Like uniforms and homework, dental braces were once inextricably linked with school days. But times change. The promise of quick results and the availability of discrete braces have prompted more adults to consider orthodontic treatment and many dental practices now offer these treatments in-house.
According to a July 2016 survey of orthodontists and dentists in high street practice by the British Orthodontic Society (BOS), 75% of respondents had seen an increase in the number of adults seeking treatment. More than 80% worked in practices where more than half the patients were adults.
David Manger, a GDP who now focuses solely on orthodontic practice, believes braces have become acceptable because of their widespread use to treat children. At the same time, society's growing emphasis on appearance has motivated more people to seek cosmetic dental treatment. Orthodontics has traditionally had a functional purpose - treating malocclusions caused by overcrowded or crooked teeth - but many patients are also delighted by the aesthetic results.
Even more attractive is the possibility of achieving a quick result with one of the new brands of short-term orthodontic appliances, rather than traditional comprehensive 'train tracks'. However, as David explains, short-term orthodontics is something of a misnomer. 'It's perfectly possible to achieve quick results with conventional orthodontic treatment; I've recently treated a patient with a traditional fixed brace in just seven months. The difference is that many of these appliances focus on moving the anterior six teeth, which is why limited treatment orthodontics is a better term and the one used by the BOS.'
Limited treatment orthodontics (LTO) is enabling many general practices to diversify and boost their revenue but David counsels dentists to think carefully. He points to the BOS's guidance on LTO which sets out the risks and appropriate precautions for GDPs and specialists.
While the BOS recognises that LTO can be appropriate 'as long as this option is presented in addition to all the other viable restorative and comprehensive orthodontic options and all diagnostic criteria have been assessed', it warns that an LTO approach would be inappropriate if there may be 'long-term consequences such as tooth-wear, jaw joint discomfort or damage to dental restorations'. Specific treatment aims and objectives should be discussed with the patient and documented and patients should be warned about 'the risks of decalcification, periodontal disease, root resorption devitalisation and relapse.'
While the same risks apply to orthodontics in general, David notes that LTO is heavily marketed on the time element and discussing this is key to obtaining informed consent. 'The time frame is part of the appeal, but it's important to be honest with marketing and temper patients' expectations about what can be achieved. This is in the dentist's interests too. After all, if a patient expects their treatment to take a year and it takes six months, they think you're brilliant; but if you tell them the treatment will take six months and it takes a year, they'll think you're somewhat less than brilliant!'
'In the same way, I would never suggest to patients that their teeth will be perfect after treatment because moving teeth generally creates a degree of instability which is never ideal. It may be that an LTO appliance will achieve the purpose of tipping a patient's teeth and they will be happy with the result. However, they should also be warned at the outset that the result may not be stable and they will need to wear retainers to prevent relapse.'
The time frame is part of the appeal, but it's important to be honest with marketing and temper patients' expectations about what can be achieved.
Before accepting a patient for LTO, dentists should do the 'proper groundwork', continues David. This includes radiographs to check bone heights and dental condition and taking a full medical history so you are aware if the patient has a medical condition which may make treatment more challenging.
'And as with all treatments, if things aren't going as planned, you need to be honest and have a back-up plan: if after nine months, there has been no progress and you haven't had a conversation with your patient, they will rightly be disgruntled.'
David suggests that mentors on LTO courses would be beneficial so dentists have an opportunity to contact one if problems arise. He also recommends dentists develop a good relationship with a local hospital consultant, specialist practitioner or dentist with a special interest in orthodontics who they can turn to for advice. 'I have been working in orthodontics for 15 years and I'm still learning so it's unwise to think you know everything. You have to accept that orthodontics doesn't always go to plan and have systems in place to deal with it.'
It's easy to see why LTO has become so popular. It offers adult patients a way to achieve straighter, more even teeth, without resorting to more invasive and costly treatments such as crowns and veneers. And there is no shortage of LTO training courses to help dentists meet demand, although many of these are run by appliance providers rather than an independent provider.
David advises GDPs who are interested in exploring orthodontics to do their research: 'Find a local specialist practice or hospital department and ask to see what they do. You can also visit the BOS website for guidance on how to become a GDP with a special interest in orthodontics.' David himself has completed a Diploma in Primary Care Orthodontics (DPCO), a three-year part-time course and exam which was run by the BOS and FGDP (UK).
With orthodontic training and experience, dentists should improve their patient selection and understanding of the appliances. But as David reflects, the core skills required for orthodontics are akin to those that every GDP needs in their daily practice. 'Ultimately, it's about recognising and working within your scope of competence,' he says, 'understanding what the patient wants and what you can achieve with the treatment; and ensuring they are fully aware of their options.'
The orthodontist's view
The success of limited treatment orthodontics is linked to wider economic factors, according to consultant specialist Claire Nightingale. 'Apparently, after the financial crash in 2008,' she explains, 'patients who wanted to improve the appearance of their teeth found they were unable to finance extensive smile makeovers. However they could still obtain the necessary finance for cosmetically-focused orthodontic treatments.'
Claire recognises that many patients are attracted to the promise of a quick result and the prospect of receiving treatment from their regular dentist in familiar surroundings. However, she cautions that limited treatment orthodontics carries risks which need to be discussed with the patient at the outset. For example, she agrees with David Manger that patients should be warned that it might not be possible to achieve the desired result within six months, as well as other unsatisfactory outcomes such as a poor occlusion or an increased overjet.
'While successful treatment depends on making the right diagnosis and careful treatment planning, obtaining fully informed consent is also vital,' asserts Claire. 'I usually talk with patients for 30-40 minutes about their options, including the option of no treatment. It is important to manage people's expectations and in my experience, it's much better to under-promise and over-deliver.
'I also try to anticipate potential problems as much as I can,' she continues. 'For example, patient compliance is important with orthodontic treatment so you need to be sure they are committed and understand exactly what is involved: I'd be wary if the patient had a history of poor attendance. Clinical warning signs include patients who have previously had orthodontic treatment, as root resorption can have occurred, and evidence of periodontal disease or tooth surface loss. You should only move healthy teeth.'
'All treatment options can succeed in the right hands,' she reflects, 'but it is really important to practice reflectively and know your own limitations. I've been practising exclusively as an orthodontist since 1993 but hardly a day goes by when I don't learn something new!
'You shouldn't try to treat a problem if you can't see or understand it so if you are in any doubt at the start, speak to a specialist. As with all forms of dentistry, the first principle should always be 'do no harm'.'
Interviews by Susan Field
BDS, DipPCOrth (RCS Eng)
David qualified from Cardiff Dental School in 1987 and worked in general practice from 1998 to 2003. During this time he worked as an orthodontic clinical assistant in Peterborough Hospital and completed the Trent two-year orthodontic training course for GDPs. In 2003 he left general practice to work full time in orthodontic practice in Kettering and in 2010 he was awarded a Diploma in Primary Care Orthodontics from the Royal College of Surgeons.
David is an active member of the British Orthodontic Society; he is the current honorary treasurer and trustee and has previously served as chairman of the society's Practitioner Group.
See more by David Manger
MSc, BDS (Hons), FDS (Orth) RCS (UK), MOrth RCS (Edin), FDS RCS (Eng)
Claire qualified as a dentist from Newcastle Dental School in 1989 and completed her masters in orthodontics at Bristol Dental School in 1996. She has her own private orthodontics practice in South Kensington, alongside an NHS Consultant post at Watford General Hospital. In addition to being involved in post-graduate orthodontics training, Claire is the author of a number of textbooks and papers on the specialty.
See more by Claire Nightingale