Our current patients may have significant psychosocial problems and stress factors that make them different from the patients we treated in decades past. Previously, when treatment began to fail, orthodontists tended to focus only on what they were doing wrong. Today, however, we know that there are other factors, some of which are beyond our control. Unless we are aware of these challenges, our current biomechanics may fail. The solutions depend on recognizing these challenges and solving them concurrently with traditional orthodontic treatment.
The Psychological and Biological Health of Today's Orthodontic Patient and Family
Thirty years ago, orthodontic patients did not spend hours a day using cell phones and computers. These new habits involve different head and neck postures that can be detrimental to facial growth and development.
These same patients appear to experience more daily stress than previous generations. A number have only one parent. They may be bullied at school and home. Many have sleep disorders, and suffer stress due to the pressure to only succeed and never fail. Many parents and patients are too busy to function as a family. Parental guidance, motivation, and caring may be deficient.
The end result may be adolescent patients who disappear for months at a time during treatment. Orthodontists may encounter patients who have psychosocial problems that interfere with their ability to focus on the oral hygiene required for orthodontic treatment. Lack of compliance with full-time elastic wear can temporarily stop treatment for extended periods of time.
Recent research on today's orthodontic patient base reveals dietary problems that can significantly alter or interfere with gingival and alveolar bone remodeling. What can initially appear as a normal patient's periodontium can drastically change when we apply normal biomechanical treatment forces.
Because these factors may not have been part of our orthodontic training, we often require additional resources.
Finding the Best Help
1) A PhD Clinical Neuropsychologist
A careful and detailed medical history may disclose potential psychological/medical disorders, such as bipolar dysfunction, attention deficit disorder, depression, sleep disorders, seizure disorders, congenital growth deficiencies, and trying to live in a dysfunctional family. These are just some of the myriad problems that were not noticeable 15 to 20 years ago. Our orthodontic population is changing, but many parents may not disclose this critical information because, "We are just here to get his or her teeth straightened."
This is one of the reasons why my orthodontic team members will review the four-page medical and dental history with the parents and patients before I spend 20 to 30 minutes performing my initial examination. In 36 years of orthodontic practice, I have found that when I also review the medical/dental history, oftentimes a second series of questions may elicit additional, critically important details that can dramatically affect the success or failure of orthodontic treatment. If I identify any such patient information, I nearly always request a written consultation with the pediatrician or other health care professionals who have treated the patient.
A few critical occurrences in children's lives that can alter their compliance may include the following: a death in the family, a physical or mental trauma, a previous traumatic dental treatment event, or a significant motor vehicular accident.
Some of today's parents do not want to be parents anymore. Instead, they only want to be a friend to the patient. They often say, "I cannot do anything with him or her." Conversely, one recent patient said, "I have enough friends. I need parents." It is challenging to try to communicate the lifestyle changes required to become a good orthodontic patient when the children are completely in charge of their current lifestyle. In these types of patients, even the best clinical skills can rarely achieve a "winning smile" when constant periodontal disease and/or severe decalcification are rampant.
If any of the above factors are interfering with successful and timely orthodontic treatment, I have found that referral to a clinical neuropsychologist (for patient and parents) often yields positive results. Parents often thank me for such a referral and report improvement in school achievements and other social factors.
Neuropsychologists have extensive knowledge of today's adolescents and teenagers. Consulting with them is not only appropriate, but may be the difference between orthodontic treatment's success or failure. Their diagnosis alone can help redirect orthodontic treatment toward success. I have hired a psychologist as a consultant to assist me and my team to better communicate and empathize with many troubled patients. Other medical professionals routinely refer to psychologists. Why should orthodontists not also use this important health modality?
To ensure success in referring to a psychologist, it is critically important to select a qualified professional, and then spend several hours with him or her expressing exactly what your concerns are and what assistance you need. Many times, clinical psychologists are helpful in effectively communicating to patients and parents how much orthodontists truly care about their patients and why they are constantly monitoring oral hygiene and treatment cooperation. Upon hearing this from another trained professional, patients and parents often change their attitude toward the clinically directed orthodontic team.
2) A Board-Certified Neurologist
Some patients may require the additional assistance of a board-certified neurologist. These medical specialists have advanced training in stress control, uncontrollable destructive habits, and sleep disorders (including severe clenching and night grinding). The neurologist can supplement the psychologist's treatment. Together, they can add the necessary treatment to permit orthodontic compliance and the completion of treatment.
Orthodontists should use the same care in selecting and communicating with a neurologist as they do when working with a psychologist. I request a complete neurological diagnosis and treatment plan, as well as complete reports and follow-up progress events. Currently, my neurologist has been successful in minimizing severe night grinding and assisting in stopping fingernail biting and other destructive habits.
Other Factors Affecting Treatment Success
1) Dietary Factors
Many current orthodontic patients do not eat breakfast. Lunch can be a sweetened soda and a candy bar. Dinner can be a pizza or fast food. Such a diet lacks nutritional basics, including a balance of proteins, minerals, and vitamins. Two endocrinology studies1,2 have found that a significant number of pre- and post-pubertal teenagers actually suffer from osteopenia (lower than normal bone density). There are indications that this is becoming a worldwide problem.
Orthodontists stimulate bone and soft-tissue remodeling while trying not to create root shortening. Without an adequate level of calcium entering the bones, osteoblastic cellular activity may be limited or not possible. Calcium's entering bones is dependent on the presence of Vitamin D. In the past, most young people spent hours per day outside, exposing their skin to sunlight. Because of concerns about skin cancers, many current youngsters spend less time in sunlight, use sunscreen, or cover their skin. As I previously mentioned, many young people choose to stay indoors, spending time on cell phones and computers. The total effect is a worldwide deficiency of adequate levels of Vitamin D.
Orthodontists have a difficult time motivating patients to cooperate with oral hygiene and elastic compliance. To also attempt to change their current dietary problems is a daunting task. In my office, we suggest that parents analyze their child's current diet and consider supplementing this diet with multivitamins, which have correct levels of zinc, B-complex, and vitamins C and D. We also advise that these supplements be ingested in the middle of a meal and not on an empty stomach. We have found that when parents and patients comply with these requests, the result is an apparent increase in bone and soft-tissue health while we are remodeling their periodontium. Improved tissue and bone health also often makes clinical adjustments (such as archwire changes) much more comfortable.
2) TMJ Factors
In my textbook,3 I begin with the statement, "The TMJs affect the teeth and bone; the teeth and bone affect the TMJs; and orthodontics affects both."
From the initial examination, through clinical treatment, to retention, we constantly examine each patient's TMJ status. This exam includes testing the range of motion, noting opening and closing deviations and measurements, bimanual palpation of the external surface of the TMJs, and palpation of the muscles of mastication.
3) Displaced Condyles
A patient presenting with posteriorly displaced condyles could affect an orthodontist's ability to achieve Class II correction. Such patients may also have "dual bites." Taking progress panoramic images in "centric occlusion" may also reveal condylar positional discrepancies. Destructive habit control training4 may help solve the above problems.
Periodic molar and bicuspid bonded composite "functional covers," creating TMJ vertical unloading, can also help improve these intercapsular problems.
4) Ankylosis, Airway Factors, and Tongue Thrust
Ankylosis, like many other dental factors, can alter your treatment goals. Here again, consultation with general dentists, endodontists, or university radiologists can shed important light. These colleagues can make treatment suggestions to change a "no progress" problem into a completed treatment.
Chronic mouth breathers change the oral environment with abnormal drying of gingiva and other periodontal problems. Allergists have many new prescriptions that can eliminate or minimalize this problem.
Abnormal tongue posturing or anterior or lateral thrusting can place forces on teeth so heavy that they exceed the light orthodontic forces. This can interfere with closing spaces or open bites. We routinely evaluate resting tongue posture (visible on lateral cephalometric radiographs) and periodically use bonded composite mandibular tongue trainers (from Ortho-Arch) to re-train the tongue . Some estimate that patients swallow 40 times an hour or 960 times per day.5 Without addressing these destructive forces, even the best mechanotherapy can fail.
Consulting with Peers
Sole practicing orthodontists often feel alone when encountering treatment problems. Former teachers, current continuing education lecturers, and study club members can be very helpful, especially since records can now be sent digitally. So as not to unfairly impose on these specialists, I routinely send a check to remunerate them for their help. I predict that this sort of confidential, digital consulting service will become the "standard of care" for future orthodontic practice.
This second article in the "Troubleshooting Orthodontic Treatment" series has been presented to help orthodontists solve nonbiomechanical problems that may interfere with treatment. Part 1 focused on recognizing and controlling destructive habits. Future articles will focus on identifying and solving problems with multiple tooth size discrepancies, abnormal variations in the anatomy of certain teeth, and "prefinishing equilibration."
Michael C. Alpern, DDS, MS, maintains a private practice in Port Charlotte, Fla. He can be reached via e-mail at firstname.lastname@example.org.