Need and Demand for Orthodontic Treatment

• Need vs want vs demand:

  • Want = an individual's own assessment of their dental state. Their 'want' for better oral health. The demand for dental intervention is derived from this basic 'want'.
  • Demand = those of their 'wants' that the individual converts into demands by seeking the assistance of a practitioner
  • Need = a state of oral health deemed as in 'need' of intervention by a dental practitioner

  
• Consumer factors influencing demand:

  • Improved appearance
  • Desire to look 'normal' (wide variation perception)
  • Gender (females want attractiveness more than males)
  • Age and peer group norms
  • Parental aspirations
  • Higher socioeconomic groups
• Factors influencing provision:

  • Remuneration (money paid for a service)/cost
  • Awareness and attitude to orthodontics
  • Perception of treatment need
  • Access to advice/support/treatment
  • Proper assessment of treatment need - indices/rationing
• There are many indices in orthodontics:

  • Indicators of occlusal discrepancy, severity of malocclusion and appropriate treatment:
  • Angles molar classification
  • Incisor classification
  • Skeletal classification
  • Indicator of treatment quality = PAR (Peer Assessment Rating)
  • Indicator of treatment need = IOTN (Index of Orthodontic Treatment Need
• IOTN (Index of Orthodontic Treatment Need) is used to assess Treatment Need/Rationing. It has 2 components:

  • Aesthetic component
  • Dental health component
  • 1 = None
  • 2 = Slight
  • 3 = Borderline Need
  • 4 = Need Treatment
  • 5 = Need Treatment

  
• IOTN (Index of Orthodontic Treatment Need) - Dental Health Component:

  • MOCDO
  • M = Missing
  • O = Overjet
  • C = Crossbite
  • D = Displacement of contact point
  • O = Overbite

  
• Potential benefits of orthodontic treatment:

  • Function - mastication, speech
  • Dental health - TMJ, tooth impaction, caries, periodontal disease, trauma
  • Multidisciplinary - restorative/surgical
  • Psychological - confidence/teasing, self-esteem
• Function:

  • Eating
  • Severe Class II, III or AOB (anterior open bite)
  • Pts perceive improved function
  • Need for improved masticatory efficiency?
  • Speech
  • Affects place but not manner of articulation
  • AOB (anterior open bite), lip trap, crossbite, Class III
  • Adaptation
• Options for impacted teeth:

  • Expose
  • Risk root damage/crown damage/ankylosis (tooth fusing to bone)
  • Help with alignment and decrease risk of cyst/resorption
  • Leave
  • Risk of cyst formation/root resorption
  • But no treatment risks
  • Extract
  • Surgical risks/damage (roots)
  • But decrease cyst risk/resorption
  • Autotransplantation (tooth is extracted and reinserted in the position it's supposed to be in)
• Claims for impact of orthodontic treatment on caries:

  • Straight teeth are easier to clean - individual variation
  • People keep their teeth cleaner after orthodontic treatment - weak evidence
  • Straight teeth have less caries - no evidence
  • Caries is multifactorial - carbohydrate intake important
• Orthodontic treatment may facilitate oral hygiene, and may improve position of periodontally compromised teeth. But there's also the risk that it may make perio condition worse.
• Dental health - trauma:

  • Overjet - increased overjet associated with increased trauma
  • Overbite - deep overbite associated with palatal trauma
• Multidisciplinary orthodontic treatment - facilities:

  • Conservation
  • eg hypodontia
  • Implants (roots/space)
  • Complex crown and bridge (overbite etc)
  • Partial denture
  • Surgical treatment - decompensation prior to orthognathic surgery
• Psychological impact of orthodontic treatment - teasing:

  • Most common insult in children is about teeth
  • But also teasing about treatment
  • Quality of life influenced by hypodontia, overjet, or a score of 4/5 on the IOTN
  • Better occlusion associated with increased self-confidence - effect may continue over lifetime
• Risk of orthodontic treatment:

  • Iatrogenic damage: caries, root resorption, bone loss/perio problems, loss of vitality, trauma
  • TMD pain
  • Stability issues with occlusion
  • Face profile changes
  • Discontinuation of treatment

  
• Orthodontically induced inflammatory root resorption:

  • Inevitable - 1-2mm root length loss
  • 2% patients lose > 2mm
  • Some repair - cementum (rest periods)
  • Increased with:
  • Distorted apices
  • Thin roots
  • Compromised teeth
  • Excess force
  • History of resorption
  • Asthma (thought to be due to increased allergic response)

  
• Bone loss/periodontal problems:

  • Generally no long term effects
  • Poor oral hygiene can exacerbate though
  • Inappropriate tooth movements can bring it on - expansion, proclination, torque
  • Pre-existing disease may stay though
  • Treatment
  • Screening (BPE 3/12)
  • Oral hygiene instruction
  • Chlorhexidine mouthwash (CHX MW)
• Loss of vitality/trauma:

  • Reversible pulpitis
  • Pain - generally transient - occurs for a few days after activation/adjustment of appliance
  • Irreversible pulpitis
  • Risk increased with trauma
  • Vitality - baseline, 3/12
  • Informed consent
  • Previous RCT
  • Radiographs - check for PAP
  • If ok, normal treatment
• Trauma/iatrogenic damage to soft tissues related to orthodontic treatment:

  • Headgear
  • Eye injury (small risk but significant consequence)
  • Skin injury/allery
  • Allergy
  • Trauma
  • Burns
• TMD (temporomandibular disorder):

  • Does malocclusion cause TMD
  • Weak evidence for: AOB (anterior open bite), increased overjet, posterior crossbite, RCP-ICP slide, deep overbite
  • Evidence against: weak correlation, 60% of population have malocclusion (5-35% TMD), TMD no more common in patients with severe malocclusion than controls
  • Does orthodontic treatment cause TMD?
  • Contradictory evidence for and against
  • Do extractions cause TMD?
  • Contradictory evidence - but probs not
  • Does orthodontics improve TMD? - probs not
  • Can TMD pts have orthodontic treatment? - if 'under control' and no pain
• Patients can develop TMD whilst undergoing orthodontic treatment.

  
• Stability and relapse in orthodontic treatment:

  • Relapse is inevitable
  • Factors in orthodontics that are problematic for relapsing: spacing, rotations, expansion, periodontal problems
  • Elastic recoil PDL fibres - remodel over around 1 year
  • Retention
  • Full time - now rare for Essix retainers, 6 months for Hawley (because less effective than Essix retainers)
  • Night time - at least 1 year
  • Occasional - lifetime
  • Lower incisor crowding due to mandibular growth - retention particularly important to end growth
• Facial profile:

  • Soft tissue contours determined by:
  • Skeletal foundation
  • Dental support
  • Soft tissues
  • Claim that extractions damage profiles:
  • Small effect
  • Growth is more important
  • Profile evaluation subjective
• Reasons for discontinuation of orthodontic treatment:

  • Pain
  • Misunderstanding of treatment requirements
  • Inability to get time off work/school
  • Peer pressure
  • Forced decision in the first place
  • Poor compliance
  • Poor cooperation