Why I don’t use Invisalign

There are a number of clear orthodontic aligner systems on the market. The name that patients know best is Invisalign®, which is a product of Align Technologies. Patients always ask me for Invisalign, and I tell them I don’t use that brand of aligners. Why not?

Invisalign costs a lot more than other aligner systems. Therefore, patients must pay a lot more to have this particular brand of aligners.

Align Technologies wants dentists to take a weekend course and be “licensed” to use Invisalign. It is ridiculous for a dentist like me, who has been doing orthodontics for over twenty years, to have to spend nearly $2000 for such a proprietary weekend course, the sole purpose of which is to teach me how to use their product!

Align Technologies utilizes a team of lawyers who try to put other aligner companies out of business for alleged patent violations. Aligners have been used for many years before Invisalign was invented. I don’t like corporate bully-boys who try to eliminate their competition this way.

Align Technologies is a publicly traded company which must answer to shareholders. Their business is to sell as many aligners as possible. I have seen Invisalign treatment plans that were overly aggressive and had little chance in success. Many inexperienced dentists get into trouble when they are “sold” such cases by Align Technologies.

Finally, as you can see in the “Lab Work Made in USA” section of my website, I support American labs and American jobs. Align Technologies has offshored its aligner fabrication to Mexico, and its clinical staff planning the cases to Costa Rica. The labs I use for aligners are 100% U.S. based.

Consumers are too easily influenced by advertising hype in printed media and television advertising. Just because something is highly advertised does not mean it is the only game in town, nor the best deal.  Patients don’t know which brands of dental materials work best, nor which are the most cost effective. Leave that decision to the experts- the dentists who use them!  Be assured that I will always be concerned for the health of your mouth AND of your pocketbook.

CORPORATE ORTHODONTIC CARE- A BAD MOVE!

Parents of a 13-year-old child came in to have me review the appropriateness of their son’s orthodontic treatment. The father had wanted to bring their son to me for treatment originally, but the mother saw an advertisement for a chain of orthodontic clinics, promising substantial savings. The mother’s wish prevailed, and the child was 1 year into orthodontic treatment at this clinic with little progress.

I examined the boy. His was not a particularly difficult orthodontic case. I could have treated it in a little over a year and a half. But the corporate clinic had only fabricated some kind of removable expanders the child could not tolerate wearing regularly, and nothing much had been accomplished in the year of treatment.

It was hard to give the parents my conclusion. “I hate to tell you, but if I were to treat this case as it should have been when you started, it will cost you just under $4000 to complete. I guess your only consolation will be you didn’t spend much on the treatment that did not work.”

The mother looked visibly disturbed. She said, “Oh no. We have already paid $4000 for the treatment that has been done so far!” This woman had brought her son to a corporate orthodontic clinic thinking she would save money, and they totally wasted more money than what I would have charged to do the case correctly!

Not to brag, but I have been doing complete bracketed orthodontic cases since 1987. I know what I am doing. If patients cooperate, we get cases done quickly. I know a hard case when I see one, and have the sense to refer it to a select few orthodontists I know the ones who are super-competent.

Patients heed my recommendations about orthodontists very seldom. They listen to what I say. Then they go home and ask their friends and neighbors where to go, or they see some silly TV advertisement for a corporate orthodontic clinic, and go there.  Many times, their case will never be completed correctly, if it is ever completed at all!

One of my adult patients asked me about straightening his teeth. I could see his case would be very difficult, with a high probability of needing jaw surgery to complete. I made a strong recommendation of one or two excellent orthodontists for such exacting treatment. The patient ignored me, and went to a corporate clinic. Fortunately, he later called telling me that they planned to do his initial exam and put the brackets on the same day. This was preposterous!

Any sane dentist would do an exam, take records, then do analyses and feasibility studies to work up such a difficult case as his. I spend at least 2 hours of analysis to work up an easy orthodontic case! Timing in orthodontics is often critical as well. Many cases, if started too early, will drag on for too long. These days, I often post photos of patients’ mouths online (omitting patient name, of course) and seek other orthodontists’ opinions about how the case should be treated. It would be ridiculous to put brackets and archwires on a patient the same day as the exam!

After being warned of the foolhardiness of proceeding, this patient changed his mind, took my advice, and saw a competent independent orthodontist. This is not always the outcome! Unfortunately, too often corporate orthodontists succeed in slapping on brackets and archwires to “lock in” the patient’s treatment at that clinic. Only afterwards do they try to figure out how to treat the case!

All good orthodontists forward a copy of their findings and treatment plan for a patient case to the treating general dentist. I virtually never receive these from corporate clinics, leading me to question whether there is even any logical treatment plan. I have received requests to extract teeth from corporate orthodontic clinics, then had to demand a rationale for the extrac­tions before I proceeded. I guess these orthodontists are under such pressures to perform, they allow no time for communication with the patient’s dentist!

Corporate ownership of orthodontic practices began in the early 1990s, as a result of the oversupply of orthodontists. Private equity investors thought they could use the same sales and business techniques to straighten teeth as they used dealing with auto repair and vacu­um cleaners. Health care is different, because all humans are all unique. No two orthodontic cases are exactly alike. There are even some orthodontic cases that should not be attempted. It is important that treating orthodontists not be subject to the will and profit incentive of non-dentist investors to treat the maximum number of cases without regard to appropriate timing or case difficulty or without sufficient diagnostic preparation.

Not every case I have seen from corporate orthodontic clinics has been done incompetently, but there are enough substandard case completions to be worrisome. One thing for sure: I don’t see any patient cost savings from corporate clinics, despite what is claimed in their glitzy advertisements.

As with every other service, I have personally found that the highest customer satisfaction is given by professionals who own their own business. It is true for general dentistry, and it is true for orthodontics as well. Please be skeptical about TV, radio, or print ads telling you to patronize any particular chain of orthodontic clinics. If you have any doubt before treatment, don’t hesitate to ask me about any particular orthodontic group you are thinking of using.

Kim Henry

January 24, 2015

When should my child have braces?

 I am often asked this simple question by parents. And I have a simple, but not very satisfying, answer- it depends!

There are a few problems that I would correct even in a 5- or 6- year old.  These are “crossbites”, where either the upper front or back teeth are locked inside the lower teeth.  If left uncorrected, cross bites will soon make the child’s jaw grow abnormally crooked or long. Often such abnormal growth may be remedied only by extensive surgery later in adulthood!

This child of 8 has her upper incisors locked behind her lower incisors in crossbite. If untreated, this will become a very complicated surgical-orthodontic case.

Another important interceptive strategy in children this young is to stop thumb or lip sucking habits, or modify the way the tongue moves during swallowing.  Teeth can be moved into very unnatural positions by unusual tongue, lip, or finger habits.  If not corrected early before orthodontics, tooth movement will not be stable.

Many things we do at an early age can minimize or even prevent your child’s need for braces. The most important is keeping baby teeth in the mouth until they are ready to come out. Pulling back baby teeth early has severe consequences. It is guaranteed to cause the need for complicated orthodontics later!

The earliest age we usually treat children orthodontically is age 7 to 9.  This is called “Phase I treatment.”  We can make most of the corrections in difficult cases here, leaving only a little to do when all the permanent teeth come in at age 12 to 13. There are many advantages to Phase I treatment. The most important are that children this age cooperate better, orthodontic corrections are easier and more stable, and we can more often avoid extractions of permanent teeth. The most common Phase I treatment we do is expansion of the growing arches, to make sufficient room for eruption of the permanent teeth.

This child had a narrow palate, making it impossible to erupt the permanent canine teeth. A “Hyrax” ex-pander was placed in the roof of her mouth. Over the course of several days the device was expanded, until there was enough room to bring the impacted teeth into the arch.

Usually too many teeth are erupting at age 10 and 11 to do fixed braces. All we can do is place space maintainers to preserve every bit of space as the last baby teeth are lost. This age may still be a critical time for treatment, as far as growth alteration is concerned. Some girls are nearly finished with bone growth at the end of their 11^th year.

Age 12 and above, when all permanent teeth are in the mouth, has been the traditional time of most orthodontics. Most Phase I cases need final correction at this age. However, even this is variable.  I do not know why, but many children are getting all the permanent teeth in the mouth earlier.  I am now able to put complete braces on some 11 year- olds and finish the treatment by age 12.

A critical event occurs at age 18. Two bones in the roof of the mouth fuse together, and no longer can be expanded easily. It is at this point that orthodontics can really be slow going!

One of the many advantages to your child’s treatment in this practice is my many years of experience doing orthodontics, beginning in 1987. At each dental checkup, we monitor your child’s growth and tooth eruption. In fact, I spend more time doing this than checking for cavities! We will alert you to critical times for possible orthodontic intervention, so your financial outlays and time in braces can be minimized.

Kim Henry, D.M.D.

 

 

Tips on obtaining Good Orthodontics

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 2^nd premolars are slightly smaller than 1^st premolars, I most often extract the 2^nd 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