You probably already know that we prefer orthodontics to crowns and veneers when improving patient smiles. Not only is orthodontics more a more cost-effective esthetic solution, but it requires less maintenance over time.
Patients are forever seeking orthodontic treatment methods that are fast, cannot be seen, don’t hurt, and don’t cost much. Unfortunately, the “straight tooth pill” has yet to be invented! However, if you compare orthodontics now to 40 years ago, great advances have been made. We can put bonded brackets instead of bands on nearly every tooth, and nickel-titanium wires act much longer and more gently than stainless steel wires. The result is faster and more comfortable orthodontics, with fewer extractions necessary. Braces are so much easier for both dentist and patient than when I was a teenager!
There are a lot of good dentists out there doing orthodontics. However, I still encounter a lot of patients who have been in braces too long and paid too much. They fall prey to slick advertising, and don’t know enough to ask the right questions before commencing orthodontic treatment. Knowing that an informed patient is better able to make good treatment decisions, I decided to write this article.
Who can do orthodontics?
Orthodontists attend a two-year residency after dental school, and by law must limit their practice to orthodontics. There are plenty of them around, as you see in yellow-page ads.
Often pediatric dentists and general dentists who have taken additional coursework can treat the majority of orthodontic cases, reserving the most difficult for orthodontists. A great deal of orthodontics in the US is done by dentists who are not orthodontists. I am one of them, treating cases since 1987. In many instances, general dentists may do orthodontics just to have more variety in their workday, and be willing to charge less for treatment than the average orthodontist.
Is it a good idea to use an orthodontic chain clinic you saw advertised on television?
These places employ orthodontists and sometimes general dentists on a commission basis. Orthodontist-employees consider these clinics as merely a job to work until they can start their own practices. Their goal is not so much long-term patient satisfaction as maximizing short-term compensation while they are employed. Despite the slick advertisements, treatment in orthodontic chain clinics is almost never a good deal.
As with other consumer services, you will find the best service comes from small owner-operated businesses.
The problem with no-money-down and low monthly payment plans
Never lose sight of your goal of wanting excellent orthodontic treatment finished in a reasonable amount of time and at a reasonable cost. This may seem obvious, but many advertisements focus on providing braces with no money down and low monthly fees, never mentioning the total case price the patient is paying! Heeding this advertising can be a BIG mistake!
Why? Well, putting braces on is a big expense for the dentist, both in time and money. It is a big risk if the patient decides not to continue treatment. So many orthodontists advertising no money down plans put the brackets on gradually, over weeks or months. This makes treatment last longer than it should.
Likewise, orthodontists who advertise low monthly payments do this by holding the patients in braces for far longer than necessary, just to make lower monthly payments for the patient.
Orthodontics should always be completed as quickly as possible! Leaving brackets on teeth for longer than necessary can cause cavities and gum disease. There are very few cases I have not finished in 2 years. Most cases I have finish in 1 ½ years or less. Yet I encounter many children whose orthodontic treatment has spanned 3 years and more. And when the patient or parent adds up the total they have paid, it is often the most expensive treatment around!
In review, be sure to ask the total case price and number of months in treatment. It may be better for you to save money to pay more at the outset, to bring down monthly payments.
Are there any charges not included?
Now that you know to ask the price of the treatment and how long it will last, you need to ask something else. Almost all dentists charge separately for the workup records, usually including panoramic and cephalometric x-rays, impression for models, and pre-op photos. How much will these cost?
Some orthodontists charge separately for retainers. It is important to add such charges when considering total treatment costs.
You will be moving to a new city in the next year. Should you start orthodontics now and transfer to another orthodontist near your new home, or wait until you have moved to start treatment?
This is easy to answer. ALWAYS try to avoid changing orthodontists. The new orthodontist must take new mid-treatment records for legal protection. YOU will pay for these. It is unlikely that the new orthodontist will use the same brand of brackets as you started with, making it hard to replace broken brackets. No practitioner wants transfer cases! Changing orthodontists mid-treatment will cost you lots of extra time and money. It is better to wait to start treatment, except during growth-critical treatment of a child.
Should you undertake a “Phase I” early intervention for your child?
It is bound to happen. Your child’s teeth might be really crowded at only 6 to 9 years of age. You feel bad because your child may be teased at school, or may be anxious about the ugly smile. So you take your child for an orthodontic consult. A “Phase I” early orthodontic therapy is recommended, lasting 1 to 1 ½ years. You are told that a second phase of orthodontics will probably be necessary at age 12 or later.
The way it is priced, this early treatment may eat up most of not all of any orthodontic insurance benefits. Should you do it?
Probably not. Studies show little benefit in early intervention, except in very specific problems types. What are these types of problems?
- Crossbite of either front of back teeth. Untreated, this may lead to asymmetric jaw growth.
- Severe shift of the midlines of upper and lower growth.
- Developing open bite.
- Deficiency of growth of the upper jaw.
If Phase I treatments seldom offer any tangible benefit, and increase the cost of treatment, why are they so often done?
- Pressure from parents to make their child feel better.
- Frankly, some orthodontists fear that if they do not initiate Phase I treatment on the child, the parents will seek another orthodontist who will. Not wanting to lose a patient, orthodontist initiate therapy, even if there is little long-term benefit.
We have seen Phase I treatments started too late, at age 9, and more permanent teeth start to erupt during treatment. The child is then stuck in braces for 3 or 4 years during Phase I AND Phase II combined. The child’s cooperation wanes, cavities develop around the brackets, and the gums become very inflamed.
Unless you hear some very good reasons otherwise, Phase I treatments are usually not useful nor cost effective. Many children erupt all permanent teeth by age 11 these days. Save yourself the trouble and expense, and do the corrections in one concise treatment.
What about extracting teeth for orthodontic treatment?
It seems the pendulum swings from one extreme to the other. Once upon a time, an orthodontic philosophy was popular in which premolar teeth were extracted in the majority of cases. Now, some dentists are so zealous, they proclaim teeth should never be extracted for orthodontic treatment.
Fewer extractions are being done for orthodontics than ever before in my career. However, there are still cases in which the teeth are just two big for the size of the jaw. There is a limited amount of space that can be gained by expanding the arch, and driving molars backward is a very difficult movement. So the reality sometimes there is no other way to do a case other than extract premolar teeth. Because 2nd premolars are slightly smaller than 1st premolars, I most often extract the 2nd premolars.
Should you choose clear brackets?
Brackets of clear or white porcelain or plastic are available. They cost more, break more often, and are more difficult to work with. Archwires are silver in color anyway. It is our recommendation to use metal brackets, if your vanity can tolerate it.
What about those clear Invisalign aligners?
Invisalign was a great invention. It is fine for a limited number of easy cases. It is too bad the company is hawking it as a money-maker to general dentists who lack sufficient diagnostic skills to do orthodontics. In addition, Invisalign has these problems:
- It is NOT cheap. Invisalign treatment will cost a significant amount more than conventional orthodontics.
- It is NOT conservative. Most Invisalign protocols involve significant grinding on the sides of teeth to generate more space. This can make teeth very sensitive.
- It is NOT for the majority of cases. It is for cases with no or only slight crowding that do not require extraction of teeth.
Invisalign requires excellent patient cooperation. It is not a passive appliance. If you do not wear the aligners, your treatment will not progress.
Now, you are armed with some knowledge about orthodontic care!
You may choose my practice for orthodontic treatment, or you may not. But perhaps you can now make a wiser decision in orthodontic treatment. Having straight teeth decreases the chance of gum disease, and will be a great investment in your or your child’s health!
Kim Henry, D.M.D.
July 18, 2007