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Orthodontics/Finding an Orthodontist

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QUESTION: Hi Dr. Supan
I am considering getting a consultation from an orthodontist who treated a friend of mine years ago. This friend of mine did have a very positive experience with this person. I checked on the American Association of Orthodontists website and discovered that this orthodontist is not a member. Should I or would you be hesitant to see and get treatment from this practitioner?
Thanks

ANSWER: Dear Ben,

I am glad that orthodontic patients and other health care consumers like you are examining the credentials and training of the doctors they are choosing. You asked about membership in the American Association of Orthodontists (AAO) and posed an interesting question.  

You asked namely:

" I checked on the American Association of Orthodontists website and discovered that this orthodontist is not a member. Should I or would you be hesitant to see and get treatment from this practitioner? "  

Kindly allow me to answer this question in stages.

#1  Is the doctor you are seeing in fact an Orthodontist (a dental specialist), or a General Dentist, or perhaps Pediatric Dentist who is providing orthodontic services ?  

There is nothing wrong or illegal about orthodontic services being provided by doctors who are not Orthodontists. What is disheartening is when you the consumer, are not fully aware of the doctors background and credentials. If in fact you do specifically want a trained and Board Certified Orthodontist to be providing your care, many consumers have a hard time understanding that some doctors for example,  are in fact general dentists.

This confusion comes from the frequent manner in which such practices are often promoted, namely presenting themselves as “ Family Dentistry & Orthodontics “ . I have patients whom I have treated who exclaim that their family dentist is also an Orthodontist. Actually not, but the manner in which some doctors present their practices often makes it confusing for the dental consumer.

Likewise, I have seen ads noting “ Orthodontics care by a Specialist “. Such a statements seems legitimate enough, but it failed to be complete. The “Specialist” was a Pediatric Dentist, and not an Orthodontist. Now I feel Pediatric Dentists are fully capable of providing many types of orthodontic services, It is not their qualifications which concern me, rather the somewhat misleading language.

This leads me to the question I posed, namely are you in fact seeing am Orthodontist? Only an Orthodontist can be a member of the American Association of Orthodontists. The AAO is the official professional association in the USA for Orthodontists. Other groups such as the American Orthodontic Society is actually largely an organization of non-Orthodontists who provide orthodontics.

There are 9 traditionally recognized dental specialties in the US. A recent Texas Court decision in early 2016 has questioned whether only the American Dental Association should be the body to recognize and sanction dental specialties. That is a discussion for another day. The current ADA recognized specialties are outlined in the 2 links listed below.

From the ADA Website Links:  
http://www.ada.org/en/education-careers/careers-in-dentistry/dental-specialties/
http://www.ada.org/en/education-careers/careers-in-dentistry/dental-specialties/

#2  So at this point, let us assume your doctor is in fact a dental specialist, and in fact an Orthodontist. Why is he or she not an AAO member?

A Physician who is a specialist and has completed a Dermatology residency for example can practice a specialty such as dermatology and hold themselves out as “Specialists in Dermatology  “ without being a member of the American Medical Association (AMA) or the American Academy of Dermatology (AAD). Likewise an Orthodontist can practice the specialty of Orthodontics and hold themselves out as “Specialists in Orthodontics” without being a member of the American Dental Association (ADA) or the American Association of Orthodontists (AAO).

It is my personal opinion that Orthodontists should be members of the AAO in order to take better advantage of the many educational benefits offered and the contact with other Orthodontists that many of the AAO functions provide. However, I would not discount choosing an Orthodontists simply based on membership in the AAO.

#3  So is there something else to look for if the Orthodontist is not a member of the AAO ?

Again, this is my personal opinion, but I believe choosing a specialist who has achieved Board Certification is worth considering. I personally would not choose a Dermatologist who is not Board Certified. In terms of Orthodontic care by an Orthodontist, given the choice, I would prefer one who is Board Certified. I will not go so far as to say that one should only choose a Board Certified Orthodontist.   

To see if your Orthodontist is in fact “Board Certified”, the recognized board certification organization is the American Board of Orthodontics. An Orthodontist is said to be “ABO Certified” once he or she has passed a rigorous written examination and presented a Clinical Phase where before and after records of actual patient cases are reviewed and graded. Currently it is unfortunate that less than 50% of Orthodontists in the US are “ABO Certified”.

I therefore will say that all things being equal I would personally feel more comfortable with and recommend an Orthodontist who is ABO Board Certified.  Again, in my opinion it is not a deal breaker so to speak. To check to see if your doctor is an ABO Certified Orthodontist, go to the following link

Link for American Board of Orthodontics:  
https://www.americanboardortho.com/portal/public/Default.aspx#

# 4  So what should I do?

I would say make sure that the person is an Orthodontist. Whether he or she is a member of the AAO, or is ABO Certified should not be a deal breaker. However, now that you have more background, research your options a bit more , and then make a final decision.

In summary, I hope my comments have been helpful. As you know Ben, the website here encourages readers like you to rate the answers and to resubmit with follow up questions. Good luck with choosing a doctor for your upcoming consultations. If you would like to submit a follow up I would be happy to answer in more detail.

Ben, thank you for writing.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com


---------- FOLLOW-UP ----------

QUESTION: Hi Dr. Supan.
I have a few more questions if that's ok. I first would like to explain my history.

I am 39 years old and 20 years ago, I had surgical assisted rapid palatal expansion followed by braces and then removable retainers. At the time of the surgery, I was almost 19.5 years old and I had stopped growing by age 15. This treatment was to correct my crossbite, which caused me to have a fairly significant malocclusion. I had a bonded expander attached to my upper teeth followed by the surgery about a week later. My surgeon did the first few turns of the expander and I completed turning the expander a few weeks to a month later. About 3 months after the expansion of my palate was complete, my orthodontist removed the expander and I wore top and bottom braces for about 10 months. (While I wore the expander, he put braces on my bottom teeth and on my front top 6 teeth that were not covered by it.) This was followed by top and bottom removable retainers, which I wore full time for another 3 months, and then every night for another 3 months. I diligently followed all of the instructions by my oral surgeon and orthodontist. My orthodontist told me to wear my retainers at night, as needed to maintain my bite, which I wore about once a week.

For about 7 years, my bite was very comfortable. It then began at feel a little off but I was able to restore it by wearing my top retainer more than my bottom one.

A little over a year ago, my upper and lower teeth began to feel out of alignment, and I noticed my top right front tooth tilting slightly inward as well a crossbite, more so on my right posterior side. I did see my surgeon who examined me and recommended I see an orthodontist. The one who treated me retired. I’ve seen 2 orthodontists who are recommending either braces or Invisalign for about a year. They said the only way to totally fix my cross bite would be to have another palatal expansion surgery, which they do not recommend. I also have no intention of having this a second time.

-I have recently read that palatal expansion in adults can be possible without surgery? Do you agree, or would you be doubtful of any orthodontist claiming this?
-Also, is it possible that I have a posterior cross bite on my right side because I’ve usually slept on that side?
-Was I a few years too young to have SARPE? Should I have waited until I was in my early 20’s?
-Should I have worn the expander for longer than 3 months once my palate was fully expanded?
-Should I have worn a palatal bar once the expander was removed to act as a retainer to prevent too much relapse?
-One orthodontist I recently saw recommended Invisalign because, compared to braces, it would be able to move my right front top tooth forward without putting as much reciprocal pressure on the adjacent teeth. He recommended this because I have some root shortening on my top front teeth from my previous treatment. Do you agree that Invisalign can do this?

Thank you
Ben

ANSWER:

=================================================
Dear Ben,

Pardon the terrible delay in responding to your latest follow up. It is a complicated question and I was trying to run down some information, but it is taking too long. Therefore, at this point, allow me to address some of your specific questions.


#1)
-I have recently read that palatal expansion in adults can be possible without surgery? Do you agree, or would you be doubtful of any orthodontist claiming this?

Interesting question. Maturation and sealing of the palatal growth sutures generally takes place earlier in females than males.  While a classical  rule of thumb has been to avoid skeletal palatal expansion after the traditional adolescent growth period, the suture itself does not actually suddenly become rigid. Visualize if you will the upper roof of your mouth with a left and a right half. Running down the middle is a jagged line which defines a boundary interface between these two distinct pieces. Whereas in early youth  these two halves are distinct and form a grown suture, much like the geological tectonic activity involving the middle Atlantic ridge, in the late teens these halves become less distinct. The left and right halves cease growing, and the boundary interface starts to slowly fuse. This fusion means that the transverse palatal growth and increase in transverse dimension begins to decrease and eventually cease.

In your case the question is, can further non-surgical expansion be accomplished in adults after the so called “fusion” has occurred. Logically and traditionally one would think not. However the “fusion” process is not spontaneous, and the interface first becomes what has been characterized as ‘sticky”. How long does it stay” sticky” before completely fusing? I am not sure the definitive research has been done on this, and clearly it will vary greatly among populations, genders, ethnicities, etc. At age 39 it is almost certain that your growth sutures are now fully fused.

The information I was trying to find for you Ben, had to do with some appliances being used by a Doctor named Williamson. I too a course years ago from him, and used one of his appliances on a 30 year old make to achieve some palatal expansion. I did not think t would work, but it did.  Unfortunately, I have not been able to find any Evidence based Dentistry with studies to validate this appliance. It may exist, but I could not find it. He appliance I used basically spanned the roof of the mouth (the palate) and using bands, attached to a molar and premolar on each side. Compressed coil springs gently pushed the halves apart over a one year period. I was amazed that it worked, but this is a completely anecdotal story based on a sample of one.

Guess the message here is that palatal expansion (or perhaps better called skeletal “plastic remodeling” in patients whose palatal sutures likely have already fused may be possible. I simply do not know, and in the past week as I looked into this for you, i was not able to come across much substantial evidence.  I will leave it at that.


#2
-Also, is it possible that I have a posterior cross bite on my right side because I’ve usually slept on that side?

It has been my observation that in growing children if a person sleeps just one one side some very very slight asymmetries can sometimes be noted. When I see patients for the first time for an initial consultation and examination, I will sometimes ask, do you sleep mainly on your left (or right depending on what I see) side. They often act surprised that i could say this based just on my examination of their facial symmetry.

In your case Ben I can not exclude that possibility entirely, but it would seem unlikely that even chronic sleeping on only one side would create a skeletal posterior crossbite.


#3
-Was I a few years too young to have SARPE? Should I have waited until I was in my early 20’s?

This is difficult to say because the severity of various different problems and the variation in the ages of skeletal maturation can all vary rather widely. If your oral surgeon and orthodontist concluded that SARPE was appropriate, then in all likelihood you probably were not too young.


#4
-Should I have worn the expander for longer than 3 months once my palate was fully expanded?

Again, the clinician will decide this, and keeping the appliance in for three months is very common. In general, three months is seen as sufficient to help ensure stabilization in most circumstances.  Again, see the comments regarding the trans-palatal bar for guidance on this question.


#5
-Should I have worn a palatal bar once the expander was removed to act as a retainer to prevent too much relapse?

This is an interesting question that has two answers, namely yes and no. If the expansion performed was very profound because the initial transverse discrepancy between the relatively narrow upper vs lower jaw was very large, then perhaps a palatal bar should be considered.

In less dramatic circumstances where the palatal expansion to correct the crossbite is not so extensive and the initial upper narrowness is not so narrow and V shaped, then perhaps an arch wire alone can be sufficient to hold the expansion. There is no hard and fast rule to this, and it is left to the judgement of the clinician.  

Such trans palatal stabilization bars generally are not permanent. They are removed after a few months when the expansion has stabilized. Again, this is in the clinician’s best judgement regarding what to do, and each patient is unique.

#6
-One orthodontist I recently saw recommended Invisalign because, compared to braces, it would be able to move my right front top tooth forward without putting as much reciprocal pressure on the adjacent teeth. He recommended this because I have some root shortening on my top front teeth from my previous treatment. Do you agree that Invisalign can do this?

I can not really respond here because there are too many considerations. Root resorption and blunting is often seen in cases where there has been extensive and prolonged treatment.  Clear aligner treatment, such as Invisalign, can often serve to correct minor tooth relapse as well as move other teeth in a slower and more gentle manner so as to not further exacerbate any existing root shortening.  If you do have a skeletal crossbite due to relapse,  or late additional transverse growth of the lower, then clear aligner therapy may not be able to correct the problem as well as more traditional braces.

Again, the braces on the other hand, may exacerbate the root shortening situation. The guidance of an experienced and qualified clinician is your best option. Such intricate questions are beyond the scope of internet columns like this.

Ben, I wish you the best of luck. One option may to also simply live with the crossbite, and to wear an occlusal guard or retainer to reduce/prevent premature enamel wear from grinding.  Also, I appreciate your patience in waiting for this response. Thanks for an interesting, albeit very complex, question Ben.


Paul Supan, DDS, MA, MPH
Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

---------- FOLLOW-UP ----------

QUESTION: Hi Dr. Supan
I just had a consultation with an orthodontist who suggested Invisalign on my top and bottom teeth because he felt it could control tooth movements better than braces. He also said that the only way to reduce my crossbite on my back right side would be to tip these molars outward, which he did not recommend because this could compromise the stability and even health of these teeth. He also said that if you try to tip the molars out on one side, the molars on the other side would also move due the Newton's 3rd law: "For every reaction, there is an equal and opposite reaction." Do you agree with these two points?

I was also wondering if I could have top braces put only on my top teeth to straighten my top two front teeth (My right one is the only one to make contact with any of my bottom teeth when I bite and chew.) as well as to maintain my upper arch or very slightly outwardly tilt my back teeth. Once this has been achieved, the orthodontist and I would decide if anything should be done to my bottom teeth. What do you think of this?
Thank you
Ben

Answer

Hi Ben,

I won't repeat the usual preamble about my comments not being a diagnosis or specific treatment recommendation; you already know this.

As much as I try to visualize the dental conditions which readers like you describe, I often have difficulty because I can envision many possible scenarios which fit the description offered. In your case, I am not sure regarding the exact nature and disposition of the posterior teeth. Factors including periodontal bone height support, root length, bone density, vertical pocketing, working occlusion, presence of restorations and/or root canals, and more can influence a diagnosis.

I do concur with Newton's Third law. I am unable to fully address the question of selecting the appropriate treatment strategy for the posterior teeth.

Regarding eh other question you had about using limited fixed appliances ( braces) on the top teeth to address some mal-alignments, that certainly is worth considering. You also noted:

" Once this has been achieved, the orthodontist and I would decide if anything should be done to my bottom teeth.  "

That does sound reasonable. Moreover, changes in the anterior alignments may in fact also have an effect on the occlusion of the teeth. I would concur with your suggestion of considering limited upper treatment for the anterior problems first, and once completed then evaluating the next step. At that point you may very well have a better sense of direction of what is possible and reasonable for the remaining posterior issues.

Good luck Ben. I want to commend you for the amount of back ground research you are doing for your treatment. I do wish more patients would do their homework prior to starting orthodontic treatment.

Paul Supan, DDS, MA, MPH
Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

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Paul Supan, DDS, MA, MPH

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First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

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American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

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Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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