Your Child's Orthodontist Could Be Wrong

Ade Adeniji's orthodontist says he needs braces. It's not for cosmetic reasons; Ade is a handsome 16-year-old in New York City with a warm, engaging smile. Nor is it for health reasons; his teeth aren't giving him any trouble.

It's because his lower teeth are crowded, making it difficult to clean between them. Ade's parents have left the decision about whether to get braces up to Ade and, so far, he isn't interested. His parent's hands-off approach isn't reckless -- they just realize that no matter what decision he makes, he'll be fine. Even with the crowded teeth, he's never had a cavity.

Other children and young adults could make similar decisions to wait. According to the National Institutes of Health, most misaligned bites (technically known as malocclusions) are so minor that they do not require treatment. Yet, currently, nearly 4 million children under the age of 18 in the U.S. and Canada are wearing some kind of braces. Their parents are paying anywhere from $3,000 for a basic set to upwards of $10,000 for newer "invisible" braces.

How many of those sets of braces are truly necessary? No one's really sure. But Timothy Wheeler, DMD, PhD, professor and chair of the Department of Orthodontics at the University of Florida, is trying to find out. He's in the midst of long-term research, funded by the National Institutes of Health, on the timing of orthodontic intervention.

Wheeler says that the most common malocclusion -- affecting perhaps as many as 90 percent of children -- is overcrowding, usually of the bottom teeth. "Mild crowding doesn't have to be addressed at all," he says. And more severe crowding may improve on its own when your child's jaw grows to its full adult size. Even if it doesn't improve, there's generally no harm in waiting until the late teens or early 20s to begin treatment.

Another common form of malocclusion, called an open bite, happens when the front teeth don't come completely together when a child bites down. A few years ago, a study in the journal Pediatric Dentistry questioned the wisdom of early intervention in treating an open bite. Researchers noted that top and bottom rows of front teeth often continue to grow toward each other as the child ages, and suggested that, in most cases, people wait until all the baby teeth have been lost before considering treatment.

Then there's the overbite, commonly called "buck teeth." According to Wheeler, about 25 to 30 percent of children have an overbite. This is a skeletal abnormality and is treated with external devices -- not braces -- that correct the problem by realigning the jaw. Until recently, most experts believed that skeletal abnormalities needed to be addressed when the child is young, before the bones have hardened. Wheeler's research, however, has shown that the outcome is no different when children are treated for this problem at 7 or 8 years of age than if they wait until they are teens or older.

Most orthodontists feel that crossbites and underbites (much less common than overbites and crowding in children) might be easier to correct if addressed early, but the research is not yet in on this. And these problems can be corrected later, even if not so easily.

When to Wait

All of this may sound like heresy to anyone who has visited an orthodontist lately, but in fact, literature distributed by the American Association of Orthodontists states, "even if a problem is detected, your orthodontist may not recommend immediate treatment. Chances are, your doctor will take a 'wait-and-see' approach."

Of course, none of this means there aren't some very good reasons for choosing to go ahead with braces, regardless of whether your child is pre-puberty or a teenager. Other than to make cleaning easier (in the case of crowded teeth), the primary reason for getting braces is cosmetic. If your child is uncomfortable with the way her teeth look and she has finished growing, orthodontic treatment may be the answer.

"Some malocclusions can be disfiguring and can make it difficult for a child in school, relationships, and even in finding employment later in life," says James Caveney, DDS, president of the American Association of Orthodontists. These issues aren't to be taken lightly.

Also, about 15 percent of orthodontic patients have a handicapping malocclusion, which can keep them from chewing properly or can cause them pain. These people should undergo treatment as soon as possible.

But the important thing to bear in mind is that an orthodontist's recommendation is often exactly that -- a recommendation. Ask your orthodontist exactly why he or she is suggesting braces. The chances are high it will be because of hygienic or cosmetic issues. And when you're talking about a treatment of such expense, it's a very good idea to get a second or third opinion from other orthodontists.

If you can't afford thousands of dollars for orthodontic work at the moment, it can oftentimes wait without jeopardizing your child's health or the chance for successful treatment later in life. In fact, there are about a million adults wearing braces right now. Also, ask your orthodontist about payment plans if you do decide to go ahead right away. Most offer some sort of financing option.

Above all, don't fret that you're being an irresponsible parent if you decide to wait or even, in some rarer cases like Ade's, skip the braces. "It is not the case that if you don't have braces doom and gloom will follow you forever," says John Phillips, DMD, an orthodontist in private practice in Hoover, Alabama.

For more information about braces or to find a dentist or orthodontist near you for second opinion, visit these Web sites:

• American Dental Association >>

• American Academy of Pediatric Dentistry >>

• American Association of Orthodontists >>

Originally published in Better Homes and Gardens magazine, April 2004.