STRAIGHT TALK ON TEETH
(As published in Time Magazine, July 7, 2003 by Daniel Williams)

Orthodontics improves smiles, but it can be unwise to start too early.

Being told their child needs orthodontic treatment is bound to upset most parents, who can expect bills running into the thousands and at least two years of reassuring their child that he or she looks fine with a mouthful of metal. But it's also a time when parents need to be alert. A small proportion of dentists and orthodontists push treatments that could be a waste of time and money.

The first thing parents should realise is that, though many in the profession claim otherwise, orthodontics is at least as much about beauty as it is about health. Crooked teeth - which about half of all kids develop - might not look nice and can be more prone to decay, but they break down food perfectly well. And practitioners disagree about whether people with crooked teeth are significantly more likely to develop arthritis of the jaw than people with straight teeth. Except in severe cases, parents weighing up orthodontic treatment on behalf of their child should know that its main - if not only - benefit is cosmetic.

Standard treatment for crooked teeth is to wait until the child has lost all of his or her baby teeth, usually by the age of 12. An orthodontist then fits braces, which move the teeth into perfect alignment over two years. Coupled with retention treatment that lasts a year or more, the process costs about $A5,000. Parents presented with this plan can feel sure they're not being taken for a ride.

What should set off an alarm bell, or at least cause parents to ask questions, is when a dentist or orthodontist recommends "early treatment" - for a patient as young as seven who still has many baby teeth. The practitioner might argue that there's a need to "grow", "develop" or "reposition" the jaws in preparation for braces, and that the best way to do that is with a functional appliance. Removable devices made of plastic and metal, these appliances were invented early last century. When used as a primer for braces, they blow out the treatment time to five years and the cost by at least another $A2,000.

Some orthodontists strongly oppose the use of functional appliances, which they say are uncomfortable, unhygienic and don't do what's claimed of them. "The concept of growth modification is rubbish", says an experienced New South Wales orthodontist who asked not to be named. "In some circumstances the use of these appliances amounts to child abuse". His argument that they don't work is backed by numerous recent studies, which have shown that young jaw bones subjected to these devices don't grow any longer than they would have if left alone.

So why are some practitioners - roughly 15% of the total in Australia, more in the US - still prescribing them? The least charitable explanation is that some of them are ignoring the evidence and trying to expand their practice by taking on younger children as patients. Critics of functional appliances point to the American entrepreneurs who travel the world encouraging dentists to prescribe them. "If you add orthodontics to your practice, your income will increase significantly", says an advertisement for seminars hosted by Dr. Brock Rondeau in Queensland last year. "The great thing…is that you do not have to do any external marketing, the patients are already there".

There's disagreement in the Australian dental community about how many general practitioners have been seduced by this type of argument and are indiscriminately prescribing functional appliances to their young patients. Some say there could be hundreds; Michael Woods, professor of orthodontics at the University of Melbourne, estimates it would be only a "handful". Whatever the case, most parents - anxious to do what's best for their child - are usually easy prey.

But there are also many reputable orthodontists who prescribe functional appliances (and their use is taught in all the major Australian orthodontic schools). These practitioners acknowledge the studies on jaw growth, but argue the devices can still be useful for certain patients with severe abnormalities. And though they may not be able to grow a jaw beyond its potential, they say, the appliances can still help other patients by making that growth happen sooner. "The opinion that functional appliances should never be used is extreme," says Ian Watson, president of the Australian Society of Orthodontists.

Parents who are advised to submit their child for early treatment should ask themselves two questions: Is my child distressed by the state of his or her teeth? And is he or she more likely than other kids to damage them in an accident because of their imperfect alignment? If the answer to both questions is no, then the best option is probably to defer treatment. Seeking a second opinion is also, as always, a good idea.

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