It used to be that braces were an annoying part of being a teen, right up there with acne and overactive sweat glands.
Now braces and other orthodontic appliances are being worn by children still young enough for the tooth fairy.
The trend reflects the belief of many orthodontists that some problems can be fixed better if tackled early, when the jaws and face are still growing. Many of today’s zealous parents also want a sooner-rather-than-later approach to correcting their child’s crooked smile.
A new advertising campaign by the American Association of Orthodontists urges parents to have their children screened no later than age 7 to detect potential problems.
But does it really make a difference when a child begins orthodontic treatment?
Two recent studies funded by the National Institutes of Health found that, at least in the case of buck teeth, the answer is probably no.
“Whether you treat early or whether you treat later, you get the same results,” said Orhan C. Tuncay, chairman of orthodontics at the Temple University School of Dentistry. “The only difference is that if you begin treatment early, you end up in treatment longer.”
One study done at the University of Florida found that children who started treatment early — either by wearing headgear or a retainer-like appliance — spent three years on average going to the orthodontist, as opposed to two years for the children who waited to get braces, according to researcher Timothy Wheeler.
University of North Carolina researchers found that those children who first wore an appliance spent several months less in permanent braces later on, but in the end there was no difference between early or later treatment.
“The quality of outcome was identical,” said Camilla Tulloch, professor of orthodontics at North Carolina’s School of Dentistry.
Tulloch said the findings give parents “a little bit of room for choice” when it comes to treatment timing. “They don’t have to feel guilty if they decide not to do it right now.”
In the last few decades, braces have gone from being a luxury that only the well-off could afford to a more routine part of many families’ dental care. About 4.4 million people in the United States, most of them children and teens, are now in orthodontic treatment, according to the orthodontists association.
One study that analyzed the government’s latest health data found that the number of teens in orthodontic treatment tripled from the mid-1960s to the early 1990s, and the number of children in treatment increased four-fold.
“It’s quite clear that teeth matter. And straight teeth really matter,” Tulloch said. “There certainly is a public perception that people who have crooked teeth are socially or economically inferior.”
Dental insurance often covers only a fraction of the cost, typically about $3,000 to $6,000 depending on the complexity of the case. Many parents pay for their children’s braces in the same way they pay for a new car, using a monthly installment plan.
Many orthodontists like to see children around the age of 7 or 8 because the permanent adult teeth are starting to come in, giving some indication of how things will shape up. At the same time, the jaws and face are still growing, allowing the orthodontist to take advantage of a fluid situation.
“Years ago, you would wait until all the baby teeth were gone and then you’d go to the orthodontist,” said Joel Fromer, an orthodontist in Pottstown, Pa. He is typical of practitioners who sometimes take a two-step approach to dealing with overcrowding and bad alignment between the upper and lower jaws.
In the first round, children wear a headgear, a retainer-like appliance or something called a palate expander to help coax the jaws into proper alignment and move the teeth into better position.
Then, a couple of years later, when most of the permanent teeth are in, they wear fixed braces to put the finishing touches on a straight smile.
Glenn Burkland, who practices in the Philadelphia suburbs, said early treatment may reduce the need for pulling teeth or doing jaw surgery.
“You have growth on your side with a child,” he said. “Plus you have a cooperative child.”
Children may be more willing than teens to wear appliances as prescribed and to forgo bubble gum and sticky candy.
Sarah Powell, who just turned 12, was 7 years old when her parents first took her to see Cherry Hill, N.J., orthodontist Gerald Jacobson. Her teeth were bucked and crowded, and one tooth was poised to come in out of place.
Her father, Alan, said he wanted his daughter to have “anything that helps her feel good about herself.”
Sarah wore her first set of braces for 10 months, followed by a retainer for two years. She is now in another set of braces, finally closing in on the end of treatment, which will exceed $6,000, partly paid for by insurance.
“I look at old pictures, and my teeth are really far apart and I say, ‘Oooh,’ ” said Sarah, a 7th-grader.
Jacobson said Sarah had benefited from early intervention.
“You have to be very selective,” he said. “There is no question that there are certain types of cases where it’s much better to wait until all the teeth are in.”
“We have children we started at 7, 8 or 9, and we . . . continue to observe (many of them) until they are older.”
It is estimated that half of U.S. children need braces. The study of federal health data from 1989 to 1991 found that while nearly 28 percent of white teens had orthodontic treatment, just 6 percent of black teens did. Children from families that earned $50,000 or more were most likely to get braces.
Because orthodontics, like many branches of medicine, is as much an art as a science, a practitioner’s own style, habits and training can influence decisions on the timing of treatment. The studies, funded by the National Institutes of Health’s National Institute on Dental Research, were designed to provide some more scientific answers.
Orthodontic problems can be clumped into three broad categories — the alignment of the jaws is correct, but the teeth are crooked and crowded; the upper jaw protrudes, creating what is known as buck teeth; or the lower jaw juts in front of the upper jaw.
Researchers focused on buck teeth because it is the most common reason to get braces, said Wheeler, chairman of orthodontics at the University of Florida’s College of Dentistry. The 300 children in his study were divided into three groups: Two wore either a headgear or an appliance beginning, on average, at the age of 10 and then later moved into braces; the last group didn’t get treated until their teens.
“All three groups ended up at the same place at the end of treatment, whether it was early or later,” Wheeler said.
He also looked at self-esteem because many parents worry that their children will develop a poor self-image as a result of their crooked teeth. The surprising answer: “The kids didn’t care about their teeth,” Wheeler said. “The parents did.”
North Carolina’s Tulloch said that while it was often assumed that early treatment would lessen the need for extractions and surgery, her study found there was no difference in either of those measures whether treatment was early or late.
“Is it worth it? Some parents truly feel they want to start treatment early because they think the kids will go through grade school looking odd and being teased,” Tulloch said. “What I would say to a mom: ‘If that’s your reason to do treatment, that’s a good reason.’
JoAnne Grube, of Westtown, Pa., said she and her husband were particularly concerned about their daughter when they went to see Burkland.
“My husband and I kept looking at her and wondering, ‘When are we going to get her into braces?’ When she smiled, you just saw these teeth sticking out,” Grube said.
When Shannon, now 10, started wearing an appliance last year, she didn’t like it. No sooner did she head off to school than she popped it out of her mouth. “It was hard to talk with,” Shannon says. “It sounded like I was sick.”
Her brother Jason, 11, started out last year with braces and then was switched to an appliance. Some nights he skips wearing it, but he’s good at fooling his parents.
The Grubes have $3,600 in bills so far for their children’s teeth, partly reimbursed by insurance.
Richard Albright, a Lancaster, Pa., orthodontist who helped develop the advertising campaign on early screening, said that “whether the patient needs treatment, doesn’t need treatment, or needs treatment later, the goal is to just recognize the problem.” Some parents will go away relieved that they won’t have the expense of braces or the hassle of driving their children to monthly appointments. Others can plan for down the road.
Debra Belton, of South Philadelphia, said the dentist told her a couple of years ago that her daughter, Tyleah Miller, now 11, would need braces, but she waited until last week to get them on at Temple.
“It was like she really needs them now,” Belton said. “She’s getting old.”
Tuncay, the Temple dean, thinks age 10 is ideal for initiating treatment, but he said there clearly were cases that need tending to earlier: teeth that stick so far out they might be knocked out; an adult tooth not coming in; missing teeth; or certain bite problems.
Tuncay said parents should ask the orthodontist what the advantages of early, compared with later, treatment are, and whether there is harm in waiting. Orthodontics, he said, “is an elective procedure, and parents should not hesitate to get a second opinion.”
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NEXT WEEK: Fear and loathing in the dentist’s office.
