orthodontic problem. Providing early orthodontic treatment for young children (aged 7-9 years) with prominent upper front teeth is of questionable clinical signicance. It may be prudent to delay treatment until early adolescence. However, important factors such as psychological impact and the reduction of associated accidents (trauma) to the protruding front teeth need to be evaluated on an individual basis14. Treatment of impacted (buried, partially erupted) teeth: Unerupted teeth may cause resorption (dissolving) of the roots of adjacent teeth. Cyst formation can also occur around unerupted wisdom or canine teeth. Extra (supernumerary) teeth may also give rise to problems and prevent the normal eruption of a permanent tooth. Unerupted or partially erupted wisdom teeth can often be left alone in the mouth if they are not giving the patient any problems. Improvement in dental/facial aesthetics: Often resulting in improved self-esteem and other psychosocial aspects of the individual. Until recently, this aspect has been harder to measure and quantify. A number of studies over the years have conrmed that a severe malocclusion can be a social handicap. Social responses, conditioned by appearance of the teeth, can severely affect an individuals whole adaptation to life. This can lead to the concept of a patients malocclusion being handicapping. One of the most signicant effects of a malocclusion is its psycho-social impact on the individual patient. There is little doubt that a poor dental appearance can have a profound psycho-social effect on children. Shaw et al. (1980) found that children were teased more about their teeth than anything else e.g. clothes, weight, ears. A persons dental appearance can have a signicant effect on how they feel about themselves15. Children and adolescents with poor teeth can often

become targets for teasing and harassment from other children. This results in these patients being unsure of themselves in social interaction and having lower self-esteem. Adolescents who complete orthodontic treatment report fewer oral health impacts on their daily life activities than those who had never had treatment. Groups of children who need orthodontic treatment exhibit signicantly higher impacts on their emotional and social well-being16. Malocclusion has a negative impact on the oral health related quality of life of adolescents. Children aged between 11 and 14 years old with malocclusion demonstrate signicantly more impacts i.e. worse quality of life, compared with a minimal malocclusion group based on the IOTN17. Johal et al. (2006) investigated the impact that a malocclusion has on a childs quality of life by assessing the effect of an increased overjet (>6mm) or spaced front teeth. These groups of children also had more signicant social and emotional issues than children with well-aligned teeth18. Their research also found that both these occlusal traits had a signicant negative impact on the quality of life of their parents and other family members. Shaw et al. (2007) carried out a major multidisciplinary longitudinal study in Cardiff back in 1981 of an initial sample of 1,018 11-12 year olds. A 20-year follow-up study looked at the dental and psycho-social status of individuals who received, or did not receive, orthodontics as teenagers19. Unfortunately, only a third (n=337) of the original sample could be re-examined in 2001 due to a 67% dropout rate. Those patients with a prior need for orthodontic treatment, who had treatment completed as a child, demonstrated better tooth alignment, better self-esteem and satisfaction with life scores. However, orthodontics seemed to have little positive effect on psychological health and quality of life in adulthood. Unfortunately, this long-term study suffered with problems of an archaic treatment regime (mainly removable appliances being used), antique methodology and short retention regime. Its relevance to 21st century orthodontics is therefore debatable.

In summary, it appears that both psycho-social and functional handicaps can produce a signicant need for orthodontic treatment in addition to the dental health benets described. The benets of orthodontic treatment include an improvement in dental health, function, appearance and self-esteem. These perceived benets are described in more detail below. Prospective patients (and their parents) seem to be condent of the gains that they expect to achieve by undergoing a course of orthodontic treatment. The benets of orthodontic treatment often go beyond improving a persons dental health. People may feel they look better, which can contribute to self-esteem and ones overall quality of life20.

5. Risks of orthodontic treatment


In the vast majority of well-planned cases, the benets of orthodontic treatment outweigh the possible disadvantages. Patient education and the selection of appropriate treatment plans for individuals reduce this risk considerably. The most important aspect of orthodontic care is to have an extremely high standard of oral hygiene before and during orthodontic treatment21. i. Early tooth decay: poor oral hygiene (tooth brushing) can lead to damage of the teeth around orthodontic braces. Early tooth decay (decalcication) will occur when plaque accumulates around a xed brace in the presence of frequent sugar intake. Thorough dietary advice, excellent oral hygiene and the use of uoride supplements are used routinely by orthodontists to minimise this risk. ii. Root Resorption: mild loss of tooth root tissue (dissolving) is very commonly seen as a consequence of tooth movement but this does not cause any long-term problems for the vast majority of patients. iii. Loss of Periodontal Support: if a patients oral hygiene is poor during treatment, orthodontics may exacerbate gingival inammation and susceptibility to periodontal (gum) disease. Patients who have undergone orthodontic treatment do not have any increased predisposition to developing periodontal disease22.
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6. Demand for orthodontic treatment


Orthodontics has played an increasing role in dentistry over recent years and this trend is likely to continue in the future. Recent surveys of the long-term effects of orthodontic treatment reveal that the vast majority of individuals who have undergone orthodontic treatment feel that they beneted from the treatment and are pleased with the result. Many patients will demonstrate dramatic changes in their dental and facial appearance. It is well known that not all patients with malocclusion, even those with extreme deviations from normal, seek orthodontic treatment. The perceived need for treatment is inuenced by both social and cultural factors and currently the demand for treatment greatly exceeds the resources available. There has been a marked increase in demand from both children and adults seeking treatment since the 1980s as a result of more dental awareness by the public in conjunction with an increased social acceptance of xed braces.

7. What is the best time to carry out orthodontic treatment?


Each year, in excess of 130,000 patients (most of whom are children under the age of 18 years) have braces tted under the NHS in England & Wales. There is a wide range of opinion on the best time to start orthodontic treatment but the vast majority is carried out on children who have lost all their baby (deciduous) teeth and have most of their adult teeth (except for wisdom teeth) present in the mouth. This means that the earliest the majority of children commence their orthodontic treatment is between 11-12 years of age. Orthodontic treatment provided whilst many baby teeth are still present in the mouth, i.e. at age 7-9 years, is regarded as early or interceptive treatment. A common example of this type of orthodontic treatment is in cases with anterior and/or lateral crossbites with jaw displacement on mouth closure23, 24. Simple expansion appliances (removable or xed types) are usually employed to deal with this clinical situation over a
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few months. Another example of valid interceptive orthodontic treatment is where the timely removal of a baby tooth can enable the spontaneous (natural) correction of a dental centreline shift or allows an offtrack (ectopic) adult tooth to erupt into its correct position in the mouth without the need for braces. Most UK orthodontists do not favour early treatment to correct increased overjets, deep overbites or severe dental crowding and prefer to carry out this treatment at the more ideal age of 10-12 years or later. Early treatment for increased overjets is commonplace in the USA and mainland Europe. It is described as two phase treatment as it involves a period of early active treatment with a functional or removable appliance followed by a second phase with xed braces once all the adult teeth are present in the mouth. This compares with one phase treatment of adult teeth where the functional and xed brace treatments are combined thereby reducing the overall treatment time and possibly cost. The optimal timing for treatment of children with increased overjets remains controversial25 and needs to be based on individual indications for each child. Good communication skills can identify specic children whose psychological well being can be improved by early treatment26.

8. Providers of orthodontic care


In the United Kingdom (UK), orthodontic care is provided within the state funded NHS at no direct cost to the patient or their parents. All Specialist Orthodontists are Dentists but only about 3% of Dentists are Orthodontists. An Orthodontist is a specialist in the diagnosis, prevention and treatment of dental irregularities and facial growth anomalies. An Orthodontic Specialist must complete an initial 5-year dental undergraduate programme at a University Dental School and then successfully complete an additional 3-year post-graduate programme of advanced education in orthodontics. By the completion of their specialist training, trainees will have undertaken a Masters Degree and the Membership in Orthodontics from one of the Royal Colleges. Currently, hospital and university trainees complete two years of additional
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training before they can become eligible to apply for consultant posts. At present, there are approximately 1200 orthodontic specialists in the UK. These are made up of specialist practitioners, hospital consultants and community orthodontists. Compared with the rest of the developed world, the UK is severely short of qualied orthodontists. The UK is 15th out of 17 European countries in terms of orthodontic provision with 1 orthodontist per 73,000 population - 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 European countries utilise orthodontic therapists to work along side orthodontists as part of the orthodontic team. The number of funded training places and the very recent introduction of orthodontic therapists in the UK will inuence the future availability of orthodontic care. There is a wealth of evidence to show that orthodontic treatment is more likely to achieve a pleasing, successful result if xed appliances rather than removable appliances are used27-30 and if the operator has had some postgraduate training in orthodontics31, 32. The likelihood that orthodontic treatment will benet a patient is increased if a malocclusion is severe28 and if appliance therapy is planned and carried out by an experienced orthodontist29. However, the likelihood of either a health or psycho-social gain is reduced if the malocclusion is mild and treatment is undertaken by an inexperienced operator33.

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References
1. Lader D, Chadwick B, Chestnutt I, Harker R. et al. Childrens dental health in the United Kingdom 2003. Summary Report Ofce for National Statistics: March 2005. 2. Brook PH, Shaw WC. The development of an index of orthodontic treatment priority. European Journal of Orthodontics, 1989; 11: 309-320. 3. Richmond S, Shaw WC, OBrien KD, Buchanan IB. et al. The development of the PAR index: reliability and validity. European Journal of Orthodontics, 1992; 14: 125-139. 4. De Oliveira CM, Sheiham A, Tsakos G and OBrien KD. Oral health-related quality of life and the IOTN index as predictors of childrens perceived needs and acceptance for orthodontic treatment. British Dental Journal, 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 between overjet 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 of Oral 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 inammation. Journal of Periodontology, 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 literature review. 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. Childrens dental health in the United Kingdom. London: Ofce of Population Census and Surveys, 1985. 14. Harrison JE, OBrien KD, Worthington HV. Orthodontic treatment for prominent upper front teeth in children. Cochrane Database of Systematic Reviews, 2007; Issue 3. 15. Shaw WC, Meek SC, Jones DS. Nicknames, teasing harassment and the salience of dental features among school children. British Journal of Orthodontics, 1980; 7: 75-80. 16. De Oliveira CM, Sheiham A. The relationship between normative orthodontic treatment need and oral health-related quality of life. Community Dentistry Oral Epidemiology, 2003; 31: 426-436. 17. OBrien C, Benson PE, Marshman Z. Evaluation of a quality of life measure for children with maloccluson. Journal of Orthodontics, 2007; 34: 185-193.

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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 health gain from orthodontic treatment: Psychological outcome. American Journal of Orthodontics & Dentofacial Orthopedics, 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 Dental Journal, 2004; 196: 71-77. 22. Sadowsky C, BeGole EA. Long term effects of orthodontic treatment on periodontal health. American Journal of Orthodontics, 1981; 80: 156-172. 23. Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database of Systematic Reviews, 2001; Issue 1. 24. Pietil I, Pietil T, Pirttiniemi P. et al. Orthodontists views on indications for and timing of orthodontic treatment in Finnish public oral care. European Journal of Orthodontics, 2008; 30: 46-51. 25. Tulloch JFC, Proft WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment. American Journal of Orthodontics & Dentofacial Orthopedics, 2004; 125: 657-667. 26. OBrien K. et al. Effectiveness of early orthodontic treatment with the Twin-Block appliance: a multicenter, 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 a consecutively 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 the General Dental Service of England and Wales: a critical appraisal of standards. British Dental Journal, 1993; 174: 315-327. 29. OBrien KD, Shaw WC, Roberts CT. The use of occlusal indices in assessing the provision of orthodontic treatment 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 and Wales I: Factors inuencing effectiveness. British Dental Journal, 1999a: 187: 211-216. 31. Fox NA, Richmond S, Wright JL, Daniels CP. Factors affecting the outcome of orthodontic treatment within 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 and Wales 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 to Orthodontics 3rd edition, Oxford University Press, England.

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Produced by the Clinical Standards Committee of the British Orthodontic Society 2008

British Orthodontic Society 12 Bridewell Place London EC4V 6AP Email: 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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