Seminars in Orthodontics

EDITOR -IN-CHIEF
Elliott M. Moskowitz, DDS, MSd

EDITORIAL BOARD
EDITOR-IN-CHIEF EMERITUS
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent

Mani Alikhani, New York, NY (2017) Peter Ngan, Morgantown, WV (2017)

Rolf G. Behrents, St. Louis, MO (2017) Perry M. Opin, Milford, CT (2017)
S. Jay Bowman, Portage, MI (2017) Jae Hyun Park, Mesa, AZ (2017)
James Caveney, Wheeling, WV (2017) Sheldon Peck, Newton, MA (2017)
John Grubb, Chula Vista, CA (2017) William R. Proffit, Chapel Hill, NC (2017)
Greg Huang, Seattle, WA (2017) Eugene Roberts, Indianapolis, IN (2017)
Robert J. Isaacson, Edina, MN (2017) Emile Rossouw, Rochester, NY (2017)
Laurance Jerrold, Brooklyn, NY (2017) David L. Turpin, Federal Way, WA (2017)
Lysle E. Johnston, Jr., Eastport, MI (2017) James L. Vaden, Cookeville, TN (2017)
Donald R. Joondeph, Bellevue, WA (2017) Robert L. Vanarsdall, Jr., Philadelphia, PA (2017)
Robert G. Keim, Los Angeles, CA (2017) Katherine Vig, Columbus, OH (2017)
Richard Kleefield, Norwalk, CT (2017) Christos Vlachos, Homewood, AL (2017)
Steven J. Lindauer, Richmond, VA (2017) Timothy T. Wheeler, Gainesville, FL (2017)
James A. McNamara, Jr., Ann Arbor, MI (2017) Leslie A. Will, Boston, MA (2017)

INTERNATIONAL
Adrian Becker, Jerusalem, Israel (2017) Rakesh Koul, Lucknow, India (2017)
Jose´ Alexandre Bottrel, Rio de Janeiro, Brazil (2017) Birte Melsen, Aarhus, Denmark (2017)
Theodore Eliades, Nea Ionia, Greece (2017) Antony McCollum, Bryanston, South Africa (2017)
W.G. Evans, Johannesburg, South Africa (2017) Eliakim Mizarahi, Ilford, England (2017)
Jorge Faber, Brasilia, Brazil (2017) Bjørn Øgaard, Oslo, Norway (2017)
Joseph Ghafari, Beirut, Lebanon (2017) Nikolaos Pandis, Corfu, Greece (2017)
Vicente Hernandez, Alicante, Spain (2017) Pratik K. Sharma, London, UK (2017)
Nigel Hunt, London, England (2017) George Skinazi, Paris, France (2017)
Haluk Iseri, Ankara, Turkey (2017) John C. Voudouris, Toronto, Canada (2017)
Roberto Justus, Mexico City, Mexico (2017) William A. Wiltshire, Winnipeg, Canada (2017)
Sanjivan Kandasamy, Midland, WA, Australia (2017) Björn U. Zachrisson, Oslo, Norway (2017)
 Seminars in Orthodontics
VOL 22, NO 3 SEPTEMBER 2016

Orthodontics / Pediatric Dentistry Issues of Common Concern

George J. Cisneros, DMD, MMSc
Guest Editor

■ Orthodontics/pediatric dentistry: Issues of common concern 159

George J. Cisneros

SOCIO-POLITICAL CONCERNS

■ The fragmentation of childrens’ oral health: Access to care in pediatric dentistry

and orthodontics 161
Nadia Laniado

■ “Medically necessary” orthodontic care: Challenges and applications 167

Joseph George Ghafari

■ Intra- and inter-office communication: Important in achieving optimal treatment

outcomes and patient satisfaction 177
Mary Eve Maestre, Robert Peracchia, and George J. Cisneros

ORAL HEALTHCARE CONCERNS

■ Non-cavitated dental radiolucent lesions: A challenge for the dental healthcare provider 185
Sarah S. Ahn, Paul K. Chu, and George J. Cisneros

■ Demineralized white spot lesions: An unmet challenge for orthodontists 193

Matthew J. Miller, Shira Bernstein, Stephanie L. Colaiacovo, Olivier Nicolay, and
George J. Cisneros

■ The pediatric dental trauma patient: Interdisciplinary collaboration between the

orthodontist and pediatric dentist 205
Courtney H. Chinn

TRANSDISCIPLINARY CONCERNS

■ Challenges managing individuals with hereditary defects of the teeth 211

John Timothy Wright

■ The case for environmental etiology of malocclusion in modern civilizations—Airway

morphology and facial growth 223
Anthony T. Macari and Ramzi V. Haddad

■ Eating disorders in children and adolescents 234

Nina K. Anderson and Olivier F. Nicolay
 Seminars in Orthodontics
VOL 22, NO 3 SEPTEMBER 2016

Orthodontics/pediatric dentistry:
issues of common concern

Introduction relevance of this concept for pediatric dental

care, but what about orthodontics? Our patients
hen Elliott Moskowitz offered the oppor-
W tunity to guest edit an edition of Seminars in
Orthodontics on Orthodontics and Pediatric Den-
perceive the need for our care but do we as
specialists in the field concur with their per-
spective? And more importantly where is its place
tistry, a thought immediately came to mind: do we
in healthcare? Joe Ghafari’s insightful discussion
really need another conversation about early
on this topic challenges our parochial perspec-
treatment? Fortunately, for all of us he was not at all
tives about our specialty’s place in the healthcare
interested in that idea. He was challenging me to
delivery continuum.
put together something much more substantive.
From that evolved the working title for this edition:
Pediatric Orthodontics: Beyond E.T. (Early Treatment). Communication
So, I sought out old friends like Joe Ghafari, Tim Although it is at the core of everything that we say
Wright, Nina Anderson, Rob Peracchia, and Olivier and do, when there is a lack of it, usually bad
Nicolay, and some newer friends such as Sarah Ahn, things happen, e.g., misunderstanding, non-
Courtney Chinn, Paul Chu, Anthony Macari, and compliance, dismal outcomes, and can even lead
Ramzi Haddad, as well as a number of former and to litigation. Proper use of communication usually
current students like Nadia Laniado, Eva Maestre, leads to positive outcomes and shows your patient
Matt Miller, and Shira Bernstein, and Stephanie that you really care about them and re-enforces
Colaiacovo, to get the job done. What came out of their trust in you as their care provider. Eva
this interaction is now here for your consideration. Maestre and her husband Rob Perrachia present a
compelling story on how they have integrated the
magic of communication, and its corollary, edu-
Socio-political concerns cation, into every aspect of their practices.
Access to care
We hear these words all the time but what do they Oral healthcare concerns
really mean and what does it have to do with the
Non-cavitated and white spot lesions
future of our practices? Quite possibly more than
one may realize. It certainly can make all the Both are challenges for all of us to be involved in
difference for the children and adolescents that and mandates that our specialties work better
need our services. Nadia Laniado’s article on the together on each of them. The former, often
matter is an enlightening dissertation on the called “Hidden Caries,” ironically, may have
matter—in many ways, ironically, a “Tale of Two evolved from our successful use of fluorides over
Specialties.” these many decades, the latter, curiously, too
often the negative side effect of creating an
Medically necessary esthetic dentition.

Another term often discussed but rarely appre- Dental trauma

ciated. Most of us readily understand the
Always an important area of common concern
& 2016 Elsevier Inc. All rights reserved. and interest for both specialties and Courtney
http://dx.doi.org/10.1053/j.sodo.2016.05.001 Chinn has done a masterful job using a single

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 159–160 159

160 Cisneros

case to illustrate an ideal collaborative approach that needs much more attention from the dental
to the management of this situation. community at large. It is a long overdue discussion
on this topic for us in dentistry in an area that we
all can contribute to help recognize and treat
Transdisciplinary concerns individuals suffering from such disorders.
Hereditary dental defects
Tim Wright’s article on the subject is a “state-of- Conclusion
the-art” comprehensive exposition that remark- As you can see, we have attempted to touch
ably simplifies a very complex dilemma. It is an upon a number of common areas for concern
encyclopedic discussion of some of the more for us as healthcare providers. Yet there are so
challenging anomalous conditions that we will many more candidates for discussion and col-
see in our practices. It also provides us access to laboration, i.e., childhood obesity, self-percep-
online databases to better define the clinical tion, speech language disorders, and, of course,
conditions that challenge us. One can easily early treatment and cleft lip/palate/craniofacial
envision this article become part of the reading disorders, as well. The list could be quite
lists for both the ABO and the ABPD. extensive.
Orthodontics and pediatric dentistry are two
Airway and facial growth of the finest specialties in healthcare—the for-
This has been a topic for controversy in growth mer, the oldest in dentistry, the latter the fastest
and development that has existed dating back to growing specialty. However, what make us so
and even before E.H Angle, himself. The coher- special are the patients that we serve. The child
ence of Anthony Macari’s and Ramzi Haddad’s and adolescent, are among the most vulnerable
treatise on the issue transcends all of the historic as they are the least able to protect themselves
hullabaloo and beautifully discusses the topic in all and have the lowest access to healthcare. Let us
of its depth and breadth—another potential and continue to advocate for them, keep our energies
appropriate candidate for the Boards’ reading lists. focused to work in partnership to enhance
healthcare outcomes for them all.
Eating disorders George J. Cisneros
Lastly, Nina Anderson and Olivier Nicolay Guest Editor
present a timely conversation about a condition E–mail: [email protected]
The fragmentation of childrens’
oral health: Access to care in pediatric
dentistry and orthodontics
Nadia Laniado

Improving access to care in order to reduce the burden of oral disease has
gained increased attention with the passage of the Patient Protection and
Affordable Care Act (ACA) in 2010. With regard to oral health, it is primarily
children, and not adults, that have been the beneficiaries of the new
mandates and policies of the ACA. There are three stakeholders involved:
patients, caregivers, and payers. Each have unique needs and constraints
that ultimately affect the ability of children to receive necessary dental care
including both preventive/restorative and orthodontic treatment. The
definition of “medically necessary care” for pediatric dentistry and ortho-
dontics is crucial in determining access to care for children. (Semin Orthod
2016; 22:161–166.) & 2016 Elsevier Inc. All rights reserved.

I mproving access to care in order to reduce

the burden of oral disease has gained
increased attention with the passage of the
The patient
In the United States there are 82 million children
(ages 0–19 years), representing 25% of the total
Patient Protection and Affordable Care Act
population.2 Unfortunately, those who need care
(ACA) in 2010. With regard to oral health, it is
the most are least likely to get it. One quarter of
primarily children and not adults, that have been
children ages 2–5 years and one-half of those 12–
the beneficiaries of the new mandates and pol-
15 years have tooth decay.3 The National Center
icies of the ACA.1 To understand the complexity
for Health Statistics (NCHS) reported in 2015
of the access to care issue one must look at each
that Hispanic/Latino children and African
of the three entities involved: the patient (i.e., the
American children are twice as likely as white
child), the caregiver (i.e., the dentist or mid-level
children to have untreated tooth decay in
provider), and the payer (i.e., government and
primary teeth.4 About 17 million low-income
commercial insurers). Each have unique needs
children go each year without basic care that
and constraints that ultimately affect the ability of
could prevent the need for higher cost treatment
children to receive necessary dental care
later on.5 Although there has been steady
including both preventive/restorative and
progress toward childrens’ access to dental
orthodontic treatment. The purpose of this
care, there remain disparities based on
article is to compare and contrast how access to
insurance, income level and race/ethnicity of
care is addressed in the specialties of pediatric
the patient (Table 1).6
dentistry and orthodontics in the post-ACA
The recognition that oral health is essential to
landscape.
overall health has been affirmed by making
pediatric oral health services one of ten “essential
health benefits” (EHB) under the ACA.7 More
than five million children with Medicaid and
Department of Dentistry/OMFS, Jacobi Medical Center/North Children’s Health Insurance Program (CHIP)
Central Bronx Hospital, Bronx, NY. have dental coverage under the Early Periodic
Address correspondence to Nadia Laniado, DDS, MPH, Depart- Screening Diagnostic Treatment (EPSDT) pro-
ment of Dentistry/OMFS, Jacobi Medical Center/North Central Bronx
Hospital, Bronx, NY 10461. E-mail: [email protected]
gram. However, while the EHB requires a dental
& 2016 Elsevier Inc. All rights reserved.
benefit to be offered, the law and subsequent
1073-8746/16/1801-$30.00/0 regulations do not require it to be purchased
http://dx.doi.org/10.1053/j.sodo.2016.05.002 when offered separately on the Exchanges.

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 161–166 161

162 Laniado

Table 1. Percentage of children ages 2-17 with a dental malocclusion type, severity, or prevalence in the
visit. United States.
1997 2005 2012 In the ACA, one of the ten “essential health
benefits” is “medically necessary” orthodontic
Children ages 2–4 years 45 48 57 coverage for children under the age of nineteen.
Children ages 5–11 years 81 84 89
Children ages 12–17 years 77 82 87
In 2014 the American Association of Ortho-
dontics (AAO) defined “medically necessary
Source: America’s Children: Key National Indicators of Well-
Being, 2014 www.childstats.gov
orthodontic care” (MNOC) as “the treatment of a
malocclusion (including craniofacial abnormal-
ities/anomalies) that compromise the patient’s
Unlike dental caries and periodontitis, a mal- physical, emotional, or dental health. This treat-
occlusion is not a disease but a variation from ment should be based on a comprehensive
ideal standards. As a specialty in dentistry, assessment and diagnosis done by an ortho-
orthodontics is primarily thought of as a cosmetic dontist, in consultation with other health care
service. However, we know that untreated mal- providers when indicated.”9 Although not used by
occlusions can lead not only to poor oral function orthodontists for diagnostic purposes, ortho-
but psychosocial issues that can adversely affect dontic indices were developed to define maloc-
quality of life. For these individuals, their severe clusion severity and create objectivity in order to
structural and functional deviations and dento- determine the neediest cases. This would include
facial disharmony not only have physical sequelae patients whom, in addition to severe occlusal
but also have an enormous psychosocial impact. disharmony, have difficulty with biting, chewing,
In pediatric dentistry there are many oral swallowing, speaking, and experience psycho-
health surveillance systems on both state and logical trauma and social issues.
local levels that track measures such as last dental The need to prioritize and triage with regard
visit, last prophy, untreated decay, sealants, to orthodontic treatment is therefore critical.
missing teeth, and fluoridation status. However, Unfortunately, there is no nationally accepted
in orthodontics there is little to no surveillance. criteria for determining orthodontic necessity; it
The last study of prevalence and treatment need is up to each state to determine its own defi-
in orthodontics was carried out in the National nition, and cutoffs for eligibility often hinge on
Health and Nutrition Examination Survey economic dictates.10 Most states have adopted an
(NHANES III) in 1988–1991.8 Subsequent efficient and cost-effective way of screening
surveillance efforts have been halted due to orthodontic severity using one of two popular
budgetary constraints. There is a database that orthodontic indices: the Handicapping Labio-
monitors the occurrence of cleft lip and cleft Lingual Deviation (HLD) index11 and the
palate, but currently there is no surveillance for Saltzmann index.12 Neither index is used for
diagnostic purposes, but points are given for
various conditions and numerical scores assigned
based upon the degree or severity of the con-
Table 2. States with the worst dentist shortages. ditions. Inconsistencies in the definition and
States % population underserved eligibility criteria for MNOC create problems in
the continuity of care for children who may have
1. Mississippi 36.3 changes in coverage due to financial or geo-
2. Louisiana 24.4
3. Alabama 24.4 graphic reasons. This applies to both government
4. New Mexico 24.2 programs as well as commercial insurance plans.
5. Delaware 21.9 Not surprisingly, socioeconomic factors that
6. South Carolina 20.6
7. Tennessee 19.8 affect access to care for orthodontic treatment
8. Florida 18.0 also mirror the pediatric dental findings. One of
9. Idaho 17.5 the few studies to look at ethnic disparities in
10. Oregon 17.3
orthodontic care found that there was less
Source: U.S. Department of Health and Human Services, likelihood for African American and Hispanic
Health Resources and Services Administration, State
Population and Health Professional Shortage Areas Designation children in comparison to white children to
Population Statistics, data as of January 9, 2013. access orthodontic care. In addition, it has
 The fragmentation of childrens’ oral health 163

been determined that there may be a higher In recent years there have been several suc-
prevalence of severe malocclusion in minority cessful programs aimed at addressing the dis-
groups.13 The prevalence of an orthodontic visit proportionately small number of minority
among children ages 9–18 years remained providers in the United States. These include
relatively constant (ranging between 14.3% Pipeline, Profession and Practice—a Robert
and 16.8%) from 1996 to 2004.14 Medical Wood Johnson Foundation initiative to help
Expenditure Panel Surveys (MEPS) from 1996 dental schools increase access to dental care
to 2004 reveal that males, children from low- for underserved populations and increase
income families, children eligible for Medicaid, recruitment of underrepresented minority and
and children with other public insurance or no low-income students. The American Dental
insurance were less likely to have had an Association also has the Institute for Diversity in
orthodontic visit.14 Leadership which is designed to enhance the
leadership skills for underrepresented racial and
minority dentists.
The provider
There is a shortage of providers willing to
Providers are the second crucial determinant in serve those with the greatest needs.19 This
access to pediatric oral health care. Of the shortage is greatest among disadvantaged
approximately 230,000 dentists in the United populations and in certain geographic areas. A
States, 78% or 180,000, are active general den- disproportionate number of dentists work in
tists.15 Orthodontics is the second largest suburban areas, not in inner cities and rural
specialty at 26.8% or 10,000 orthodontists, and communities where need is greatest. The Health
pediatric dentistry the fourth largest specialty Resources and Services Administration (HRSA)
with 14.5% or 6,000 pediatric dentists.16 defines a “dental health professional shortage
According the ADA Health Policy Institute, area” or “DHPSA” as one where there are 5,000
pediatric dentists account for approximately or more people for every one full-time dentist.
3.3% of all professionally active dentists. The There are currently 4,400 DHPSAs that include
number of dental specialty education programs 48 million people (roughly the population of the
in pediatric dentistry has increased from 61 in West Coast of the United States) (Table 2).5
2001/2002 to 77 in 2013/2014. There has also HRSA estimates that there is a current shortage
been a dramatic increase in applicants to of 7,300 dentists in the United States.20 In
pediatric dentistry programs although ortho- addition, there are more dentists retiring each
dontic residency numbers have stayed relatively year than there are dental school graduates to
flat. replace them. Emergency departments are conti-
With regard to pediatric dentists, the per- nuing to be used as a safety net and still see a
centage of female pediatric dentists has significant proportion of visits for non-traumatic
increased from 14% to 62% since 1998. With dental issues.21 The number of emergency
regard to race and ethnic distribution, 86.2% of department visits for dental conditions in the
dentists are white, 3.4% African American, and United States has risen 16% since 2006, costing
3.4% Hispanic. Enrollment by race/ethnicity the government billions of dollars.
indicates that 55% of pediatric dentists are white, Providers’ willingness to accept government
20% Asian, 10% Hispanic, and 5% African insurance is also a factor affecting access to care.
American. Approximately, 75% of all ortho- A recent survey indicated that fewer than half of
dontic residents are white.17 A study of general dentists saw children less than 2 years of
orthodontic residents found they had positive age who had Medicaid.22 Although most dentists
attitudes about treating minorities but this did in the United States do not accept Medicaid,
not accompany a desire to accept reduced fees or pediatric dentists provide significant services to
treat pro bono.18 These statistics reflect that children participating in government insurance
there is an underrepresentation of minority programs. Approximately 23% of pediatric
dentists in the United States. An area that patients are on public insurance and there are
requires further study is whether minority an estimated 7.4 million Medicaid visits per
dentists are actually filling the gaps in year. Overall, 70% of pediatric dentists accept
providing care to minority patients. Medicaid, CHIP, or both. Over 50% of all
164 Laniado

pediatric dentists are accepting new Medicaid benefit is offered separately from a health
patients. insurance plan through a stand-alone plan,
In contrast, orthodontists do not widely accept there may be an incentive to opt out of pur-
Medicaid patients, primarily because reim- chasing dental coverage if a family is concerned
bursement rates are very low. In 2004, approx- about the added cost. This leaves many children
imately 6% of US children and adolescents without benefits.
insured through Medicaid received orthodontic Approximately 8.7 million children are
care, compared with 17 percent of privately expected to gain some form of dental benefits by
insured youth. There is also considerable varia- 2018 as a result of the Affordable Care Act, an
tion in rates of orthodontic utilization by state. In increase of 15% relative to 2010. This will reduce
some states, that is, Washington and North the number of children without dental benefits
Carolina, less than 1% of Medicaid eligible by about 55%. Another 3.2 million kids are
children received orthodontic treatment from anticipated to get coverage under Medicaid and
2002 to 2003.23 These rates are especially low another 2.5 million through employer-sponsored
given estimates that approximately 14% of all insurance, according to the American Dental
children and 29% of adolescents have severe or Association. However, only about one-third of
very severe handicapping malocclusions.23 children with Medicaid receive dental services,
In the medical field, mid-level providers such as compared to 58% of children with private dental
physician assistants and nurse practitioners have insurance who receive care.28
proven very successful in expanding access to care According to the American Dental Association
and reducing health disparities. In recent years, Health Policy Institute (HPI), Medicaid fees
there has been expansion of the dental workforce ranged from a low of 30% of market rates
with alternative dental health care providers such (California) to a high of 69% of market rates
as the dental therapist and the community dental (Arkansas) in 2012.29 In fact, many dentists lose
health coordinator (CDHC). This has been a money treating Medicaid patients, not to
controversial topic within the ADA for the past two mention the abundant paperwork and waiting
decades. The definition of a mid-level provider, as time which is an additional deterrent to care.
well as policies delineating their supervision levels Due to EPSDT, children have better benefits
and scope of practice, also vary from state to state. than adults, but having coverage does not mean
With the increased demand for pediatric dental having care. It is difficult for eligible children to
care that the ACA has driven, the use of these find and connect to participating providers.
providers in underserved areas such as Alaska and Disparities in coverage also do not necessarily
Minnesota has proven successful and vital to follow socioeconomic status. In fact, a 2012
alleviating the dental shortage.24 report by the Kaiser Commission on Medicaid
and the Uninsured reports that low-income
children and ethnic minorities are more likely
The payer
to have dental coverage than higher income
The third component in access to care is the children due to Medicaid and the Children’s
availability of dental insurance. Lack of insurance Health Insurance Program (CHIP).
is a good predictor of whether a child has unmet The passage of the Affordable Care Act in
dental needs. In 2012, it was estimated that 25% 2010 has impacted the process of qualifying for
of children in the US did not have dental medically necessary orthodontic treatment. As
insurance (public or private).25 Since 1967, the discussed earlier, private insurers and state gov-
EPSDT provision specifies a comprehensive set of ernment payers have created their own defi-
benefits for enrollees under age 21 years.26 nitions based on a particular orthodontic index
However, oral health benefits are handled with arbitrary cutoffs for eligibility. The American
differently than other EHBs on the state and Association of Orthodontists is currently working
federal exchanges. Dental coverage is optional on establishing recommendations on standard-
and often sold separately from medical izing the process for all states and carriers. With
insurance. Exchanges are mandated to offer the passage of the ACA, most orthodontists,
pediatric dental benefits, but consumers are including those who do not participate in gov-
not mandated to purchase them.27 When the ernment programs, will be required to provide
 The fragmentation of childrens’ oral health 165

proof of “medical necessity” for orthodontic Efforts underway to recruit more minority and
services covered by insurance. culturally competent dentists is also critical in
terms of the long-term demographics of our
country. The US Census Bureau reports that the
racial makeup of US is changing and by 2030
Conclusion
current racial/minority ethnic groups will be
For both specialties of pediatric dentistry and “majority” groups. In the dental public health
orthodontics, access to care is about more than community the problems with access to care have
just having dental insurance. It is a complex been well articulated. However, we are dealing
problem that involves the needs of the patient with a fluid system with no uniformity or con-
and the provider as well. Despite the passage of sistency between states. Both pediatric dentistry
the ACA, socioeconomic disparities and cultural and orthodontics specialties need to work
barriers persist which make it difficult for all together with policy makers, providers, and
children who need care to access it. Fur- payers toward a more equitable system to provide
thermore, the geographic maldistribution of care to our neediest children. No doubt we have
dentists and the small percentages of providers made significant strides in the last decade but we
who will accept Medicaid exacerbate the prob- need to continue to expand our efforts under-
lem. Pediatric dentistry, including preventive and standing the constraints of all parties involved.
restorative care, is now considered an “essential
health benefit” but the threshold for orthodontic
care is variable and not well-defined. References
The current system to determine orthodontic 1. Nasseh K, Vujicic M, O’Dell A. Affordable Care Act
eligibility falls short in many areas. The devel- Expands Dental Coverage for Children But Does Not
Address Critical Access to Dental Care Issues. Health Policy
opment of a uniform definition of MNOC which
Institute. American Dental Association April 2013. Available
applies across states and dental plans is needed to at: http://www.ada.org/~/media/ADA/ScienceandRe
capture those individuals who are in need of search/Files/HPRCBrief_0413_3.ashx.
care. The development of a standardized process 2. National Population Projections. In: US Census Bureau,
for all states and carriers is essential. A two-tiered editor. 2014.
policy structure (traditional and medically nec- 3. Sanders B. Dental Crisis in America: The Need to Expand
Access. US Senate Committee on Health, Education, Labor &
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be addressed, and describing populations in
5. The Cost of Delay: State Dental Policies Fail One in Five
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shortage areas. Increasing provider participation 7. Summary of Oral Health Provisions in Health Care
in Medicaid by increasing payment rates and Reform: Children’s Dental Health Project; 2010. Avail-
decreasing time-consuming paperwork will also able at: https://www.cdhp.org/resources/239-summary-
of-oral-health-provisions-in-health-care-reform.
help to enroll more providers. Recent studies 8. Profitt WR, Fields HW, Moray LJ. Prevalence of maloc-
show that reforming Medicaid, including clusion and orthodontic treatment need in the United
increasing reimbursement rates closer to market States: Estimates from the NHANES III survey. Interna-
levels, is associated with an increase in dental tional Journal of Orthodontics and Orthognathic Surgery.
1998;13(2):97–106.
care utilization.30 Such reforms are urgently
9. AAO Bulletin Medically Necessary Excerpt July 2015.
needed if the increased demand for dental Available at: https://www.aaoinfo.org/news/2015/07/aao-
care on the part of Medicaid children is to leads-effort-establish-consistency-medically-necessary-ortho
be met. dontic-care.
166 Laniado

10. Abdelkarim A, Ehrmantrout Z, Oesterle LJ. Medicaid dental conditions: Profile and predictors of poor out-
expenditures for orthodontic services. AJODO. 2007;132 comes and resource utilization. Journal of the American
(6)728e1-72e8e. Dental Association. 2014;145(4):331–337.
11. Draker HL. Handicapping Labio-lingual Deviations: A 22. Garg S, Rubin T, Jasek J, Weinstein J, Helburn L, Kaye K.
proposed index for public health purposes. Bulletin of the How willing are dentists to treat young children?: A survey
American Association of Public Health Dentistry. 1958;18 of dentists affiliated with Medicaid managed care in New
(4):295–305. York City, 2010 JADA. 2013;144(4):416–425.
12. Saltzmann JA. Handicapping malocclusion assessment to 23. McKernan SC, Kuthy RA, Momany ET, McQuistan MR,
establish treatment priority. American Journal of Orthodon- Hanley PF, Jones MP, et al. Geographic accessiblity and
tics. 1968;54(10):749–765. utlization of orthodontic services among Medicaid chil-
13. Nelson S, Armogan V, Abei Y. Disparity in orthodontic dren and adolescents. Journal of Public Health Dentistry.
utilization and treratment need among high school 2013;73:56–64.
students. Journal of Public Health Dentistry. 2004;64(1): 24. Simmer-Beck M, Walker M, Gadbury-Amyot C, Liu Y,
26–30. Kelly P, Branson B. Effectiveness of an Alternative Dental
14. Okunseri C, Pajewski NM, McGinley EL, Hoffmann RG. Workforce Model on the Oral Health of Low-Income
Racial/Ethnic Disparities in Self-Reported Pediatric Children in a School-Based Setting. Am J Public Health.
Orthodontic Visits in the United States. Journal of Public
2015;105(9):1763–1769.
Health Dentistry. 2007;67(4):217–223.
25. Children and Oral Health: Assessing Needs, Coverage
15. Valachovic RW. Current Demographics and Future
and Access Washington, D.C.: Kaiser Family Foundation;
Trends of the Dentist Workforce 2009. Retrieved from:
June 2012. Available at: kaiserfamilyfoundation.files.word
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press.com/2013/01/7681-04.pdf.
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26. EPSDT Program Background 2012. Available at: mchb.
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hrsa.gov/epdst.
16. Supply of Dentists in the US 2001-2013. American
27. Patient Protection and Affordable Care Act; Standards
Dental Association. 2015. Available at: http://www.ada.org/
Related to Essential Health Benefits, Actuarial Value, and
~/media/ADA/.../HPIData_SOD_2013.ashx.
Accreditation. Department of Health and Human
17. Burk T, Orellana M. Assessment of graduate orthodontic
programs in North America. Journal of Dental Education. Services. 2013. Available at: gpo.gov/fdsys/pkg/
2013;77(4):463–475. FR-2013-02-25/pdf/2013-04084.pdf.
18. Brown BR, Inglehart MR. Orthodontic care for under- 28. Manski RJ, Brown E. Dental Coverage of Children and
served patients: professional attitudes and behavior of Young Adults under Age 21, United States, 1996 and
orthodontic residents and orthodontists. Angle Orthod. 2006. Agency for Healthcare Research and Quality. 2008.
2011;81(6):1090–1096. Available at: https://meps.ahrq.gov/data_files/publica
19. Decker SL. Medicaid Payment Levels to Dentists and tions/st221/stat221.pdf.
Access to Dental Care Among Children and Adolescents. 29. Nasseh K, Vujicic M, Yarbrough C. A Ten-Year, State-by-State,
JAMA. 2011;306(2):187–193. Analysis of Medicaid Fee-for-Service Reimbursement Rates
20. Munson B, Vujicic M. Supply of Dentists in the United for Dental Care Services. Health Policy Institute. American
States is Likely to Grow. Health Policy Institute. American Dental Association. October 2014. Available at: www.aapd.
Dental Association. October 2014. Available at: http:// org/assets/1/7/PolicyCenter-TenYearAnalysisOct2014.pdf.
www.ada.org/~/media/ADA/Science and Research/ 30. Nasseh K, Vujicic M. The Impact of Medicaid Reform
HPI/Files/HPIBrief_1014_1.ashx. on Children’s Dental Care Utilization in Connecticut,
21. Allareddy V, Rampa S, Lee M, Allareddy V, Nalliah R. Maryland, and Texas. Health Services Research. 2015;50(4):
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“Medically necessary” orthodontic care:
Challenges and applications
Joseph George Ghafari

Medicine targets health in issues of saving life and improving quality of life.
Most orthodontic procedures deal with the latter goal. Medical necessity is
presented within the scope of pediatric orthodontics, stratified in medically
guided treatment, when orthodontic procedures contribute to the correction
of a systemic problem, whether or not associated with a local orofacial
problem (respiration and sleep disorders, emotional problems, and hospital
calls); and orofacial-guided treatment, when addressing growth matters,
craniofacial anomalies, and orofacial functions (mastication, understandable
speech, and temporomandibular pain). Medical necessity that may involve
the care of the orthodontist alone or in a medical team, also brings up the
issue of separation between dentistry and medicine, at educational and
various operational levels, posing a challenge regarding their integration in
the context of health being indivisible. (Semin Orthod 2016; 22:167–176.) &
2016 Elsevier Inc. All rights reserved.

“M edically necessary orthodontic care is

defined as the treatment of a maloc-
clusion (including craniofacial abnormalities/
orthodontics may possess less procedures that are
medically necessary than other dental specialties.
At another level, the AAO statement camou-
anomalies) that compromises the patient’s flages the fact that medicine and dentistry are
physical, emotional, or dental health. This treat- separate, from education through even public
ment should be based on a comprehensive perception, prompting the question: is the line
assessment and diagnosis done by an ortho- between a headache, even mild, but life-
dontist, in consultation with other health disrupting and a toothache, whether mild or
care providers when indicated”. 2014 House of debilitating, real or artificial? Health is indivisible
Delegates; American Association of Ortho- —a “self-evident” truth. If medicine seeks health,
dontists (AAO) oral health is a component of total health. The
This statement may be viewed from two per- immediate implication is that they must be
spectives. First, the association of “medically integrated.
necessary” with insurance coverage would Part 1 of this article relates the level of inte-
exclude from this description procedures unre- gration, if only to provide an intellectual
lated to critical health improvement, albeit framework for what increasingly seems as an
possibly augmenting well-being and self-image, artificial rather than convenient separation. Part
such as cosmetic procedures. In this context, 2 groups under the umbrella of pediatric
orthodontics the commonly recognized “medi-
cally necessary” orthodontic treatments, which
actually presume a continuum of dental and
Division of Orthodontics and Dentofacial Orthopedics, American
medical entities.
University of Beirut, Beirut, Lebanon; Department of Orthodontics,
Lebanese University, Beirut, Lebanon; Department of Orthodontics,
University of Pennsylvania, Philadelphia, PA.
Address correspondence to Joseph George Ghafari, DMD, Division Medicine and dentistry: One and
of Orthodontics and Dentofacial Orthopedics, Medical Center, separate?
American University of Beirut, P.O. Box 11-0236, Riad El-Solh,
Beirut 1107 2020, Lebanon. E-mail: [email protected] The schism likely stems from ensconced history
& 2016 Elsevier Inc. All rights reserved.
and entrenched stakeholders, thus must be
1073-8746/16/1801-$30.00/0 considered regarding dentistry in general from a
http://dx.doi.org/10.1053/j.sodo.2016.05.003 historical depth, and regarding orthodontics

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 167–176 167

168 Ghafari

specifically within the frame of the discipline latter panel is developed in Part 2 of this article,
itself. Integration, when approached, may be cast focusing on pediatric orthodontics.
in various scenarios.
The challenge of a paradigm shift to medical
Historical issues and the prevalence of integration: Targeting health
morphological outcome
Despite the burden of history, the separation
Is orthodontic treatment compatible with medi- between medicine and dentistry is not an issue of
cal necessity? To answer this question, one must educational disparity or professional equality. It is
consider the urgency of the medical conditions, inherently a matter of definition: the unity of
defined in relation to sustenance of life (life and health, and health care. Should dentists and
death issues), or quality of life. By and large, physicians engage in the question of integration,
dentistry, and particularly orthodontics, pertains they would soon realize that from conceptual and
to quality of life. This relationship may have scientific outlooks, present boundaries seem
maintained the dental profession set apart from artificial, and thus integration may not follow
the rest of medicine, notwithstanding the his- only one mold.
torical rooting of tooth extraction. Avulsion Dentofacial sciences could indeed belong to
was the most common solution to toothache, an independent department within the medical
within the repertoire of the barber-surgeon, school, but other alternatives could be viable,
who performed “surgical” procedures including such as oral medicine being part of internal
the removal of damaged diseased teeth, blood- medicine, oral surgery and periodontics grouped
letting, and even amputating limbs badly injured in a division within the department of Surgery,
in war.1 pediatric dentistry in the department of Pediatric
In this sense, countless medical procedures, if and Adolescent Medicine, and orthodontics as a
not their majority, are not life-threatening and division in Otolaryngology/Head and Neck
may be classified under maintenance or Surgery, and possibly in Plastic Surgery or
improvement of quality of life. Nevertheless, Pediatrics. The department of Dentistry, per se,
dealing with pain moves dentistry to center stage might include restorative/reconstructive den-
medicine, if only witnessed by the fact that tooth tistry and endodontics. “Oral biological” sciences
pain (usually following extraction of third would also be grouped under a copyrighted
molars) has served for long as a research model umbrella or merged within the respective
to test the efficacy of pain medication.2 medical basic sciences pedigrees.
The seminal description of “normal” ortho- In the educational process, it would be con-
dontic outcome in orthodontics as a morpho- ceivable for students of medicine to rotate in the
logical interdigitation between maxillary and “dental” department, as they would in other
mandibular teeth, the universal Class I or neu- “medical” departments, then choose to specialize
troclusion, seemingly undermines the alignment in general dentistry through a corresponding
of orthodontics with medicine, or even true sci- residency, or any other current “dental” dis-
ence.3 The “science of occlusion” has been cipline. In such a scheme, the “generic medical”
labeled “pseudoscience,” like astrology, because student may fulfill an ambition of specializing in
it has been driven more technologically than periodontics or oral surgery. The latter discipline
biologically or physiologically.3,4 It is probably has already moved toward integration within
this conceptualization that places the ortho- medicine at various universities where a medical
dontist on the “medical defensive.” degree is required after dental school for max-
Rather than barricade (or resign) themselves illofacial surgery training. Organized dentistry
in such an arena, dentists and orthodontists can shall remain in its present independent status,
adopt a dual approach—assert their role as much like various medical specialties organize
medical care providers, and educate physicians within their respective specialty or subspecialty.
and patients about their important role in the The current of integration may be difficult to
indivisible health care chain. The former panel resist at some future point, particularly when
relates to professional and personal self-image developments in genetic science force deeper
and is not within the scope of this article. The the roots of amalgamation or make it inevitable.
 “Medically necessary” orthodontic care 169

More importantly, within such boundary-less child sleeps with the lips apart without snoring
integration, would the definition of “medically noises of various degrees. Excluding a category of
necessary” dental treatment differ in nature or habitual mouth breathing with adequate nasal
in scope? patency, enforced mouth breathing develops
through nasal resistance or obstruction, which
can occur in the anterior (maxillary) airway, in
Pediatric orthodontics
the posterior (pharyngeal) airway, or both. The
Adhering to the AAO definition would be maxillary section is more prone to obstruction,
practical to discern medical necessity in ortho- because it offers greater resistance in the nasal
dontics. The following two key components airway that can be raised by conditions affecting
emerge from the definition: (1) malocclusion hard tissues (e.g., deviated septum; turbinate
compromising physical, emotional or dental irregularities; congenital, traumatic, or thera-
health and (2) treatment by the orthodontist peutic asymmetries of the nasal cavity) and soft
alone or with other providers when indicated. tissues (e.g., catarrhal and allergic rhinitis, nasal
Health issues are approached in this section as polyps).6
they relate to the target of treatment being The association between hypertrophied ade-
medically, or orofacially guided. noids and tonsils and facial morphology is well
documented, represented in the nearly syn-
Medically guided treatment ergetic relationship between airway clearance
and the inclinations of palatal and mandibular
This section involves the application of ortho-
planes in mouth breathing children. The effects
dontic procedures to heal or help correct a sys-
of decreased airway clearance on facial mor-
temic problem, whether related or unrelated to a
phology follow a sequential process, starting in
local orofacial problem.
structures closest to the obstruction, namely
inferior–posterior tip of the maxilla; in turn, the
Respiration and sleep disorders
mandibular plane rotates backward.7 However,
Mouth breathing and respiration-related dis- individual response is such that various
orders have consequences on health and cra- malocclusions may develop, including Class II,
niofacial morphology. Breathing problems range open bite, anterior crossbite, and maxillary arch
from snoring (3–12%) to obstructive sleep apnea constriction. The more severe effects may reflect
(OSA = 1–10%).5 However, an insidious silent more medical necessity than others (Fig. 1).
form of mouth breathing exists that has not been OSA often results from adenotonsillar hyper-
accounted for in epidemiologic studies, when the trophy, neuromuscular disease, and craniofacial

Figure 1. Cephalograms of three children (less than 6 years old) with chronic mouth breathing and nearly total
airway obstruction by enlarged adenoids (Ad) and tonsils (arrows). Different malocclusions may result from mouth
breathing: Class II, division 1 (A), Class III (B), and open bite (C). Whereas similar medical conditions of impaired
breathing existed, the definition of medically necessary orthodontic care may differ based on the severity of
dysmorphologic features.
170 Ghafari

abnormalities. The majority of children with OSA (using CBCT) following rapid palatal expansion are
have mild symptoms, and many outgrow the con- different from prior 2-dimensional cephalometric
dition.5 OSA can lead to serious clinical studies. The key determinant is the location of the
consequences such as failure to thrive, behavior “bottle neck” in the nasopharyngeal airway blocking
problems, enuresis, and corp ulmonale. Sustained nasal breathing, nearly irrespective of volumetric
mouth breathing with or without OSA can result changes within the nasal cavity. Palatal expansion
in some or all characteristics of the long-face might impact breathing only if the maxillary/nasal
syndrome. airway is involved, either in its hard tissue compo-
Treatment ideally should address the etiology. nents, or in the differential “leeway” between hard
Accordingly the following two important con- tissue widths and soft tissue hypertrophy within the
siderations are noted: nasal cavity. Focused research is needed to sort out
the contribution of all such variables.
(1) Inasmuch as the lymphoid tissues (adenoids
and tonsils) are the main culprit and
Psychological issues
research indicates their early removal,
parents and actually ENT specialists may The AAO definition of “medically necessary”
resist such approach, particularly when the places physical and emotional components of
concern is over developing long-face syn- health before dental health. Psychological issues
drome characteristics rather than medical are often under addressed, if not under-
consequences.8 Dealing with hypertrophied estimated. Not readily tested like the visible
turbinates (often the inferior turbinates) is a malocclusion, the emotional dimension may be
more contested issue, because the problem the most difficult to grasp, possibly associated
may be grafted on that associated with with simple habits (e.g., digit sucking) or mal-
adenoids and tonsils, or stand alone, and occlusion, ranging from increased overjet to
research is lacking relative to that on skeletal dysplasia.
adenoids and tonsils. Interaction between In the past 2 decades esthetic imperatives have
orthodontist and laryngologist is crucial for nearly matched or surpassed the requirements of
mutual education and practice. function in justifying orthodontic treatment,
(2) Orthodontic methods potentially improving probably helped by cultural and peer pressures
respiration include functional appliances for improved appearance and self-image. How-
and palatal expansion. Orthodontists have ever, the priority of the psychologic panel has yet
been involved in OSA treatment because of to be asserted. Most studies relating malocclusion
their expertise in Class II functional appli- to self-esteem and perception do not show, on
ances, which increase airway patency when average, a strong correlation. Early reduction in
the mandible is positioned forward. Such overjet did not produce the “claimed” psycho-
appliances specifically target OSA in adults; logical effects10 or affect the child’s self-esteem,
in children, they may serve dual purposes of including the child’s concept of self-worth.11 Yet
simultaneously correcting Class II malocclu- individual variation from central tendency
sion and addressing OSA. The intervention deserves consideration, as the stigma of a “buck
must be coordinated with the treating physi- teeth” image can weigh heavily on a child’s
cian and after proper diagnosis, including present and potentially future development
polysomnogram data. (Fig. 2). While the panel of interaction between
esthetics and psychology is richly developed in
Improvement of nasal breathing following palatal countless studies, the interface between function
expansion is not predictable. Even an initial amel- and psychology, although less researched, merits
ioration may not be sustained. Various parameters distinction, such as the impact on social
are at play, including nose width, turbinate hyper- perception and life of masticatory deviations
trophy, amount of expansion, and stability of results. (e.g., speech, sounds, and appearance), tooth
Methodologically standardized studies on 3-D grinding, or temporomandibuar joint dysfunction.
cephalometric analysis are still needed9; non- Moorrees12 captured the significance of patient
etheless, it is arguable whether clinically relevant individuality in his provision of a constitutional
results from 3-D imaging studies of nasal volume assay of the “total” person comprising anatomic
 “Medically necessary” orthodontic care 171

teasing by peers in a society that often portrays

decreased intelligence with severely “buck teeth.”
The effects of those portrayals on the mind and
personality of a child growing with the burden
of a physical stigma may be remarkable. There-
fore, personalized treatment, today’s central axis
of any medical intervention, encompasses the
heretofore nearly outcast emotional component
of malocclusion.

Hospital calls
These consultations are usually of general dental
aspect (infections and trauma) provided by gen-
eral and pediatric dentists and oral surgeons.
However, orthodontists have been called to deal
with traumatic emergencies (e.g., to help
reestablish prior occlusal contacts), oncologic
treatment (such as removal of orthodontic fixed
appliances before cancer treatment or designing
Figure 2. While research showed that on average early tissue-shielding appliances before radiation ther-
correction of a severe overjet did not affect a child's apy), or pediatric intensive care units (e.g., to
self-esteem, this child refused to attend school because provide for appliances that prevent self-injury).
of the jibes of her peers, whereby her orthodontic
treatment became a “medical necessity.” These interfaces emphasize the importance of the
medical model in dentistry, within the above dis-
cussed necessary integration between medicine
and dentistry.13 Associated with this practice is the
(somatotype, dentofacial morphology, and
consideration of the advantages of specialty
dysplasia), physiologic (growth and development
training within the medical model, compared
and functional occlusion), immunologic
with the dental model.14
(susceptibility and reaction to infectious disease
and allergy), and psychobiologic (self-image and
emotional maturity) components. He stated that Orofacial-guided treatment
by removing the stigma of unattractiveness or This treatment targets orofacial health in its
“ugliness,” and thus “bolstering self-image and relationship to the growth and functions of
social adjustment,” orthodontic treatment reflects the body.
an important health service for adolescents and
adults. In this medical constitutional evaluation,
Moorrees further explored the connection Table. Potential interpretation by peers of a child's
between dysplasias in bodybuild (Sheldon’s body or facial appearance, and possible psychologic/
somatotype assessment) and marked malocclusion behavioral consequences on the child.
or facial dysmorphology. Appearance Interpretation Possible consequence
From this standpoint, appearance begets
judgment, particularly that most people encoun- Body
tered in life are “passers by,” not acquaintances Tall and muscled Strong Intimidation
person
whose personality and human qualities overcome Obese child Inactive and lazy Slow and
the “first impression.” A body physique or facial disorganized
type suggests stereotyped attributes, such as obe- Frail child Weak, more prone Avoidance or more
to disease attention
sity foretelling inactivity and laziness (Table).
People with mandibular prognathism may be Face
Mandibular Aloofness Peer isolation, more
perceived as aloof, becoming isolated by their prognathism introversion
peers and consequently more introverted. A child Severe overjet Less intelligent Cruel teasing,
with a severe overjet may be the prey of cruel (buck teeth) aggressiveness
172 Ghafari

Growth matters growth, unbalanced by concomitant growth of a

maxilla growing at a comparatively slower rate,
In the presence of a Class II, division 1 malocclusion,
coupled with the inaccuracy of mandibular
often related to mandibular retrognathism, growth
growth forecasting, requires the orthodontist to
is critical for treatment outcome and success: the
anticipate the growth spurt to minimize its
more severe the skeletal discrepancy, the more
effect (e.g., favoring maxillary growth or man-
essential the needed amount of mandibular growth.
dibular rotation to counteract additional man-
Would the determination of medical necessity be
dibular growth).19 Often, early treatment
equivalent to that inferred from a child with short
combines maxillary expansion and facemask
stature, concerned with not reaching at least average
and aims at overcorrection, that is, increase of
height? Seeking body height increase may not be of
overjet, which results from both the maxillary
health consequence, excepting a chronic psycho-
protraction (with a side effect of countercloc-
logic stigma. However, if the severe Class II coexists
kwise rotation) and mandibular clockwise
with sleep apnea, compromised facial esthetics, and
rotation. Barring excessive mandibular growth
emotional discomfort, treatment may be more
that may steer treatment toward later
medically necessary. This comparison discloses the
orthognathic surgery, the interaction between
fact that medical necessity carries various individual
overjet overcorrection and mandibular growth
weights, and personalized decisions are not always
defines success through one of these
straight forward, whereby the difficulties encoun-
possibilities (Fig. 3).
tered by funding agencies in gauging medical
(i) Mandiblular forward growth equals the
necessity.
amount of overcorrection; then, the
This comparison underscores the value of
present compensatory incisor angula-
growth and the importance of its monitoring in
tions are maintained.
children. The orthodontist must be aware of
(ii) The mandible grows less than the
growth variations and the means of its evaluation,
amount of overcorrection; thus the
and maintain a rapport with the pediatric endo-
mandibular incisors are proclined for
crinologist when aberrations exist. Not only
the residual overjet correction.
growth opportunities related to skeletal growth are
observed, but also those associated with dental
development. Amount of skeletal growth, Accordingly, also from a medical perspective,
sequence of dental development, and timing of the orthodontist is a growth “specialist,” a student
both affect timing of treatment. Dentally, the of somatic growth by training and practice who
optimal timing would be prior to the loss of the must take advantage of growth opportunities
primary second molars in the late mixed denti- (both dental and skeletal) when needed, and
tion, to preserve the leeway space.15 For skeletal who may actually be the first to determine growth
growth, the following considerations are noted for deviations (delay or advancement).
the two basic malocclusions whose treatment is The majority of clinicians routinely seek infor-
affected by growth namely, Class II and Class III: mation on general growth mostly in the above
delineated instances (Class II and Class III) asso-
(1) Clinical trials on the early treatment of Class ciated with discrepancies such as mandibular ret-
II, division 1 malocclusion concur about rognathism or prognathism.20 Often, growth
starting treatment before the onset of pub- evaluation is limited to assessing skeletal matura-
erty, albeit in late childhood as the first phase tion on hand–wrist radiographs, and gauging the
of a one-stage treatment.15–17 Nevertheless, physical expression of the adolescent growth spurt
patients with severe malocclusion were likely through height increase or sexual maturation signs
to maintain a Class II phenotype, suggesting (onset of menarche in girls; facial hair or change of
the limitation of growth modification to voice in boys). In the absence of accurate prediction,
affect growth potential, yet indicating the and in an attempt at individualizing time of
merit of maximizing the contribution of treatment to benefit from craniofacial growth
growth during treatment.18 changes, the clinician deems it adequate to locate
(2) A reverse rationale applies in the treatment of the child’s growth as either prepubertal, pubertal,
Class III malocclusion. Further mandibular or postpubertal. However, passage through
 “Medically necessary” orthodontic care 173

Figure 3. Lower face profile views with superimposed lateral cephalometric mandibular anterior components of
10 years and 9 months old female who presented with Class III malocclusion and concave profile (A). She was
treated with maxillary expansion and protraction facemask to an overcorrected overjet in a first phase of treatment
lasting 6 months (B). After an extended period of retention that lasted beyond the adolescent growth spurt, fixed
appliances were used to achieve the well interdigitated neutroclusion nearly 6 years later (C), and improvement
(reversal of steps) in the relation between upper and lower lips. The overjet was overcorrected in anticipation of
one of two possibilities: (1) mandibular growth equal to the amount of overcorrection would lead to maintaining
pretreatment mandibular incisor angulations or (2) mandibular growth less than the amount of overcorrection
would justify proclination of the mandibular incisors for the remainder of overjet correction. The actual outcome
was a combination of more proclined mandibular incisors, than at pretreatment, and a facial profile more
orthognathic than the original concave outline. Orthognathic surgery was avoided at the expense of a long
treatment because appliances were kept beyond a late-occurring adolescent growth spurt. (Adapted with
permission from Ghafari et al.19)

pubescence may be rapid or slow. Deviations from Craniofacial anomalies

average tendencies reflect the need to develop
These conditions represent the ultimate multi-
dependable growth prediction models, particularly
disciplinary challenge and most readily recog-
when the imperatives of dental development may
nizable for medically necessary orthodontic (and
require a timing of treatment independent of the
non-orthodontic) care. Severity and functional
requirements of craniofacial growth.
handicap (mastication, speech, and respiration)
Growth monitoring has been limited to meas-
are the primary determinants of medical neces-
ures of height and skeletal maturation because of
sity. Arguably, craniofacial anomalies would
the difficulty in identifying and collecting other
belong to medically guided treatment as well,
biological data that may correlate with facial
particularly in relation to more vital functions
development. In addition, the provision of con-
and psychology. However, they are categorized in
comitant frequent measures of facial growth cor-
this section because of the prevalence of ortho-
relates and parameters of treatment outcome is
dontic intervention throughout treatment.
hindered by the contraindication to expose
The primary and most common condition in
patients to multiple radiographs in short period of
this category is cleft lip and palate (with all var-
time; venipuncture to gauge hormonal levels on a
iations), followed by hemifacial microsomia and
routine basis in children is deemed an invasive
many other syndromes. These dysmorphologies
procedure. Attempts at using more practically
mostly fit the definition and scope of pediatric
obtainable salivary levels of various biochemical
orthodontics, as treatment spans the periods of
substances included serum and salivary DHEAS
infancy through young adulthood.
and osteocalcin, which did not increase the accu-
racy of growth depiction.20 Salivary levels of
Vital functions: Speech and mastication
testosterone and estradiol did not yield the
accuracy of blood levels, while IGF1, a growth When these functions are compromised within
hormone proxy, has shown initial promise, but not more encompassing conditions, such as cranio-
yet a confirmed advantage (Fig. 4). Further facial anomalies (speech and mastication), or
exploration of potential substances in cohorts of when associated with pain (temporomandibular
patients requires multilayered research. joint [TMJ] dysfunctions), their treatment is
174 Ghafari

Figure 4. Blood and saliva levels of IGF1 were analyzed in a study on early treatment of Class II, division 1.20 A
montage of five graphs scaled on age are shown for three girls (A–C) and two boys (D and E) demonstrating saliva
levels comparable to or higher than serum levels (A, B, C, and E). In one male (D), blood levels are higher. While
the possibility of detection of saliva levels was demonstrated, unlike other substances investigated in this study (e.g.,
DHEAS, testosterone, and estradiol), additional research is needed to explore the possibility of gauging biological
markers of growth in saliva as dependable as the gold standard serum levels.

branded medically necessary. However, the label (DI),26 Salzman handicapping malocclusion
is usually dropped when a lisp is associated with index,27 and handicapping labio-lingual deviation
an open bite or a Class III malocclusion. (HLD)28)]? Can such complexity be summed up in
a score that is based on the weight assigned to the
various components of the malocclusion, knowing
Defining medically necessary orthodontic
that weight should be shifted to certain
care (MNOC)
components?
The discussion of MNOC recalls the question of Nearly all indices, except for the ABO DI, are
whether a malocclusion is malformation or based on occlusal assessment without cephalo-
malady.21 Orthodontic conditions are inherently metric evaluation of the underlying skeletal tis-
of a chronic nature, and do not pose an immediate sues. Most indices do not take into account facial
health risk. Given that severity varies across esthetics or handicap, or growth potential. To
malocclusions, should medically necessary care be adhere to the AAO definition of MNOC, such
subjected to the evaluation of need, as delineated indices address the dental component, not the
through various orthodontic malocclusion severity physical and emotional panels. Therefore, any
indices [treatment priority index,22 ICON,23 index carries some level of arbitrary assessment.
IOTN,24 PAR index,25 ABO discrepancy index Should a MNOC index be developed, assigning
 “Medically necessary” orthodontic care 175

weights and scores to all three panels would and operational levels on determining the “medical
require tremendous work and testing, prompting necessity” of the pertinent conditions when
the question: why is not any treatment sought by treated.
an entity called “patient” be medically necessary,
if it affects or “handicaps” physical, emotional,
and dental health?
At this point, dental health weighs heaviest on References
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1984;119:1171–1175.
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2. Barden J, Edwards JE, McQuay HJ, et al. Relative efficacy
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of growth when it is a critical component of 3. Ackerman JL. Was the destiny of orthodontics written in
treatment success in a child presenting partic- the stars? Am J Orthod Dentofacial Orthop 2015;147:290–292.
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(open bite and deep bite), and transverse 732–739.
(asymmetry and posterior crossbite) deviations. 5. Chan J, Edman JC, Koltai PJ. Obstructive sleep apnea in
The challenge is always in drawing the line children. Am Fam Phys. 2004;69:1147–1154.
between objective and subjective assessment, 6. Timms DJ. Rapid Maxillary Expansion. Chicago: Quintes-
but also in determining the future health sence; 1981.
7. Macari AT, Bitar MA, Ghafari JG. New insights on age-
consequences of a current condition, whose related association between nasopharyngeal airway clear-
long-term impact may be more severe than its ance and facial morphology. Orthod Craniofac Res.
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ear-nose-and throat specialist before and during ortho-
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“seeking health,” health is an indivisible concept, Class II malocclusion, and early treatment. Angle Orthod.
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underscoring possible schemes of their integra- Development; University of Michigan; 1995:81–112.
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biologic and physiologic normalcy, and orofacial- 13. Ghafari JG. The medical model in orthodontic education.
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17. Livieratos FA1 Johnston LE Jr. A comparison of one-stage
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176 Ghafari

18. Ghafari JG, Macari AT. Component analysis of Class II, 24. Jenny J, Cons NC. Comparing and contrasting two
division 1 discloses limitations for transfer to Class I orthodontic indices, the Index of Orthodontic Treatment
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19. Ghafari JG, Haddad RV, Saadeh ME, Class III maloc- Dentofacial Orthop. 1996;110:410–416.
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Huang G, Vig K, eds. Evidence-Based Orthodontics. Oxford: (Peer Assessment Rating): methods to determine out-
Wiley-Blackwell Publishing Ltd.; 2011:247–280. come of orthodontic treatment in terms of improvement
20. Ghafari J, Shofer FS, Laster LL, et al. Monitoring growth and standards. Eur J Orthod. 1992;14:180–187.
during orthodontic treatment. Sem Orthod. 1995;1: 26. Cangialosi TJ, Riolo ML, Owens SE Jr, et al. The ABO
165–175. discrepancy index: a measure of case complexity. Am J
21. Wylie W. Malocclusion: malady or malformation?Angle
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Orthod 1949;19:3–11. 27. Lindauer SJ, Thresher AA, Baird BW, et al. Orthodontic
22. Ghafari J, Locke SA, Bentley JM. Longitudinal evaluation
treatment priority: a comparison of two indices. J Clin
of the treatment Priority Index (TPI). Am J Orthod
Pediatr Dent. 1998;22:125–131.
Dentofacial Orthop. 1989;96:382–389.
23. Firestone AR, Beck FM, Beglin FM, et al. Validity of the 28. Theis JE, Huang GJ, King GJ, et al. Eligibility for publicly
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determining orthodontic treatment need. Angle Orthod. capping labiolingual deviation index. Am J Orthod
2002;72:15–20. Dentofacial Orthop. 2005;128:708–715.
Intra- and inter-office communication:
Important in achieving optimal treatment
outcomes and patient satisfaction
Mary Eve Maestre1, Robert Peracchia1, and George J. Cisneros

Optimal communication between practitioners, their patients and staff

requires a clear and focused understanding of what the mutual treatment
goals are. Education is the key to making such communication successful and
at all levels it needs to be clear and consistent. It begins with the initial phone
call and reinforced by all members of your practice team using coherent
language to build trust. The use of visual aids helps to educate and explain
treatment plans supporting the parental/patient confidence in their decision
to proceed with care. Social media can help us stay connected with our
patients/parents as well as referrers creating a de facto “dental family or
home base.” Generating a close relationship with our referrers and their team
through contact and “learning opportunities” is a substantial tool to create
the consistency and focus on our shared goal of optimal patient care.
Through clinical scenarios the above concepts will be discussed along with
potential strategies offered on how to implement them into practice. (Semin
Orthod 2016; 22:177–184.) & 2016 Published by Elsevier Inc.

I f the common goal in health care is to deliver

exceptional patient care then communication
between specialists and their patients is essential.
Wheeler et al.7 on the effectiveness of early
treatment for Class II malocclusions found that
compliance directly correlated with treatment
The exchange of information and the ability to success. Relationships that are based on trust are
work synergistically in the care of a patient will fundamental and can only be achieved through
lead to better overall treatment outcomes.1–5 A proper communication.5
patient who is well informed will have a better The pediatric dentist and orthodontist have
understanding of the treatment proposed which the privilege of seeing and caring for a patient
generally translates into better treatment from their first dental visit in early childhood into
acceptance, compliance and patient satisfaction. young adulthood. They are in a position to set up
Klein6 found that informed patients will more their patients with not only beautiful healthy
readily accept proposed dental services and have smiles but also a positive oral health attitude that
more reasonable expectations of treatment they can carry with them throughout life.
outcomes. The informed patient will also be a For us, as practitioners, to communicate
more compliant patient, which is important in effectively we must be willing to educate. More-
the success of the treatment.2,3 A study by over, better communication between our two
specialties requires an understanding of each
otherʼs treatment goals. Poor communication
Department of Orthodontics, New York University College of can lead to misunderstandings and confuse our
Dentistry, New York, NY; Department of Pediatric Dentistry,
Columbia University, New York, NY; Global Student Outreach
patients about their care. Consider the following
Program, New York University, New York, NY. example:
Address correspondence to George J. Cisneros, DMD, MMSc, Jenny presents at her orthodontic appoint-
Department of Orthodontics, New York University, College of ment accompanied by her father. Dad is very
Dentistry, 345 East 24th St, New York, NY 10010. E-mail:
concerned because during her visit with the
[email protected]
1
Private practice: 327 Central Park West, New York, NY, 10025.
pediatric dentist, the doctor pointed out to them
& 2016 Published by Elsevier Inc.
an area on her inner lower lip that looked
1073-8746/16/1801-$30.00/0 hyperplastic consistent with a possible abrasion
http://dx.doi.org/10.1053/j.sodo.2016.05.004 due to the lower braces (Fig. 1). Visual inspection

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 177–184 177

178 Maestre et al

Communication and education are essential

between specialists. Had the pediatric dentist
above simply taken the time to call the ortho-
dontist before making any recommendations,
perhaps all of this confusion could have been
averted. There likely would have been a dis-
cussion between them as to what is, or is not,
within normal limits and what could be expected
from the use of orthodontic appliances on soft
tissue. The orthodontist would have then had the
opportunity in turn to listen to the pediatric
dentistʼs concerns and both would have learned
from each other, then if the situation were to
arise again with subsequent patients everyone
would have had a clearer understanding of how
to communicate with their mutual patient.
Figure 1. A common chronic mucosal response to
As previously stated, effective communication
orthodontic brackets—eversion of the patientʼs lower
lip illustrates enlarged non-edematous hyperplastic starts at the practitionerʼs office among the staff
“impressions” or response in the buccal mucosa and with their patients, with staff education and
secondary to lower bracket placement. training and centered on proper scripting. The
initial call sets the tone for all subsequent visits. A
new patient who comes into the office for the first
of the area showed no marked inflammation or time should have had a clear explanation as what
redness. The patient did not report any pain or to expect on their first visit. All questions should
discomfort. Although the area did appear have been answered and be directed to visit your
moderately hyperplastic, Jenny was only 4 practice website with images of your office,
months away from the completion of doctors and staff, all helping them prepare even
treatment. The Pediatric Dentist went on better. It is important to have friendly staff
further to suggest that perhaps the appliances members who warmly greet all patients and
should be removed for some time until the offering office tours to new incoming patients
“problem” subsides then replaced afterwards. putting everyone at ease. Well-trained staff who
The father was afraid that the area was going know how to communicate expectations, treat-
to get infected if childʼs dentistʼs instructions ment plans and procedures provide a consistent
were not followed. message and reassure the patient/parent(s).
This situation put the orthodontist in an Communication among staff should be clear and
awkward position. How does the he/she now consistent, so that everyone relays the same
explain that this is more than likely within nor- message to avoid potential contradictions and
mal limits and that there is no need for concern any confusion. Educating your staff about your
at this time? With experience, the orthodontist standard procedures and treatment plans is a
realizes that more than likely the hyperplastic critical starting point. Scripted answers to the
area will resolve on its own with appliance many potential questions that patients/parent(s)
removal. If the appliances were to be removed may ask helps train your staff to deliver a
now, then replaced, the “hyperplasia” will more coherent response. The use of similar words by
than likely return anyway. Removing the appli- various staff members including the doctors can
ances then putting them back on after an alleviate any uneasiness and builds a strong bond
indefinite amount of time may not be the best with your patients (Fig. 2). For instance—
solution for her, as longer treatment time will Johnny arrives at Dr. Robʼs office for his 6-
only increase the risk for demineralization and month recall visit. Johnny is 7 years old and
decay. And notably whatever trust the patient and enjoys coming to his favorite pediatric dentist. Of
her father may have had in the orthodontist may course it helps that Dr. Robʼs waiting room has
now be shaken to some degree. How can sit- video games to play with and even has a big train
uations like this be avoided? that runs along the ceiling and even into the
 Intra- and inter-office communication 179

Figure 2. Practice protocols for proper communication—show that you care by starting with that first patient
phone call, using clear, consistent scripted messages/statements that are reinforced by all staff and doctors
throughout your practice and beyond.

bathroom (Fig. 3)! Johnny has been coming to interproximal lesions developing. A well-trained
see the doctor since he was 2 years old. Betty, the hygienist will not only spot these but immediately
hygienist, warmly greets Johnny and brings him explain what these shadows are, what they rep-
back to the tooth brushing station. Oral hygiene resent along with any possible treatment that Dr.
procedures are reviewed and reinforced while Rob may recommend. After reviewing the
Johnny is brushing his teeth. She then seats radiographs and examining the child, he con-
Johnny at the dental chair. Johnny picks a movie firms Bettyʼs findings and treatment recom-
to watch that plays on the ceiling while the mendations using similar language in terms that
hygienist cleans his teeth. At this visit he is due for she can understand and how it may benefit her
bitewing radiographs. Betty explains to the son (Fig. 4).
mother the reason why these radiographs are The above patientʼs mother has now had two
important and the benefits for her son. The opportunities to process the information and ask
radiographs are taken and Betty notices some any questions or communicate any concerns.
Now she merely has to make a treatment
appointment with a member of the admin-
istrative team. The scheduling coordinator
repeats the benefit statement for the particular
treatment Johnny requires and reminds them of
Dr. Robʼs competence and his gentle manner.
Repetition, consistency, and affirmation in
diagnosis and treatment by all staff members and
doctors are paramount in achieving acceptance
and compliance.
A typical initial orthodontic visit in our office
would begin as follows:
Sophie, 8 years old, has just had her 6-month
recall visit with Dr. Rob. A referral was made at
that time for Sophie to schedule an appointment
with the orthodontist. Prior to doing this, he and
his staff have already explained to them the need
Figure 3. Waiting room diversions can engage and for the care and what to expect when they see Dr.
relax your patients (model trains)—along with a warm
welcoming greeting, creating an office atmosphere Eva and her staff. Sophie and her mother arrive
that is enjoyable and welcoming to your patients really at their initial orthodontic visit. The receptionist,
helps to build a bond with them. Tatiana, warmly greets them and offers to give
180 Maestre et al

Figure 4. Reinforcing your message enhances trust and understanding. After reviewing the radiographs and
examining the child, the doctor re-confirms the hygienist's findings and treatment recommendations using the
same language and terms that have been used to educate and reinforce the need for care.

them a tour of the office. Sophie is excited to see upcoming school breaks is a great way to ease any
the game room with cool chairs and video games. tension. Creating a “patient-centered environ-
Sophie feels like a big girl here, this office is ment” and showing empathetic communication
where the older kids come to get their braces. practices by your staff and doctor are important
She is thrilled! Tatiana proceeds to check them in creating an environment that is caring and
in and takes an image of Sophieʼs fingerprint so trusting.8
that she can check herself in on the computer in Dr. Eva then comes in and introduces herself
the waiting room next time she comes to the to Sophie and her mother, asking Sophie how old
office. Liz, the assistant, introduces herself and she is and when her birthday is? Her answers may
brings Sophie and her mother to the records lead to other topics that Sophie may want to
room. Since the computer systems between the share. The idea is to engage Sophie and make
offices are connected, Liz was able to log into her feel special and show her that we care. Dr.
Sophieʼs pediatric dental chart and check any Eva then explains to Sophie and her mother that
pertinent notes and the most recent radiographs she is going to examine her and that Kyla will be
that have been taken. It appears as if Sophie is taking some notes. Dr. Eva explains to Sophie
due for a panoramic radiograph. Liz proceeds that she will be using some funny “dental words”
to take the panoramic radiograph along with to describe her teeth that she may not under-
intra-/extra-oral photographs. She uploads the stand but not to worry as this is the language
photographs into the imaging software. In the dentists use to describe the teeth. Following the
meantime, Kyla, the treatment coordinator, has examination, the images and radiographs are
introduced herself and has brought Sophie and brought up on the computer screen. Sophie and
her mother into the consultation room. Sophie her mother get an explanation of any ortho-
sits in the dental chair and starts to feel a little dontic concerns and treatment recommen-
nervous. As one of Kylaʼs roles is to make the dations.
parents and patients feel at ease, she asks if they If parents have mentioned particular issues
have any questions and spends as much time as they are concerned with during the pediatric
necessary with them to keep them company. If dental visit these are noted in the patientʼs clinic
she senses that they are getting a little anxious notes. Some parents have concerns about “get-
they will be reassured to not worry, “Today we are ting braces twice” or “kids start braces so young
going to look at your teeth and then weʼll talk a these days.” Some parents are afraid of extracting
little bit.” primary teeth. If the orthodontist has this
Engaging with your patients and having a information prior to the initial visit it can be
conversation about school, hobbies, sports, or extremely helpful. The same language is used
 Intra- and inter-office communication 181

Figure 5. Excellence in patient care. Research has shown that reviewing (educating) the key concerns and
treatment needs with patients and parents in a consistent coherent, fashion throughout the course of care helps
them better understand and comply with care.

consistently in both offices and all communica- orthodontic care or evaluation benefits the
tion is focused on how the recommended patient as well as the orthodontist as early diag-
treatment benefits the patient. This results in the nosis and timely treatment can lead to better
parent/patient hearing a similar explanation outcomes.7
three or four times and subsequently three or Two of the authors have had the luxury of
four opportunities to ask questions and fully having been able to cross-train their clinical and
understand. Learning research has shown that administrative teams. And this level of under-
repetition and review of key points can help standing between specialties has been clearly
subjects retain important information1,3,4,9 evident to the patients making them very con-
(Fig. 5). fident and comfortable about the level of care
Educating your referring dentists/specialists they receive. Each of their administrative and
and their staff is important in obtaining appro- clinical teams has had the opportunity to observe
priate referrals. It also helps build trust and a list of specific procedures in both pediatric
confidence between the patient, referring dentist dentistry and orthodontics, then given a list of
and the orthodontist. This results in more procedures with the responsibility to search out
patients accepting orthodontic treatment. the procedures and complete their observation
Our office consists of two practices, ortho- list. This can be accomplished readily in other
dontics and pediatric dentistry, in one facility. offices by simply taking the time and energy to
This has been helpful as over the years both of us inviting team members from referring offices for
have had the opportunity to learn about each observation visits in yours. This would make for a
otherʼs concerns, goals and treatment modalities. wonderful opportunity to strengthen an inter-
If we understand what we as different specialists office relationship and education at the
look for in treating our patients than we would be same time.
able to better communicate that to our patients Educating your referrers about crossbites, with
and staff. If the staff, in particular the hygienists or without functional shifts, overjets, underbites,
and treatment coordinators, also have that ectopic canines and crowding using proper terms
understanding, this reinforces our treatment and scripting that will be reinforced when future
recommendations. Usually orthodontists rely on potential patients come to your orthodontic
their colleagues, in particular, the general den- office is important in establishing that patient
tists and pediatric dentists, for referrals. Edu- trust and follow through. In our office a pan-
cating them as to what needs to be referred for oramic radiograph is taken generally at around
182 Maestre et al

the age of 7 on the pediatric dental side and then parents often do not realize that their children
about every 3 years. The staff has been trained to are overdue for such visits. With frequent
look for ectopic canines or ectopically erupting orthodontic visits they feel like they are at the
first molars, missing or supernumerary teeth, etc. dentist all the time. If the pediatric and ortho-
If this is observed on a radiograph the issue is dontic practices are separate, the orthodontic
brought up, confirmed by the pediatric dentist clinical team can inquire about up-to-date recall
and a recommendation for a referral is made. visits. The orthodontic staff can offer to contact
Early recognition of any developing orthodontic the pediatric dentist. This can build a great
problem should begin an important dialogue relationship with referrers as well as ensuring
between the pediatric dentist and the ortho- optimal dental care throughout a time of greater
dontist.5 Orthodontic and pediatric dental team caries risk.
members are cross-trained with appropriate In addition, this interdisciplinary back and
scripting in terms of how treatment will benefit forth communication has changed how early
the patient for a particular diagnosis. When the demineralized interproximal lesions on posterior
parent and patient meet the treatment coor- teeth are being managed as well. The ortho-
dinator and the orthodontist the findings are dontic team can clinically discover interproximal
confirmed in similar language. Consistent, clear demineralized areas after separator placement
communication with the patient/parent at all has created an open contact. Such lesions are
steps along the way is reassured and will likely often not visible radiographically but can
accept any necessary treatment (Fig. 6). potentially develop into large caries during the
Another example of the importance of com- course of orthodontic treatment. When alerted
munication and understanding treatment about such lesions, the pediatric dentist can treat
modalities is the management of caries pre- via a conservative ICON infiltrative restoration.13
vention. The reported prevalence of post- The pediatric team has learned about the use of
orthodontic demineralization or white spot elastic separators through exposure to the
lesions ranges from 50% to 70%.10,11 The orthodontic team. Often using them to create
orthodontist and his/her staff have a responsi- open contacts to treat carious lesions
bility to ensure that their patients experience the conservatively on all patents, not just those
lowest possible caries risk throughout treatment. under orthodontic treatment.
This can be achieved with exceptional oral In this technological age, the way we can
hygiene throughout orthodontic treatment, communicate with our patients and referring
appropriate fluoride usage and 4 month or more doctors can take many forms. Computer soft-
frequent recall visits.12 In our office we review all ware, such as Dolphin Aquarium, can allow us to
orthodontic patients who have an appointment show patients what appliances look like, how they
each day and see if any of them are overdue for work, and what effects they have. Simulated
their 4-month cleaning visit. Their pediatric treatment plans, including the extraction of teeth
charts are reviewed beforehand and if appro- or surgery, are also available to illustrate what to
priate, the parents will be contacted before the expect during and at the end of treatment.
visit to see if they would like to have their recall Videos and software illustrating oral hygiene
visit prior to their orthodontic appointment. The methods and the effects of poor oral hygiene on
parents generally appreciate this attention and the teeth and gingiva can be more effectively
support as in this day and age, well-intentioned communicated to the patient if they have a visual

Figure 6. Communication flows into all facets of treatment success. Proper communication is critical throughout
all aspects of your practice.
 Intra- and inter-office communication 183

Figure 7. The use of technology can be a real asset—visual communication is just as important as verbal and the
more you “show and tell” the greater the understanding and the more trusting your patients will become.

explanation. Visual communication is just as (1) Set common goals and expectations for
important as the verbal kind and the more you providing excellence in patient care, inclu-
“show and tell” the greater the understanding, sive of knowing their developmental, ortho-
the more trusting and compliant your patients dontic, hygiene and recall needs.
will become14,15 (Fig. 7). (2) Educate your patients, their parents, your
Social media, such as Facebook and Insta- referrers, and all staff.
gram, can keep patients and referrers connected (3) Use visual aids, cross-train all staff members
with your office and are excellent ways for you to and create learning opportunities for refer-
keep in touch with them as well as with your ring dentists/specialists and their staff.
patients. It can be a resource for all your patients (4) Start with that first patient phone call by using
and referring doctors where you can post edu- clear, consistent scripted messages/statements
cational videos and tips on maintaining a healthy that are reinforced by all staff and doctors
smile. The staff can illustrate their commitment throughout. And finally, but most importantly,
to providing exceptional care when they post (5) Show you care by providing a warm and
pictures at continuing education meetings and reassuring environment where patients/
lectures. Giving to the community by visiting local parents feel comfortable asking questions,
schools to educate children on oral hygiene and use social media to keep your patients
make great photo opportunities. Posting school connected with you and your practice.
event announcements, donations of tooth-
brushes and toothpaste to local charities and
volunteering in under-serviced areas creates a References
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spot formation after bonding and banding. Am J Orthod. philosophy. Am J Orthod Dentofacial Orthop. 1994;106(6):
1982;81(2):93–98. 654–657.
Non-cavitated dental radiolucent
lesions: A challenge for the dental
healthcare provider
Sarah S. Ahn1, Paul K. Chu, and George J. Cisneros

Pre-eruptive intracoronal radiolucencies (PIR) and post-eruptive hidden caries

(PHC) are non-cavitated intracoronal dental lesions that are usually detected
only through radiographic observation. As a result, these lesions present
numerous challenges for the dental healthcare provider that markedly differs
from that of other non-cavitated dental lesions (early/incipient/demineral-
ized white spots). Best practice principles should be employed, for example,
timely recognition and radiographic surveillance/observation, logical treat-
ment management, along with judicious communication amongst all parties
involved (parent/guardian, pediatric dentist and orthodontist). This article
attempts to review and discuss the literature of these conditions and present
a case report of a patient with PIR. (Semin Orthod 2016; 22:185–192.) & 2016
Elsevier Inc. All rights reserved.

Introduction be diagnosed radiographically, that is, panoramic,

“B
periapical and bitewing x-rays, and appear as
y definition, dental caries is an infectious
radiolucencies in the crowns of teeth. And as their
and transmissible disease because it is
names imply, the major difference between the two
caused by bacteria colonizing the tooth surfaces.”1 It
is that one occurs prior to dental emergence into
causes dental structural destruction by the constant
the oral cavity, while the other after eruption. In
exposition of the enamel and dentin to acids.
addition, their etiology and treatment modalities
The incidence of untreated dental decay in
slightly differ. This article will review the literature
children has fallen, credited mostly to the
associated with both and report on a case of PIR.
increase in (a) awareness by caretakers and
pediatricians, (b) the use of preventative meas-
ures, such as, sealants and fluoride, and (c) the Historical perspective
number of pediatric dentists. Despite these
positive strides in prevention, caries still remains Pre-eruptive intracoronal radiolucencies (PIR)
a damaging process.2 First described by Skillen3 in 1941, by definition
Unlike typical caries, which involve cariogenic pre-eruptive intracoronal radiolucencies (PIR) are
bacteria and are found clinically, pre-eruptive lesions that are only detected radiographically
intracoronal radiolucencies (PIR) and post- before eruption. The lesions are often found in the
eruptive “hidden” caries (PHC) can be missed dentin only and adjacent to the dento-enamel
even with careful dental examination with a mirror junction of unerupted teeth4,5 (Fig. 1).
and explorer. Both non-cavitated entities can only
Post-eruptive hidden caries (PHC)
Division of Pediatric Dentistry, SBH Health System (St. Barnabas
Hospital) Dental Department, Bronx, NY; Rye Pediatric Dentistry,
Nearly 40 years later, in the 1980s, the term
Rye, NY; Department of Orthodontics, New York University College of “hidden caries,” or occult caries, was first used to
Dentistry, New York, NY. describe a lesion that completely differed from
Address correspondence to George J. Cisneros, DMD, MMSc, the traditional development of dental caries.6
Department of Orthodontics, New York University College of Dentistry,
The entity could not be detected on routine
345 East 24th St., New York, NY 10010. E-mail: [email protected]
1
Private practice: Bronx, NY and Hauppauge, NY. clinical exam, as the occlusal enamel surface of
& 2016 Elsevier Inc. All rights reserved.
teeth with these lesions appeared to be healthy
1073-8746/16/1801-$30.00/0 and/or minimally demineralized. However, they
http://dx.doi.org/10.1053/j.sodo.2016.05.005 were visualized in dentin mainly by means of

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 185–192 185

186 Ahn et al

Figure 1. Example of Pre-eruptive intracoronal radiolucency (PIR). Panoramic radiograph of a 10-year-old patient
with radiolucencies observable on both unerupted second permanent mandibular molars.

bitewing and periapical radiographs (Fig. 2). It the first known case in a second primary man-
has been assumed that these lesions slowly dibular molar in a 2.5-year-old girl. Treatment for
progress in dentin, often resulting in this tooth was extraction secondary to a dental
compromised pulpal tissue (Fig. 3). abscess.7
There were no gender or racial predilections
noted, nor association with medical conditions or
Prevalence fluoride uptake/supplementation.4,5 Interest-
ingly, the incidence of PIR appears to be cor-
Pre-eruptive intracoronal radiolucencies (PIR)
related with the presence of ectopic teeth as,
As would be expected, most of the information Seow et al.4,5 found a rate of 14% in bitewings
on PIR prevalence has been derived from and 28% in panoramic radiographs compared to
radiographic studies with results varying 2% with non-ectopic teeth. Seow hypothesized
dependent upon the type of x-rays utilized that pressure from the malposed unerupted
(Table). In a study using bitewing radiographs, tooth may provoke pre-eruptive defects.
Seow et al.4 found the prevalence to be 6% in
nearly 2000 children with a few subjects exhibiting
Post-eruptive hidden caries (PHC)
lesions in more than one tooth. Seow et al.,5 using
panoramic radiographs, found the prevalence to Allan and Naylor8 carried out the first radiographic
be 3% by subjects or 0.5% of unerupted permanent study finding the prevalence to be 22% in 858 first
teeth, most commonly occurring in maxillary molars. Later studies have suggested prevalence
(4%), and mandibular (3%) first molars. In ranging from a low of 1.4 to as high as 50% in
bitewings, PIR lesions tended to be most visible permanent molars with a greater incidence in
in the mesial and central aspects of the mandibular mandibular molars.8–14 One study suggested that
first molars (4%) while in distal of premolars lesions became more common as the age of the
(2%).4,5 Although occurrence in the primary child increased.14 However, the marked variation
dentition is unknown, Seow and Hackley did report observed needs to be viewed in light of the lack of
 Non-cavitated dental radiolucent lesions 187

Figure 2. Example of post-eruptive hidden caries (PHC). Panoramic radiograph of a 12-year-old patient with
radiolucencies observable on both fully erupted second permanent mandibular molars.

Figure 3. The impact of unrecognized and untreated PHC lesion. Bitewing radiographs of an 11-year-old patient
with unobserved PHC lesion on mandibular premolar (left) and 2 years later post-op x-ray with treatment
restoration in place, in preparation to eventual endodontic therapy.
188 Ahn et al

Table. PIR vs. PHC comparative features.

Pre-eruptive intra-coronal radiolucent lesion (PIR) Post-eruptive hidden caries lesion (PHC)

Prevalence 6% 1.4–50%
(no more than 1 per person) (increases with age)
Location Lower first molar and second premolar Permanent first and second molars
(associated with ectopic teeth) (greater with lower teeth)
Etiology Controversial Controversial
(resorptive cells enter through reduced enamel (fluoride remineralization, enamel defects, specific
epithelium) bacteria)
Treatment Lesion may be progressive Progressive lesion
(early removal is suggested) (prevention is key)
Summary results from the literature regarding the etiology, prevalence and location of PIR and PHC lesions along with treatment
recommendations to manage the lesions.

standardization used to assess these conditions as epithelium due to local reaction caused by
fewer practitioners use sharp explorers to detect inflammation or infection from predecessor
occlusal caries. primary teeth. However, current studies show no
Some have suggested that there may be a rela- linkage between endodontically or infected pri-
tionship between the presence of PHC and the mary teeth and permanent tooth resorptive
patient’s risk for caries. Although a direct relation- defects, as permanent teeth without primary
ship between high caries risk and higher prevalence predecessors have also have been shown to
and severity of hidden caries may be expected, this develop the condition.4
cannot be adequately proven at this time.15
Additionally, there appears to be no evidence of a
Post-eruptive hidden caries (PHC)
relationship between socioeconomic status and
prevalence.16 Although the etiology of hidden caries is yet
unknown, there are a number of proposed the-
ories, for example, (a) structural and anatomical
Etiology defects of enamel, (b) specific microbiota, and
the most accepted theory, (c) the use of fluoride.
Pre-eruptive intracoronal radiolucencies (PIR)
Sawle and Andlaw were the first to suggest the
As the tooth has yet to erupt into the oral cavity relationship of hidden caries and fluoride use,
and unlikely to be infected with cariogenic noting that as fluoride remineralizes surface
bacteria, the pathogenesis of PIR is unclear enamel, its use may de facto prevent the char-
(Table).17 Histological sampling of these lesions acteristic cavitation typically expected to occur
have documented the presence of resorptive on the occlusal surface.10 As the enamel
cells akin to osteoclasts and macrophages.7,18 It undergoes remineralization, caries progression
has been hypothesized that such cells originated decreases in the outer layer of the tooth with the
from the surrounding bone, entering the enamel apparently intact; however, by then the
dentin through a break in the reduced enamel cariogenic bacteria have penetrated sufficiently
epithelium, poorly coalesced enamel fissures to progress through to dentin with little if any
or cementoenamel junction (CEJ) of unerupted resistance.
teeth, explaining perhaps the correlation de Soet et al.19 found that the bacterial flora in
with ectopic teeth.4,17,18 Due to the abnormal the dentin of hidden caries were different from
location of the ectopic teeth, it has been sug- that found in clinically detectable caries. They
gested that there may be a local reactive found that the bacteria present tended to be “less
response stimulating resorptive cells to complex” in the PHC lesions compared to visible
invade the dentin via enamel fissures or the surface lesions sampled, suggesting that the
CEJ.4,5 etiology of PHC lesions may be different.
Previously, it was thought that PIR might have Juhl found in extracted premolars that most
developed from a break in the protective lesions were on the walls of the fissure near the
 Non-cavitated dental radiolucent lesions 189

base, hidden from direct view. Therefore, it has tooth structure. This technique fills the cavity with
been proposed that the specific location of early the resin and seals the occlusal fissures, thus
hidden caries may also determine if the lesion preventing bacterial colonization over the fissures
can be detectable.20 and reducing leakage between the restoration and
the tooth. For more advanced deep lesions,
possible treatments can include indirect pulp
Treatment
capping and root canal therapy. Due to possible
As with all carious lesions, prevention is key and inaccuracy of radiographic monitoring and the
sealants play an important role when and potential effects of the cariogenic bacteria under
wherever possible (Table). the sealants, sealing over these lesions is highly
debatable.16
Pre-eruptive intracoronal radiolucencies (PIR)
Clinical treatment for PIR lesion depends on Is there a possible link between PIR and
the (a) extent of the defect at initial pre- PHC?
sentation, (b) progressive nature of the defect,
It is distinctly possible that these two pre- and
and (c) anticipated eruption of the affected
post-eruptive lesions are actually one and the
tooth.21 Patient compliance and caries risk
same phenomenon, and that only the timing of
factors also play important roles. If during the
detection leads us to believe that they are two
initial observation period such lesions do not
separate entities. Seow and others after close
change much while still unerupted, then one
review of their own data have suggested that
might consider waiting for dental eruption
many PHC lesions began first as PIR lesions.5,17
prior to restoring the tooth.17 Czarnecki
Consequently, it is recommended that if any
et al.22 have suggested that a shallow lesion
patient presents to one’s office with teeth
should be treated before eruption, and that
exhibiting PHC, the patient’s prior radiographs
since these lesions are susceptible to post-
should be re-examined to evaluate if the lesion
eruptive bacterial colonization and develop-
was present before eruption.
ment of caries, the use of glass ionomers (GI)
could be helpful as the fluoride within GI may
encourage remineralization. Case report
In unerupted teeth with large or, based on
This case report clearly illustrates what can occur
observation, rapidly progressing lesions, surgical
when a tooth undergoes treatment soon after
exposure and intervention would be necessary to
detection of PIR versus the risks associated with
avoid pulpal exposure.22,23 As noted before, glass
monitoring.
ionomers are the material of choice as they are
An 11-year-old female presented to St. Bar-
less sensitive to moisture in the wet working field,
nabas Hospital for evaluation. Her medical his-
set faster, release fluoride and require less sur-
tory was unremarkable while her dental history
face preparation/conditioning, that is, etch-
was significant for a highly cariogenic diet and
ing.22–24 If pulpal exposure does occur, a partial
less than optimal fluoride exposure before
or full pulpotomy would be suggested to promote
moving to the US. Intraoral exam documented
continued root formation/completion.7,23 If the
poor oral hygiene and generalized gross caries of
tooth has erupted into the mouth and there is
all primary molars, which required extraction, in
root end closure, root canal therapy would be
the initial panoramic and periapical radiographs
indicated.25,26
(Fig. 4). The panoramic radiograph revealed that
teeth #18 and #31 had PIR lesions. Tooth #31 was
Post-eruptive hidden caries (PHC)
clinically palpable while #18 was not. Due to
Sealants have been shown to be a useful tool in access and potential moisture control issues, it was
preventing PHC lesions.27,28 Once PHC lesions are determined at the time that #31 would receive
diagnosed, the first approach is periodic observa- immediate treatment, while #18 could be
tion. If treatment is necessary for shallow lesions, monitored for the time being. Due to the
Hicks and Flaitz29 have proposed preventive resin child’s poor behavior and other dental needs,
restorations as the treatment of choice to preserve beyond just the restoration of #31, treatment
190 Ahn et al

Figure 4. Pre-eruptive intracoronal radiolucency (PIR) on case report. Periapical radiograph of a 11-year-old
female with radiolucency noted on tooth #31 (right second permanent mandibular molar).

Figure 5. Post-treatment restoration on case report. Periapical radiograph of 11-year-old female showing
restoration in place on tooth #31 (right second permanent mandibular molar).
 Non-cavitated dental radiolucent lesions 191

Figure 6. Post-eruptive hidden caries (PHC) on case report. Periapical radiograph of the same 11-year-old female
now more than a year later—note the extensive radiolucent lesion that developed on tooth #18 (left second
permanent mandibular molar). The lesion worsened over time requiring indirect pulp capping using Theracal LC
and Biodentine dentin material.

under general anesthesia was suggested. After extra-oral radiographs should be carefully
tooth #31 underwent gingival incision, bulk-fill examined for these lesions, especially looking for
composite resin and glass ionomer sealant were areas of radiolucency within the dentin of
placed in the tooth (Fig. 5). Unfortunately, patient each tooth.
compliance became a problem, as by the time the As demonstrated in Figs. 1 and 2, panoramic
patient reappeared for follow up care of #18, the radiographs can be very useful for diagnosis. And
lesion had progressed significantly (Fig. 6) to as the orthodontist can be the first practitioner to
warrant indirect pulp capping using Theracal LC take panoramic radiographs on the child patient,
and Biodentine dentin material. the orthodontist has the opportunity to observe
the presence of such lesions. Consequently,
orthodontists may play an important role in
Conclusions
diagnosis. Good communication between spe-
For sure, there are many questions and chal- cialties is vital for outcomes that are more
lenges ahead for us in the diagnosis and man- successful.
agement of PIR and PHC lesions. Both may often
be missed clinically as the occlusal enamel of a
tooth may be intact without any apparent cav-
itation, or may not be obvious radiographically. Acknowledgments
As early diagnosis is key, the absence of clinical The authors would like to thank the pediatric
signs of occlusal enamel or dentinal caries dental residents of SBH Health System (St. Barnabas
does not guarantee a sound dentition. In Hospital) who assisted in patient care and Dr. Elliott
addition to the clinical exam, routine intra- and Moskowitz.
192 Ahn et al

References 15. Weerheijm KL. Occlusal ‘hidden caries’. Dent Update.

1997;24:182–184.
1. Caufield PW, Li Y, Dasanayake A. Dental caries: an
16. Ricketts D, Kidd E. Hidden caries: what is it? Does it exist?
infectious and transmissible disease. Compend Contin Educ Does is matter? Int Dent J. 1997;47:259–265.
Dent. 2005;26(5 suppl 1):10–16. 17. Seow WK. Pre-eruptive intracoronal resorption as an
2. Dye BA, Thornton-Evans G, Li X, et al. Dental Caries and entity of occult caries. Pediatr Dent. 2000;22(5):370–376.
Sealant Prevalence in Children and Adolescents in the 18. Seow WK. Multiple pre-eruptive intracoronal radiolucent
United States, 2011–2012, NCHS Data Sheet, #191, March lesions in the permanent dentition: case report. Pediatric
2015, 1–8. Dent. 1998;20(3):195–198.
3. Skillen WG. So-called intra-follicular caries. Ill Dent J. 19. De Soet JJ, Weerheijm KL, van Amerongen WE, et al. A
1941;10:307–308. comparison of the microbial flora in carious dentine of
4. Seow WK, Wan A, McAllan LH. The prevalence of pre- clinically detectable and undetectable occlusal lesions.
eruptive dentin radiolucencies in the permanent denti- Caries Res. 1995;29:46–49.
tion. Pediatric Dent. 1999;21:26–33. 20. Juhl M. Localization of carious lesions in occlusal pits and
5. Seow WK, Lu PC, McAllan LH. Prevalence of pre-eruptive fissures of human premolars. Scand J Dent Res. 1983;91:
intracoronal dentin defects from panoramic radiographs. 251–255.
Pediatric Dent. 1999;21:332–339. 21. Seow WK. Prevalence of pre-eruptive intracoronal dentin
6. Weerheijm KL, van Amerongen WE, Eggink CO. The defects from panoramic radiographs. Pediatric Dent.
clinical diagnosis of occlusal caries: a problem. ASDC J 1999;21(6):332–339.
Dent Child. 1989;56:196–200. 22. Czarnecki G, Morrow M, Peters M, et al. Pre-eruptive
7. Seow WK, Hackley D. Pre-eruptive resorption of dentin in intracoronal resorption of a permanent first molar. J Dent
the primary and permanent dentitions: case reports and Child. 2014;8(3):151–155.
literature review. Pediatric Dent. 1996;20:195–198. 23. Davidovich E, Kreiner B, Peretz B. Treatment of severe
8. Allan CD, Naylor MN. Radiographs in the identification pre-eruptive intracoronal resorption of a permanent
of occlusal caries. J Dent Res. 1984;63:504. second molar. Pediatric Dent. 2005;27:74–77.
9. Strassler HE, Porter J, Serio CL. Contemporary treatment 24. Donly KJ, Segura A. Fluoride release and caries inhibition
of incipient caries and the rationale for conservative associated with a resin-modified glass-ionomer cement at
operative techniques. Dent Clin North Am. 2005;49: varying fluoride loading doses. Am J Dent. 2002;15:8–10.
867–887. 25. Ari T. Management of hidden caries: a case of severe pre-
10. Sawle RF, Andlaw RJ. Has occlusal caries become more eruptive intracoronal resorption. J Can Dent Assoc.
difficult to diagnose? Br Dent J. 1998;164:209–211. 2014;80:e59.
11. Creanor SL, Russell JI, Strang DM, et al. The prevalence 26. Kupietzky A. Treatment of undiagnosed pre-eruptive
of clinically undetected occlusal dentine caries in Scottish intracoronal radiolucency. Pediatric Dent. 1999;21(6):
adolescents. Br Dent J. 1990;169:126–129. 369–372.
12. Kidd EAM, Naylor MN, Wilson RF. The prevalence of 27. Zadik Y, Bechor R. Hidden occlusal caries challenge for
clinically undetected and untreated molar occlusal the dentist. N Y State Dent J. 2008:46–50.
dentine caries in adolescents on the Isle of Wright. Caries 28. Thompson VP, Kaim JM. Nonsurgical treatment of
Res. 1992;26:397–401. incipient and hidden caries. Dent Clin North Am.
13. Weerheijm KL, Groen HJ, Bast AJJ, et al. Clinically 2005;49:905–921[viii].
undetected occlusal dental caries: a radiographic com- 29. Hicks MJ, Flaitz CM, The acid-etch technique in caries
parison. Caries Res. 1992;26:305–309. prevention: pit and fissure sealants and preventive
14. Weerheijm KL, Gruythuysen RJ, van Amerongen WE. restorations. In: Pinkham JR, ed. Pediatric Dentistry: Infancy
Prevalence of hidden caries. ASDC J Dent Child. 1992;59 Through Adolescence. Philadelphia: W.B. Saunders; 1999:
(6):408–412. 481–521.
Demineralized white spot lesions: An
unmet challenge for orthodontists
Matthew J. Miller, Shira Bernstein, Stephanie L. Colaiacovo, Olivier Nicolay, and
George J. Cisneros

White spot lesions (WSLs) are an all too common negative outcome of
orthodontic treatment: a disheartening truth in an esthetically driven
profession. WSLs are areas of enamel demineralization 100–150-mm deep,
with an intact porous surface layer, which can progress until a complete
inward collapse of the surface occurs. Their un-esthetic opaque appearance is
potentially reversible, but irreversible once cavitated. Clinically detectable
WSLs can occur as early as 1 month after fixed appliance placement. It is
estimated that 50% of patients develop WSLs in at least one tooth by the end
of orthodontic treatment. Although orthodontists have recognized this issue,
the problem still persists. An immediate application of fluoride to a white
spot lesion will cause a rapid surface remineralization, leaving deeper layers
demineralized, so prevention of lesion progression is necessary for an ideal
esthetic outcome. Aside from excellent oral hygiene, fluoride varnish, MI
Paste, and smooth surface sealants are currently the primary methods of
WSL prevention. There is an existing body of research related to the use of
topical fluoride and calcium–phosphate pastes to prevent demineralization
during orthodontic treatment, including at-home topical treatments. How-
ever, the self-reported compliance rate is approximately 50%. Professional
fluoride varnish is thought to have the advantages of reducing demineraliza-
tion without being technique sensitive. Other methods of WSL prevention
are available, such as placement of sealants on facial surfaces of teeth, but
preliminary research has shown conflicting results on their effectiveness.
Regression of WSLs after treatment is attributed to gradual surface abrasion
of tooth structure. Research has shown no improvement in WSLs when
comparing non-invasive treatment methods such as MI Paste to routine oral
hygiene practice. Success has been shown in treating arrested WSLs with a
resin infiltration technique, but this is most useful on a small scale. (Semin
Orthod 2016; 22:193–204.) & 2016 Elsevier Inc. All rights reserved.

Historical perspective period—roughly 10,200 BC to 2000 BC.1 They

hypothesized that the rise of agriculture
ince the advent of civilization, dental caries
S have affected mankind. For example, hom-
inids such as Australopithecus suffered from
contributed to an increase of ingested plants
and carbohydrates that contributed to this spike.2
There was a belief among ancient civilizations
cavities, and archeologists found evidence of a
that dental caries were caused by a dental worm,
sharp spike in dental caries during the Neolithic
and the ADA website exhibits a copy of an
ancient Sumerian manuscript subscribing to this
Department of Orthodontics, New York University College of belief.3 The next uptick in dental caries came
Dentistry, New York, NY. during the middle ages due to the introduction
Address correspondence to Matthew J. Miller, DDS, Department of
of sugarcane byproducts to the western world.1
Orthodontics, New York University College of Dentistry, 345 East 24th
St, New York, NY 10010. E-mail: [email protected]
With the 17th century came the age of
& 2016 Elsevier Inc. All rights reserved.
enlightenment, during which many old beliefs,
1073-8746/16/1801-$30.00/0 including the dental worm theory, were
http://dx.doi.org/10.1053/j.sodo.2016.05.006 questioned.4 The first person to reject this

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 193–204 193

194 Miller et al

theory was Pierre Fauchard, who theorized that been part of the therapeutic dental mantra for
sugar was most likely responsible for dental decades. The effectiveness of this regimen has
caries. For this contribution he is now known been well documented, confirming oral neglect as
as the father of modern dentistry.5 The 1850s saw the primary etiology for caries development.
another sharp increase in the prevalence of Proper oral hygiene instruction given to patients in
dental caries attributed to an overall change in the orthodontic office is therefore fundamental
worldwide diet as a result of the industrial and should not be overlooked by the dental team,
revolution, which brought with it the as simply the insertion of such appliances imme-
production and wide availability of processed diately places the patient into the AAPD high-risk
foods such as white sugar, refined flour, bread, category for caries (Appendix A).
and sweetened tea.6 Before the Industrial Fluoride has become our main preventative
Revolution, the most common type of caries chemotherapeutic agent against caries. As stated
were cervical or root caries, but with the advent of previously, once an acidic environment develops
processed foods, pit and fissure caries became in the oral cavity, enamel can begin to demin-
the most common form. In the 1890s, Dr. W.D. eralize, resulting in white spot lesions (WSLs)
Miller suggested that there were bacteria in the and eventually decay. However, when the enamel
oral cavity that formed acidic byproducts when surface is exposed to fluoride, the hydroxyapatite
fermentable carbohydrates were ingested crystals lose their OH
ions, which are sub-
causing caries to form.7 Dr. Millerʼs hypothesis sequently replaced with F
ions, forming fluo-
later became known as the “chemoparasitic rapatite, which is more resistant to decay. This
caries theory.”8 Research of Drs. G.V. Black process has been proven to occur even with
and J.L. Williams on dental plaque also trace amounts of fluoride such as 0.01–10 parts
contributed to the modern concept of dental per million (ppm).12 Consequently, fluoride has
caries pathophysiology. In 1924, Killian Clarke been added to most toothpastes sold in the
first suggested Streptococcus mutans as the primary United States, as well as mouthwashes and
culprit.9 Today we know that S. mutans and restorative materials such as resin-modified
Lactobacilli are the primary bacterial species glass ionomer (RMGI).
responsible for the formation of dental caries. The addition of fluoride to tap water is another
When S. mutans and Lactobacilli are combined frequent method of exposing the public to its
with fermentable carbohydrates such as glucose, benefits. Although this method seems con-
fructose, or sucrose, lactic acid is produced troversial in some geographic areas, fluoridated
resulting in a rapid decrease in the intraoral pH, water is delivered to approximately two-thirds of
specifically below 5.5, creating an acidic envi- the U.S. population.13 It has been estimated that
ronment favorable for initiating enamel decal- children who brush with fluoridated toothpaste,
cification. Intraoral pH rebounds after 30– and are exposed to fluoridated water, have an 18–
60 min due to the bodyʼs natural buffering 40% reduction in frequency of caries.14
capacity, but by then enough time has occurred Finally, fluoride varnishes can be used to
for the decay process to begin. Dr. Robert Ste- protect the individual tooth surface.15 Varnishes
phan was first to describe this pH change in 1943. are available for professional use in dental
Three factors must be present: bacteria, fer- offices, as well as for home care. Professional
mentable carbohydrates, and of course a tooth varnishes contain 5% sodium fluoride (NaF) at a
surface. Proteins from food create a biofilm on concentration of 22,600 ppm of fluoride and are
the tooth surface, which becomes colonized by painted onto dried teeth, to allow for sufficient
bacteria.10 As permanent teeth are the only penetration on to the enamel surface. At-home
natural surface of the body that does not shed, care varnishes on the other hand contain 100–
this facilitates the bacterial colonization allowing 1500 ppm of fluoride and are used in a similar
dental caries to eventually develop.11 fashion. Office fluoride gel treatments are also
Over the centuries, humanity has grappled available for patients with vulnerable enamel,
with the problem of having to keep the surfaces comprised of 1.23% acidulated phosphate fluo-
of their teeth free of plaque to prevent decay. ride (APF) to deliver 12,300 ppm fluoride.16
Brushing twice every day with fluoride tooth- MI Paste Plus is another product on the mar-
paste, using mouthwash, and flossing daily has ket, manufactured by GC America. MI Paste
 Demineralized white spot lesions 195

contains Recaldent,1 and is marketed as an anti- esthetic of the face and teeth, especially since these
sensitivity agent. Dental sensitivity is often caused lesions mainly occur in the maxillary anterior
by the wearing away of the enamel surface. This dental region23 (Fig. 1).
can be due to either mechanical forces such as Several strategies can be employed to help
bruxism, or chemical forces such as patients reduce the occurrence of WSLs, including more
suffering from GERD (Gastroesophageal Reflux frequent professional cleanings, and reinforcing
Disease). Its active ingredients are casein phos- oral hygiene instructions by using applied
phopeptide (CPP) and amorphous calcium behavior analysis (ABA). The use of chemo-
phosphate (ACP). These agents work with fluo- therapeutic agents can also reduce the incidence
ride to deliver calcium and phosphate ions to the of WSLs by means of specifically targeting the
enamel and into the oral environment. This disease-producing microorganisms (Table 1).
allows the enamel surface to remineralize, pre-
venting dental sensitivity from occurring.17–20
Fluoride resins and prevention of white spot
lesions
Orthodontic perspective
The use of resin-modified glass ionomer
Orthodontics markedly improves the patients who (RMGI) cements has been investigated in the
at the end leave the orthodontic office with cor- past as a means to prevent caries. There have
rected malocclusions, properly aligned teeth, a also been attempts at using fluoride-containing
significant boost in self-confidence, and overall glass ionomer adhesives to bond orthodontic
sense of well being. However, since orthodontic brackets. In a study conducted by Kasshani
care is mostly delivered to the 11–17-year-old et al.,24 it was shown that when comparing
patient population, a group generally defined by enamel demineralization depths adjacent to
its defiance of rules and overall non-compliance, orthodontic bands cemented with zinc
this often translates to poor oral hygiene. Indeed, polycarboxylate, glass ionomer (GI), or resin-
the poor oral hygiene of these young individuals modified glass ionomer (RMGI), the use of
can only be negatively compounded by the pres- RMGI cement seemed to provide significantly
ence of brackets, arch wires, ligatures, and other better prevention of enamel demineralization.
orthodontic appliances, which make maintaining Unfortunately, these materials have low bond
proper oral hygiene even more difficult. This leads strength, as demonstrated by Bishara et al.25 in their
to plaque accumulation and ultimately deminer- comparison of the use of either a fluoride-releasing
alization around brackets in as little as four weeks glass ionomer (FRGI) or an acidic primer in com-
time, placing them at higher risk for caries bination with an available orthodontic composite
(Appendix A). Furthermore, the increased surface adhesive. Their results showed FRGI significantly
area created by the addition of brackets, wires, and reduced shear bond strength when compared with
bands readily facilitates the accumulation of that of the conventional composite resin adhesive
fermentable carbohydrates and the adhesion systems. Orthodontists and their patients would be
and colonization of S. mutans. As a result, better served by using a phosphoric acid/composite
demineralized white spot lesions (DWSLs) all resin adhesive system, or equivalent, that provides
too often become an unfortunate outcome of clinically reliable bond strength between the
orthodontic treatment. The prevalence of new bracket, the adhesive, and the enamel surface.
enamel lesions among orthodontic patients Passalini et al.26 investigated the caries preventive
treated with fixed appliances, despite use of effect of fluoridated orthodontic resins. Experi-
fluoride toothpaste, can range anywhere from mental conditions used a simulated high cariogenic
13% to 75% with some estimates of WSLs after challenge with two kinds of acid demineralizing
orthodontic treatment as high as 97%.22 Children saliva on extracted bovine incisors. Two different
aged 11–14 years are also considered to be at orthodontic light polymerized fluoridated resins
greatest risk of developing caries.21 The were used—Transbond Plus Color Change2 and
occurrence of white spot lesions is particularly Orthodontic Fill Magic.3 The results of the study
unfortunate for a profession that focuses on the
2
3M Unitek (Monrovia, CA)
1 3
Recaldent Pty Ltd (Melbourne, Australia) Vigodent (Rio de Janeiro, Brazil)
196 Miller et al

Figure 1. Examples of WSLs. Intraoral frontal photographs of patients who have completed comprehensive
orthodontic treatment demonstrating white spot lesions of varying severity—from mild (top), to moderate
(center) to severe (bottom).

showed that the acidic saliva with a pH of 5.5 did not Research has established that fluoride is a very
induce WSLs, in contrast with those detected under effective means of caries prevention. However,
the high cariogenic acidic saliva, pH 4.5. Unlike the careful home care including flossing, brushing
previous research, this study was noteworthy in that with fluoridated pastes, and using fluoride rinses
it closely simulated the oral environment, setting a relies heavily on meticulous compliance from
standard for in vitro work in this area of study. children and adolescents. An alternative to these
methods of fluoride administration is a longer
lasting fluoride treatment done professionally to
Fluoride varnish and prevention of white spot
ensure that patients receive the appropriate
lesions
amount of fluoride. These fluoride varnish
The ideal preventative treatment is one that does applications, provided by dentists or dental
not rely on patient compliance. If there were a assistants, would ensure the varnish is applied
one-visit cure-all prevention that could be properly to a dried tooth surface (Fig. 2).
implemented on the initial day of bracket But what do we already know about the pre-
placement with no subsequent follow-up vention of WSLs using fluoride varnish? When
required, no further research would be needed. plaque accumulates around orthodontic
 Demineralized white spot lesions 197

Table 1. Advantages and disadvantages of chemotherapeutic agents useful in the prevention and management of
DWSLs.
Advantage Disadvantage

Mouthwash w/ Ease of use Compliance

fluoride NaF varies 0.02–0.05% depending on brand Less fluoride than gel/varnish
Chlorhexidine Reduces caries and number of low pH producing bacteria21 Compliance
rinse Can stain teeth and change taste
Prevident 5000þ Fluoride dose of 5000 ppm Compliance
WSL remineralization potential Rx required
Nighttime—no rinsing/eating
afterwards
Fluoride gel High dose (12,300 ppm) Office visit
Fluoride varnish High dose (22,600 ppm) Office visit
Minimal compliance
Reduces DWSLs
Sensitivity relief
Quick application
Minimal impact on tooth color
Waterproof
Low technique sensitivity
Resin sealants Reduces DWSLs Must be removed from teeth after
appliance removal
Xylitol Increases salivation, leading to remineralization and reduction of S. To be used 3–4 times per day
mutans levels29
MI paste Treats DWSLs Compliance
Sensitivity relief Contraindication: Milk allergies
Requires use of intraoral trays
Probiotics Shifts oral microflora balance leading to higher intraoral pH Compliance
May have systemic side effects
Carbamide Improves pH of oral environment Office visit
peroxide Whitens teeth Compliance

Many chemotherapeutic agents have been suggested for the treatment of demineralized white spot lesions, but the largest body of
research involves fluoride-containing products. Other agents may be effective, but good quality evidence is needed.

brackets, it causes a perfect storm. Plaque is a were assessed (p ¼ 0.01). These results unveiled
natural reservoir for cariogenic microflora, the impact that fluoride varnish could serve as
namely S. mutans and Lactobacilli.27 Orthodontic prevention of early demineralization. Additionally,
brackets have a tendency for plaque a case control study published by Karlinsey et al.31
accumulation, leading to demineralization of demonstrated that non-contact remineralization
the enamel around the brackets, leading to could occur in WSLs when 5% fluoride varnish was
white spot lesions. A particularly effective way applied to enamel cores of bovine teeth when
to prevent WSLs, and ultimately decay, is to apply exposed to demineralization solution. The cores
fluoride varnish with 5% sodium fluoride that were exposed to fluoride varnish had a sig-
(Table 2) to the enamel surface around the nificant reduction in WSL formation.
brackets.28 A randomized control trial was conducted by
Research has shown the efficacy of using flu- Divaris et al.32 on 543 Australian children from
oride varnish to prevent WSLs. Jablonski-Momeni an Aboriginal community where those in some
et al.30 assessed initial caries lesions in 12-year villages received fluoride varnish while others did
olds. The study investigated a population of not. The data concluded, like the previous
German children who were exposed to fluoride studies, that there was a 25% decrease in the
varnish twice a year compared to those who number of WSLs in the children who were
received no varnish. In those not exposed to exposed to fluoride varnish compared to those
fluoride varnish, significantly more initial lesions who were not.
198 Miller et al

Figure 2. Preventative approaches for WSLs. (A) Two categories of white spot preventative agents. At left,
Colgates PreviDents Varnish and Reliance Pro Seal and Ultradent UltraSeal XTs Plus sealants on the right. (B)
5% NaF varnish applied to air-dried maxillary anterior teeth in a patient treated with Invisalign. After contact with
saliva, the varnish begins to harden, in order to resist displacement and maximize fluoride delivery to the teeth.

Some experiments focused on combined to decipher the effect of either of these items
regimens, while others have evaluated the use alone. Although there are only few studies
of a single preventive factor alone. However, that focused on the prevention of WSLs solely
the drawback of studies that evaluated the in the context of orthodontic treatment, there
effects of both fluoride varnish and MI paste is still a significant amount of evidence
together is that investigators were never able available.
 Demineralized white spot lesions 199

Table 2. Examples of fluoride varnishes by brand.

Brand Name %Fluoride Notes

GC America MI Varnish 5% NaF Contains CPP-ACP

Ultradent Flor-Opal Varnish White 1.1% NaF For home use
3M ESPE Vanish 5% NaF Contains TCP
Medical Products Laboratories VarnishAmerica 5% NaF Contains Xylitol

Many companies manufacture fluoride varnishes, but nearly all products intended for professional use contain 5% NaF. Some
varnishes contain additional active ingredients such as casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), or
tricalcium phosphate (TCP). A varnish for home use is made containing 1.1% NaF.

Fluoride varnish and prevention of WSLs during effective, compliance was an issue for approx-
orthodontic treatment imately 50% of patients. Duraflor4 fluoride
varnish was thought to have the advantage
Derks et al.21 conducted a systematic review on of reducing demineralization without being
the “Caries-Inhibiting Effect of Preventive technique sensitive. Varnish provides protection
Measures during Orthodontic Treatment with without patient compliance by delivering the
Fixed Appliances.” This review included only fluoride in a sustained manner over a longer
randomized control trials published from 1970 to period of time. It also has longer contact time
2002 on the prevention of white spot lesion when compared with APF gel and Olaflur (amine
formation during orthodontic treatment with fluoride) applications. When applied to a dried
fixed appliances. Among the 15 studies, the surface, Duraflor provides a type of waterproof
effects of four preventative materials were coating against saliva allowing fluoride to remain
evaluated: fluoride varnish, chlorhexidine, in contact with the enamel for 4–6 h, which
sealants, and bonding materials. Preventative increases its uptake. A total of 36 extracted,
factor (PF) was the yardstick used to measure caries-free, human canines and premolars with
the caries-inhibiting effect of the study materials. brackets were used in the study. The teeth were
The PF of fluoride was 20% (SEM 0.09). The PFs divided into three groups; a control group with no
of the other preventive measures could not be treatment, a non-fluoridated varnish group, and a
calculated, although significant correlations were Duraflor varnish group. The teeth were placed in
evidenced. The use of toothpaste and gel with a both artificial saliva solutions and solutions that
high fluoride concentration (1500–5000 ppm) or simulated a carious environment. After 37 days,
chlorhexidine, during orthodontic treatment the brackets were removed and the teeth were
with bonded fixed appliances, showed a evaluated under polarized light microscopy.
demineralization-inhibiting tendency. However, Statistically significant differences were found
the use of a polymeric tooth coating on the tooth between all groups for both depth and area of
surface around the brackets, or a fluoride- lesions. The fluoride varnish group had approx-
releasing bonding agent, did not demonstrate imately 50% less demineralization than the con-
any reduction in demineralization around trol group. The fluoride varnish group had also
brackets. Unfortunately, this review could make the smallest lesions, followed by the placebo
no definitive conclusion regarding reducing group, followed by the control group. White spot
demineralization around orthodontic brackets lesions can develop within 1 month of bracket
with fluoride varnish due to a small sample size. placement; therefore it was suggested that varnish
Therefore, an experiment enrolling a larger should be applied at the initial bonding
group of individuals is warranted. appointment. This study demonstrated that a
In 1999 Todd et al.33 conducted an in vitro single application of fluoride varnish was benefi-
study looking solely at the effects of fluoride cial for reducing WSLs. It also demonstrated that
varnish around orthodontic brackets for the non-fluoridated/placebo varnish was not as
purpose of evaluating an in vitro caries effective in reducing WSLs, which tells us that
preventative measure that would not rely on there is nothing inherent in the varnish itself that
patient compliance. This study noted that while
at-home fluoride applications such as rinses are 4
A.R. Medicom Inc. (Montreal, Canada)
200 Miller et al

is helping produce these positive effects; rather it non-fluoride-containing varnish; amine fluoride
is the release of fluoride that is beneficial. and stannous fluoride toothpaste and rinse versus
In comparison, Stecksén-Blicks et al.23 using sodium fluoride toothpaste and rinse; and
an in vivo model, conducted a very similar study. intraoral fluoride-releasing glass bead device
In addition to the advantage of using an in vivo versus fluoride mouth rinse. The results of the
model, this research had the benefit of having a study comparing fluoride varnish vs. placebo (253
larger sample size, with 302, 12–15-year-old participants) showed that when varnish was
healthy children, in orthodontic treatment for applied every 6 weeks, there was moderate quality
a minimum of 6 months. This double-blind evidence supporting a 70% reduction in WSLs.
randomized study included a randomized This review had a low risk of bias, as the study
placebo-controlled design. The subjects were compared different formulations of fluoride
treated with topical applications of either the toothpaste and mouth rinse and found no dif-
active or the placebo varnish immediately after ference between an amine and stannous fluoride
orthodontic appliance placement, and then at combination compared to sodium fluoride
every 6-week follow-up visit. The incidence of products for the outcomes of white spot index.
WSLs during the treatment in the fluoride var- The study comparing a fluoride-releasing glass
nish group was approximately one third of that in bead attached to the brace vs. a daily fluoride rinse
the placebo group (7.4% vs. 25.7%, p ¼ 0.05). was a small study with 37 participants, with a high
The strengths of the study include the random- risk of bias due to substantial loss of subjects to
ized double-blind design, the number of subjects, follow-up. In its conclusion, this Cochrane review
and the data recording completed by outside found only one study of moderate evidence that
examiners. Photographs illustrated the lesions the application of fluoride varnish every 6 weeks
before and after treatment. The investigators reduces the risk of developing white spots by 70%.
believed that the key element behind the success Further well-designed RCTs are needed to con-
of the fluoride varnish was the retention and firm this result, and more studies are needed to
subsequent slow release of fluoride over a pro- find an optimal way of administering the fluoride
longed period of time, securing low concen- to patients with braces.
trations available in the liquid plaque-enamel
interface. Although the fluoride varnish did not
totally prevent WSL formation, their incidence Sealants and prevention of white spot lesions
was significantly reduced in the fluoride Another interesting idea that has been
varnish group. researched is the use of sealants on the facial
A Cochrane systematic review was conducted surface of anterior teeth, surrounding or placed
to examine the effectiveness of fluoride in pre- before bonding orthodontic brackets (Fig. 2). In
venting WSLs, and to determine the best means a study conducted by Benham et al.,34 Ultraseal
of administering fluoride to achieve that goal.28 XT Plus5 clear sealant was applied to the incisors
Types of studies included in this review were and canines of a quadrant selected at random,
randomized controlled trials, in which topical from the gingival surface of the bracket to the
fluoride was delivered by any method on subjects free gingival margin of subjects in active
of any age, all in treatment with fixed orthodontic orthodontic treatment. The control quadrant
appliances. Enamel demineralization was assessed received no sealant. The study found that the
at the start and end of orthodontic treatment. The non-sealed teeth developed white spot lesions at
type of interventions ranged from mouth rinses, a rate of 3.8 times greater than teeth with seal-
gels, fluoride-releasing bonding materials, etc. ants. In this study, a smooth surface sealant
The control groups were given a placebo or provided a significant reduction in enamel
no intervention at all. Three parallel-group demineralization during fixed orthodontic
randomized control trials with 458 subjects, two treatment, and could be considered for use by
conducted in Sweden and the other in the UK, clinicians to minimize white spot lesions.
were included and all participants were recruited A recent prospective trial by OʼReilly et al. was
at the start of their orthodontic treatment and conducted in a network of private offices to
followed until completion. Trials were grouped
into three comparisons: fluoride varnish versus 5
Ultradent Products Inc. (South Jordan, UT)
 Demineralized white spot lesions 201

determine the effectiveness of smooth surface different. It is important to note that in a well-
sealants in clinical practice. A non-fluoride- conducted RCT, no difference was found in the
containing light-cured sealant was placed on effectiveness of MI Paste Plus or PreviDent flu-
randomly allocated teeth. Teeth were analyzed oride varnish compared to a standard oral
by visual inspection for the presence and severity hygiene regimen for treating WSLs. This result
of white spot lesions. A slightly lower incidence of highlights what a challenge treating these lesions
white spots was found on treated (13.5%) vs. can be, and reinforces the need to prevent these
control teeth (17.7%), however, the white spot lesions before they occur.
severity was no different for treated vs. control A micro-invasive treatment approach is avail-
teeth.35 The ability to prevent WSLs was clinically able to improve the appearance of WSLs. The
small, but statistically significant. It was found Icon8 system can improve the appearance of
that regardless of the intervention, patients with white spots in one treatment session, and does
poor oral hygiene still developed WSLs, not require the use of local anesthesia. A recent
highlighting the continued importance for study was conducted at the University of
patient compliance. Göttingen (Germany) to evaluate the appea-
A randomized study was conducted by Bech- rance of infiltrated lesions after a period of 12
told et al. to examine two fluoride-containing months. It was found that lesion infiltration
sealants. The first sealant was a self-curing sili- improved the optical appearance of WSLs and
cone material, and the second was a highly filled was stable for at least 12 months, however, the
light-cured resin. Baseline measurements were initial size and depth of the lesion affects the
taken at the bonding appointment, and repeated esthetic outcome of treatment.37
after 6 months of treatment in 40 subjects.
Demineralization was measured by laser
fluorescence. No significant difference in fluo- Future considerations
rescence values was found between the sealants While there has been a significant amount of
and the controls, and between the two sealants. research conducted in the area of white spot lesion
The study concluded that the sealants did not prevention, notably on the use of fluoride varnish
offer enamel protection in the first 6 months of as a preventative means, there is still a significant
fixed appliance therapy.36 lack of knowledge on this topic. For example one
may ask why Stecksén-Blicks et al.23 found a
significant reduction in WSLs in their RCT. Was
Treatment of white spot lesions it due to the reapplication of varnish every 6 weeks
Other investigations have looked at methods of during the 6-month duration? Could one find
treatment of these lesions once they do occur. similar results on a 10- or 12-week regimen? These
Few in vivo studies have specifically looked at the are areas that have not yet been investigated in the
effectiveness of remineralization products to realm of orthodontics. Also, could we expect the
address the occurrence of WSLs after ortho- same 50% decrease in WSLs obtained by Todd
dontic treatment. Huang, et al. compared two et al.33 if using more than 36 extracted teeth?
products to a standard oral hygiene regimen with Additionally, how do the results of their work
fluoridated toothpaste: MI Paste Plus6 (Fig. 3), correlate when using central and lateral incisors, as
and PreviDent fluoride varnish7 in a randomized opposed to only canines and premolars as used in
controlled trial, in order to assess their his study? One should also investigate the
effectiveness over an 8-week period.22 The combination of both fluoride varnish and
results of this trial showed that there was no sealants as a means of prevention. If both are
significantly different outcome between active effective on their own, could not one expect an
treatment and control method when two blinded even greater decrease in the number of WSLs
examiners assessed WSL improvement in 115 using both simultaneously? These are all different
subjects. In addition, the self-assessment by sub- paths to be explored, and with time there is hope
jects in active treatment and controls were no that more can be discovered to prevent the
formation of WSLs during orthodontic treatment.
6
GC America Inc. (Alsip, IL)
7 8
Colgate (New York, NY) DMG America (Englewood, NY)
202 Miller et al

Figure 3. Treatment approach for WSLs. (A) MI Paste by GC America is placed into a carrier tray. In this case, the
carrier is a clear aligner. (B) Appearance of carrier tray when inserted onto maxillary teeth.

Conclusions measures are less effective when good oral

hygiene is lacking.
(1) Fixed orthodontic therapy puts our patients (3) There is at least moderate evidence that fluoride
at high risk for carious demineralization, as it varnish application at intervals of 4–6 weeks
increases the surface area for cariogenic improve the incidence and severity of WSLs.
bacteria, and makes physical removal of (4) Studies on smooth surface sealants have
plaque more difficult. found conflicting results, and more research
(2) Although preventative therapies exist, there is needed to determine their reliability.
is no replacement for patient compliance (5) Non-invasive treatment for WSLs do not
and consistent home care. Preventative show significant improvement over oral
 Demineralized white spot lesions 203

hygiene alone. Treatments such as resin 17. Reynolds EC. Cariogenic complexes of amorphous
infiltration are effective, but are less practical calcium phosphate stabilized by case in phosphopeptides:
a review. Spec Care Dentist. 1998;18(1):8–16.
for generalized WSLs. 18. Reynolds EC. The role of phosphopeptides in caries
prevention. Dental Perspectives 1999;3:6-7.
19. Sato T, Yamanaka K, Yoshi E. Caries prevention potential
of a tooth-coating material containing casein phospho-
Appendix A. Supplementary Information peptide—amorphous calcium phosphate (CPP-ACP).
Supplementary data associated with this article IADR General Session, Goteborg; 2003. [abstract 100].
20. Reynolds EC, Cain CJ, Webber FL, et al. Anticariogenicity
can be found in the online version at http://dx. of tryptic casein- and synthetic-phosphopeptides in the
doi.org/10.1053/j.sodo.2016.05.006. rat. J Dent Res. 1995;74:1272–1279.
21. Derks A, Katsaros C, Frencken JE, et al. Caries-inhibiting
effect of preventive measures during orthodontic treat-
ment with fixed appliances. A systematic review. Caries Res.
2004;38(5):413–420.
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The pediatric dental trauma patient:
Interdisciplinary collaboration between
the orthodontist and pediatric dentist
Courtney H. Chinn

Oral trauma in children and adolescents remains a significant health issue

that can benefit from an interdisciplinary approach between the orthodontist
and the pediatric dentist. The purpose of this article is to review the
opportunities for coordinated interdisciplinary care between the specialties
of orthodontics and pediatric dentistry through a case example of oral
trauma. In order to be successful, interdisciplinary care requires all parties
involved to have clear communication on roles and expectations and the
ability to resolve differences in treatment goals and values. When properly
executed, interdisciplinary care between the dental specialties holds great
potential to improve patient satisfaction and health outcomes. (Semin
Orthod 2016; 22:205–210.) & 2016 Elsevier Inc. All rights reserved.

T he growing complexity and multi-

dimensionality of health problems man-
dates the need for interdisciplinary collaboration
traumatic dental injury. Of all, 11% of patients
have reported having sustained a dental injury
before the onset of their orthodontic treatment.8
to achieve better patient care and health out- The pediatric or adolescent patient with a
comes.1 Within dentistry, the use of an history of dental trauma adds a level of com-
interdisciplinary approach has been found to plexity to the orthodontist’s plan of treatment
be of critical importance in achieving treatment already challenged with traditional issues of
success for individuals with complicated oral home care, caries risk status, and patient will-
health conditions and medical or behavioral ingness or ability to comply. Further, children are
challenges.2–4 Children and adolescents who also considered to be an inherently vulnerable
experience oral trauma can particularly benefit population. The clinician cannot assume that a
from team of dental specialists who are coordi- child can serve as a reliable health historian and
nating care, maintaining constant communica- may not have the physical faculty or legal
tion, and sharing decision-making in order to authority to make decisions regarding their own
maximize available treatment options and attain care and well being. All of these considerations
an optimal health result.5 The frequency of oral necessitate the need for coordinated patient care
trauma in US child and adolescent populations between pediatric and orthodontic specialties in
has been documented as high as 30%.6 Trauma order to achieve safer and more effective care.
to the oral region accounts for 5% of all injuries The purpose of this article is to review the
overall with dental injuries being the most opportunities for coordinated interdisciplinary
common in injuries that involve the face.7 care between the specialties of orthodontics and
Orthodontic patients are at increased risk as pediatric dentistry through a case example of
both excessive over jet and inadequate lip oral trauma.
coverage are predisposing risk factors to The common pitfalls of patient care coordi-
nation that involve multiple specialties are a lack
of clarity in specific roles and responsibilities and
New York University College of Dentistry, New York, NY. improper timing in which care is provided. This
Address correspondence to Courtney H. Chinn, DDS, MPH,
can be especially true in the management of
New York University College of Dentistry, 345 East 24th St, 9th Floor,
9W, New York, NY 10010. E-mail: [email protected]
patients involving pediatric dentistry and ortho-
& 2016 Elsevier Inc. All rights reserved.
dontics where some overlap in the abilities to
1073-8746/16/1801-$30.00/0 perform specific procedures may exist. The
http://dx.doi.org/10.1053/j.sodo.2016.05.007 guidelines of the American Academy of Pediatric

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 205–210 205

206 Chinn

Dentistry advocate for the establishment of a In some oral trauma cases, the child or ado-
Dental Home that can provide comprehensive, lescent may present to the orthodontist as a
continually accessible, family centered care.9 In referral after the emergent issues have been
many cases this involves having the pediatric addressed at the emergency room or the
dentist serve as the primary dental care provider pediatric dental office. Regardless of the timing
who then makes “referrals to dental specialists of initial involvement or who serves as the lead
when care cannot be directly provided within the primary care coordinator, the orthodontist
dental home”. Regardless of which specialist should feel comfortable contacting the pediatric
assumes this responsibility, interdisciplinary dentist or emergency physician for any missing or
care requires deliberate organization and additional patient information. If the ortho-
coordination of patient care activities as well as dontist is taking on the responsibility of coordi-
sharing of relevant information among all nating patient care, arrangements should be
participants concerned. In cases involving made to ensure that all partners involved in
pediatric dental trauma where timing and patient care are provided with information that
follow up is crucial to a successful clinical includes (1) results of the trauma evaluation, (2)
outcome, this requires that patient’s needs and medical and social history, (3) trauma history,
preferences are known and communicated to the and (4) results of the clinical examination.
right people at the right time. The initial evaluation of any pediatric patient
post-oral trauma should address or confirm
findings from the clinician’s observations and the
Case example patient’s or consenting guardian’s historical
report. Reported loss of consciousness, dizziness,
A 12-year-old male presents to your private nausea, or disorientation, non-equal or reactive
practice approximately 4 h post-trauma pupils or another cranial nerve deficiency when
(Fig. 1). His last visit to the office was for assessed should be transferred for emergency
initial evaluation last week for Phase II care right away. Circumstances of the trauma
orthodontics. The injury occurred in the should be documented including time and date
morning while playing basketball. It was of the injury, detailed description and location of
noted that teeth were chipped with one the injury, how the injury occurred, and time
tooth “pushed in.” The family has come to lapsed since injury, and any treatment that was
you because the physician at the emergency received. This information can advise on the
room thought he might need the tooth to be need for antibiotic coverage/tetanus and aid in
“pulled back into the right spot.” The child has the clinical prognosis10 and expected outcome as
a pediatric dentist with his last routine visit well as capture information for any reporting that
being over a year ago. may be required in advocacy of the child/
adolescent patient. Injuries to the head and
neck occur in 65–75% of the cases involving
physically abused children.11–13 Clinical pre-
sentations of an injury that are found to be
inconsistent with reporting or evidence of inju-
ries found to be in various stages of healing may
necessitate additional investigation and/or pos-
sible reporting to authorities on behalf of the
child.14 Gathering and reviewing a complete
medical and social history is essential in order
to ensure patient safety, confirm against any
contraindications to care, and avoid potential
complications during treatment.
A detailed history can also provide the clini-
Figure 1. Initial presentation of a 12-year-old patient cian with a clearer sense of potential behavioral
presenting as a walk-in emergency approximately 4 h challenges due to a health condition, how well
post-trauma. (Adapted from Dr. Amr Moursi.) a child may tolerate procedures, and what
 The pediatric dental trauma patient 207

modifications may be beneficial. The medical appropriate care is important. Such guidelines
history can be helpful in providing anticipatory must be credible, readily understandable, and
guidance for future incidents such as informing easily accessible. While this has been a challenge
on appropriate guarding and fall prevention with in the past, several dental trauma resources today
patients with epilepsy or seizure disorders. With are available to the clinician including online
regard to social history, it must be remembered resources and mobile applications available by
that the clinician is not only addressing an issue phone or tablet.10,15,16
with a tooth but also a child who resides within a
system of support (or lack thereof). Child pop- Extra-oral examination reveals the patient to
ulations include unique sub-groups such as foster have a contusion to the upper lip but no other
care, the juvenile justice system, and emanci- significant findings. Intra-oral exam reveals
pated minors, each requiring special attention in lacerated attached gingiva adjacent to the
issues of consent in cases of trauma or other maxillary right permanent central incisor #8.
instances where irreversible care is to be pro- Tooth #8 has also been intruded approxi-
vided. Understanding the level of parental/ mately 8 mm and uncomplicated Ellis Class II
caregiver support as well as any family life change crown fractures was noted on teeth #8 and #9.
or transition can also suggest the expected level Class I mobility is noted on teeth #7, 8, and 10.
of compliance for any needed home care No mobility of tooth #8 is noted. Teeth #7, 8, 9,
instructions and ability to provide continuity of and 10 are slightly positive to percussion and
care. palpation with tooth #8 producing a high
metallic sound. A failed lingual wire that was
The orthodontist confirms that the patient was previously bonded to the lingual of the
taken immediately to the emergency room maxillary anterior teeth from past limited
and evaluated for a closed head injury after orthodontic treatment is also noted. Radio-
the incident by his mother because he graphs confirm mature root development and
reported some disorientation and dizziness. closed apices. No facture to either the root or
Injury presentation is consistent with report- alveolus was noted.
ing. Examination was within normal limits
with no loss of consciousness and normal Dental trauma has been classified into the
review of cranial nerves. The patient was following categories16:
dismissed with his mother with no treatment
recommendations other than to immediately  Infractions
follow up at a dentist for noted dental issues.  Fractures of the enamel, enamel–dentin, and
Review of medical history reveals that the enamel–dentin–pulp
patient has ADHD and currently taking  Fractures of the root, crown and root, and/
methylphenidate (Concerta) in addition to or pulp
over the counter ibuprofen for dental pain.  Alveolar fracture
Social history reveals that patient’s parents are  Concussion
divorced with the mother having full custody.  Subluxation
A discussion with the pediatric dentist reveals  Extrusion
that shorter morning appointments have  Luxation
worked best in the past and that patient can  Intrusion
tolerate procedures well and is motivated due  Avulsion
to his desire to correct the appearance of
his teeth.
Intrusion injuries are a displacement of the
A complete and systematic clinical oral eval- tooth into the alveolar bone and associated with
uation should be performed, which includes comminution or fracture of the alveolar socket.
extra-oral and intra-oral soft tissues, skeletal hard The associated injury to the periodontium and the
tissues, and dentition. For the clinician in a pulp has been found to be associated with root
practice setting where dental trauma is infre- resorption and marginal bone breakdown as well as
quent, access to guidelines that can assist the pulpal necrosis and incomplete root formation.17
clinician in decision-making and delivering While a more common finding in patients with
208 Chinn

primary dentition, intrusion injuries are Surgical repositioning is to be considered in

comparatively rare in the permanent teeth cases of extreme intrusion of 7 mm or more and
accounting for only 0.5–2% of all dental trauma in situations where a less time demanding
affecting adult dentition.17 With little published approach is preferred. One advantage of surgical
literature, recommendations for the management repositioning is the removal of the bacteria
of intrusion injuries are considered very empirical contaminated crown from its position in the
and there remains some conflicting evidence on socket and the immediate release of peri-
selecting one of the three currently accepted radicular compression. Surgical repositioning,
treatment approaches17: regular observation to however, involves an additional traumatic event
monitor passive re-eruption and active reposition- that may increase healing complications com-
ing using either orthodontics or surgery (Fig. 2). parative to passive eruption or gradual reposi-
The amount of root development and the tioning with orthodontics.17,18 In cases of
severity of the intrusion have been associated extreme intrusion, clinicians should inform
with pulpal necrosis, root resorption, and poor families of high probability of issues with future
tooth survival.17–19 In cases involving teeth with gingival contour and esthetics as well as an
immature root development and o7 mm of increased likelihood of root resorption, failure
intrusion or teeth with mature root development and future need for extraction.19
and o3 mm of intrusion, observation of passive In cases of intrusion injury to immature per-
eruption has been suggested as the desired manent dentition pulpal revascularization may
treatment approach as it avoids further dis- occur, but due to the high incidence of pulpal
turbance to the periodontal tissues.18 necrosis for fully developed permanent teeth,
In cases involving permanent teeth with complete pulpectomy using calcium hydroxide
mature apices and an intrusion injury 43 mm, as an interim dressing to be completed within 3
active surgical or orthodontic repositioning weeks of the initial injury in order to minimize
should be considered18 as it is thought to relieve the possibility of inflammatory resorption.18
compression zones in the periodontal and pulpal
area and protect against ankylosis by creating Tooth #8 was diagnosed with an intrusion
distance between the root surface and the luxation of approximately 8 mm with no noted
contused bone socket.17,18 The use of light mobility. Tooth #9 was diagnosed with a
orthodontic forces is recommended in cases of subluxation. Teeth #8 and #9 were also found
intrusion up to 6 mm. Orthodontic repositioning to have uncomplicated mesioincisal fractures
has been found to be more protective against limited to the dentin. Due to the severity of the
root resorption than surgical repositioning and intrusion, the orthodontist, in consultation
to enable the repair of marginal bone in the with the pediatric dentist, agreed that passive
socket along with the slow repositioning of the re-eruption was unlikely and that surgical
tooth.16 Orthodontic repositioning can also be a repositioning was preferable to orthodontic
successful treatment alternative when no passive movement due to the extent of the injury. It
re-eruption has been noted or for patients who was decided that the pediatric dentist would
have experienced a significant delay in receiving take the lead in coordinating the trauma
treatment.18 management and follow up. The patient was

Figure 2. Intrusion Treatment Guidelines for Permanent Teeth. International Association of Dental Traumatol-
ogy. Available at: 〈http://www.iadt-dentaltrauma.org/〉.
 The pediatric dental trauma patient 209

able to schedule with the pediatric dentist that pediatric dentist and orthodontist should remain
same afternoon as an emergency walk-in. The in regular contact and be notified of any
patient tolerated the procedure well with abnormal findings on routine recall examination
tooth #8 receiving complete surgical reposi- or intended changes in treatment plans.
tioning utilizing local anesthesia and inhaled
Due to the extent of the injury to tooth #8, the
nitrous oxide/oxygen. A semi-rigid splint was
orthodontist and pediatric dentist were in
then placed on teeth #6–11 using 40 pound
agreement to delay previously planned ortho-
monofilament fishing line and interim glass
dontic treatment for 1 year during which the
ionomer restorations were placed on teeth
root canal therapy was completed on tooth #8.
#8 and #9. Patient was placed on soft food diet
While no complications were found at sub-
for 1 week and provided with a chlorhexidine
sequent recall, the family was informed of
rinse. The patient returned 2 weeks later for
future esthetic issues and a guarded long-term
radiographic and clinical follow up, removal
prognosis for tooth #8 with heightened risk for
of the splint, and pulpectomy of tooth #8 and
future root resorption and ankylosis.
composite resins on teeth #8 and #9. The
patient returned again at 4 weeks post-trauma As there are specific guidelines for the man-
for follow up and additional radiographs. No agement of a fully developed permanent incisor
clinical or radiographic pathology were noted. suffering an extreme intrusion injury, the clinical
decision to perform surgical repositioning in this
Current evidence supports short-term, non- particular case example is rather clear as was the
rigid splints for stabilizing luxated, avulsed and rationale to have the pediatric dentist take the
root-fractured teeth, however, the specific type of lead in coordinating care. In cases of less severe
splint or the duration of splinting have not sig- intrusion injuries, passive re-eruption or ortho-
nificantly related to healing outcomes.17 For dontic repositioning may present as more viable
intrusion injuries, it has been recommended options. In all instances, the interdisciplinary
that splint removal occur at the 2 week follow-up team must be able to communicate to achieve a
appointment and that clinical and radiographic mutually agreed upon a course of action that
re-examination occur at 2, 4, and 6 weeks, maximizes each individual member’s skillsets and
6 months, and then yearly for 5 years.16 the best opportunities for success. In cases when
Unfavorable outcomes include clinical orthodontics are favored, the orthodontist may
evidence of ankylosis, radiographic signs of be the most skilled to apply directional forces to
apical periodontitis, and external inflammatory resolve displaced teeth as well as the best indi-
root or replacement resorption. vidual to take the lead in coordinating care.5 The
As recommended by the American Academy team may decide to have the patient complete
of Pediatric Dentistry, any tooth that has suffered follow-up appointments at one specialist’s dental
trauma must be evaluated carefully prior to practice location rather than another due to
beginning or continuing any tooth movement.10 practicality. The main challenge of inter-
This includes minor trauma involving crown and disciplinary care between dental specialties is that
root fractures without pulpal involvement as well members will often possess areas of overlapping
as minor trauma to the tooth or periodontium competence. Further, dentists may enjoy a high
such as a subluxation or concussion. In these level of autonomy in their traditional private
cases, a 3-month waiting period is recommended. practice settings that may make shared decision-
In cases of moderate and severe trauma a min- making challenging. In order to be successful
imum of 6 months is recommended. For cases interdisciplinary care requires all involved parties
that involve root fracture, any tooth movement to have clear communication of roles and
should be delayed for at least 1 year. Teeth that expectations and to be able to identify and
have completed endodontic treatment may resolve potential conflicts due to differences in
begin or continue orthodontic movement as treatment goals or values.20 Role assignments
soon as healing is evident but with careful may need to be flexible in order to avoid
monitoring for the possible complication of root underutilizing others’ potential contribution
resorption during any orthodontic treatment. and expertise. When properly executed,
Following any significant oral trauma, the interdisciplinary care between dental specialists
210 Chinn

holds great potential to improve patient 10. Clinical guideline on management of acute dental
satisfaction and health outcomes. trauma. American Academy of Pediatric Dentistry. Pediatr
Dent. 2004;26(suppl 7):S120–S127.
11. Becker DB, Needleman HL, Kotelchuck M. Child abuse
References and dentistry: orofacial trauma and its recognition by
dentists. J Am Dent Assoc. 1978;97(1):24–28.
1. Vyt A. Interprofessional and transdisciplinary teamwork 12. da Fonseca MA, Feigal RJ, Ten Bensel RW. Dental aspects
in health care. Diabetes Metab Res Rev. 2008;24(S1): of 1248 cases of child maltreatment on file at a major
S106–S109. county hospital. Pediatr Dent. 1992;14(3):152–157.
2. Soares F, Britto LR, Vertucci FJ, et al. Interdisciplinary 13. Jessee SA. Child abuse and neglect curricula in North
approach to endodontic therapy for uncooperative
American dental schools. J Dent Educ. 1995;59(8):
children in a dental school environment. J Dent Educ.
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2006;70(12):1362–1365.
14. American Academy of Pediatric Dentistry. Guideline on
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oral and dental aspects of child abuse and neglect. Pediatr
management of anterior dental esthetics. J Am Dent Assoc.
Dent. 2005;27:172–174.
2006;137(2):160–169.
15. Andersson L. Epidemiology of traumatic dental injuries.
4. Hobson RS, Carter NE, Gillgrass TJ, et al. The inter-
J Endod. 2013;39(3):S2–S5.
disciplinary management of hypodontia: the relationship
16. The Dental Trauma Guide. International Association of
between an interdisciplinary team and the general dental
Dental Traumatology. Available at: http://www.dental
practitioner. Br Dent J. 2003;194(9):479–482.
traumaguide.org.
5. Chaushu S, Shapira J, Heling I, et al. Emergency
orthodontic treatment after the traumatic intrusive 17. Andreasen JO, Bakland LK, Andreasen FM. Traumatic
luxation of maxillary incisors. Am J Orthod Dentofacial intrusion of permanent teeth. Part 3. A clinical study of
Orthop. 2004;126(2):162–172. the effect of treatment variables such as treatment delay,
6. Carvalho V, Jacomo DR, Campos V. Frequency of method of repositioning, type of splint, length of splinting
intrusive luxation in deciduous teeth and its effects. Dent and antibiotics on 140 teeth. Dent Traumatol. 2006;22
Traumatol. 2010;26(4):304–307. (2):99–111.
7. Flores MT, Andersson L, Andreasen JO, et al. Guidelines 18. DiAngelis AJ, Andreasen JO, Ebeleseder KA, et al.
for the management of traumatic dental injuries. II. International Association of Dental Traumatology guide-
Avulsion of permanent teeth. Dent Traumatol. 2007;23 lines for the management of traumatic dental injuries: 1.
(3):130–136. Fractures and luxations of permanent teeth. Dent Trau-
8. Bauss O, Röhling J, Schwestka‐Polly R. Prevalence of matol. 2012;28(1):2–12.
traumatic injuries to the permanent incisors in candidates 19. Humphrey JM, Kenny DJ, Barrett EJ. Clinical outcomes
for orthodontic treatment. Dent Traumatol. 2004;20(2): for permanent incisor luxations in a pediatric population.
61–66. I. Intrusions. Dent Traumatol. 2003;19(5):266–273.
9. American Academy of Pediatric Dentistry Council on 20. Hall P, Weaver L. Interdisciplinary education and team-
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2005;27(suppl 7):18. (9):867–875.
Challenges managing individuals with
hereditary defects of the teeth
John Timothy Wright

Developmental defects of the dentition are diverse in their etiologies and

clinical presentations. There can be alterations in the number, position,
eruption, structure, and composition of the teeth creating unique treatment
challenges. Optimal management of developmental dental defects is
predicated on establishing a diagnosis and often requires a team approach
due to the diversity of the clinical manifestations. It is increasingly likely that
the molecular etiologies of developmental defects of the dentition are known
and having this information is helpful in predicting prognosis, identifying
appropriate and emerging therapies, and ensuring patients receive appro-
priate information regarding their condition. Many developmental defects of
the dentition are associated with systemic manifestations further adding to
the importance of establishing a correct diagnosis.
Orthodontic management of individuals with developmental defects of the
dentition will be highly varied and will be predicated on the diagnosis and
clinical manifestations. Individuals with missing teeth may require space
closure while people who have supernumerary teeth associated with
cleidocranial dysplasia may require alignment as well as forced eruption
of the succedaneous teeth. Developmental defects of the dentition are often
associated with jaw abnormalities such as clefts that occur with many
syndromes, skeletal open bite as occurs in cases of amelogenesis imperfecta
and mid-face deficiency as seen in conditions such as ectodermal dysplasia.
Collectively, developmental defects of teeth are relatively common in the
population and will challenge the diagnostic and clinical skills of the
practitioner who strives to achieve optimal function and facial and dental
esthetics for their patients. (Semin Orthod 2016; 22:211–222.) & 2016 Elsevier
Inc. All rights reserved.

Introduction Thus, it is not surprising that there are hundreds

D
of known molecular causes of abnormal tooth
evelopmental defects of teeth are clinical
formation that can affect virtually any aspect of
heterogeneous in their phenotypes and as a
odontogenesis. The spectrum and diversity of
result they present diverse challenges in their
these aberrations of dental development are
clinical management. Tooth formation is highly
tremendous and include variations in tooth
regulated at the molecular level requiring
number, structure, composition, eruption, and
thousands of genes to be expressed in a tightly
position in the dental arch. It is well known that
orchestrated fashion regarding time and space.1
many of the critical processes involved in
odontogenesis also are sensitive to environmental
Department of Pediatric Dentistry, School of Dentistry, The stressors that further add to the diversity of
University of North Carolina, Chapel Hill, NC. developmental defects of teeth.2 Consequently,
Address correspondence to John Timothy Wright, DDS, MS, oral health care providers are challenged to
Department of Pediatric Dentistry, School of Dentistry, The University delineate hereditary and environmental etiologies
of North Carolina, Brauer Hall #7450, Chapel Hill, NC 27599.
E-mail: [email protected]
of developmental dental defects when working to
establish a diagnosis.
& 2016 Elsevier Inc. All rights reserved.
1073-8746/16/1801-$30.00/0 Diagnosing the multitudes of different devel-
http://dx.doi.org/10.1053/j.sodo.2016.05.008 opmental dental defects can be a daunting task

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 211–222 211

212 Wright

given that many of these conditions are quite rare management of patients with a variety of
and the diversity of clinical phenotypes is tre- developmental defects of teeth. The purpose of
mendous. It is becoming increasingly important this article is to review some of the more
to identify developmental defects of teeth and commonly seen conditions and use these to
then correctly diagnose them as there are ther- discuss diagnostic and management approaches
apeutic approaches becoming available that can with an emphasis on the orthodontic interface in
only be applied if a diagnosis is made (e.g., health care.
protein replacement therapy to treat hypo-
phosphatasia OMIM ##146300, #241510, and
Abnormalities of tooth number
#241500). Oral health care providers should
become accustomed to obtaining a detailed Abnormalities of tooth number are common
family history to assess whether the condition of developmental defects in humans and can occur
interest is present in multiple generations and to as an isolated hereditary condition or can be a
help determine the possible mode of inheritance manifestation of a syndrome. Missing teeth is
(e.g., sex linked, autosomal, dominant, and more common than having too many teeth and
recessive). Clinicians should be familiar with management will depend on the number and
databases and other resources that can assist location of missing teeth and how this may be
them in their clinical diagnostics and provide complicated by other factors (e.g., clefts and
knowledge as to whether molecular-based diag- malocclusion). Abnormalities of tooth number
nostic tests are available. One such database is the are frequently referred to as hypodontia or
On Line Mendelian Inheritance in Man web site missing teeth and hyperdontia or excess of teeth.
(OMIM—http://www.ncbi.nlm.nih.gov/omim), Anodontia denotes a complete lack of teeth and
which will be used to identify conditions pre- oligodontia is defined as missing more than six
sented throughout this article. teeth excluding third molars. The more teeth
Developmental defects of the dentition are that are missing the more likely the anomaly is to
some of the most common conditions that afflict be associated with a syndrome.
humans. Having abnormal areas of enamel for-
mation ranges in prevalence from 20% to 80%
Non-syndromic missing teeth
depending on how the enamel defect is
defined.3,4 Congenitally, missing teeth, excluding Non-syndromic congenitally missing teeth are
third molars, occurs in about 6% of the pop- common in the general population and affect
ulation.5 In addition to these relatively common the permanent dentition ( 6% of people are
conditions, there are many rare developmental missing teeth excluding third molars) more
defects of teeth afflicting the population. Taken commonly than the primary dentition ( 1% of
together, it becomes highly probable that people are missing primary teeth).5,6 Family
clinicians will be faced with the diagnosis and history will often reveal that the missing tooth

Table 1. Hereditary traits associated with missing teeth.

Condition Inheritance OMIM number Gene

Hypodontia
Hypodontia—premolar and third molar Autosomal dominant 106600 MSX1
Oligodontia—incisor and molar Autosomal dominant 604625 PAX9
Hypodontia—colorectal cancer Autosomal dominant 608615 AXIN2
Hypodontia—select Autosomal dominant 150400 WNT10A
Syndrome/hypodontia
Odontoonychodermal dysplasia Autosomal recessive 257980 WNT10A
Hypohidrotic ectodermal dysplasia X-linked recessive 305100 EDA
Hypohidrotic ectodermal dysplasia Autosomal dominant–recessive 129490–224900 DL
Incontenentia pigmenti X-linked dominant 308300 NEMO
Witkop/tooth and nail syndrome Autosomal dominant 189500 MSX1
Reiger syndrome type I Autosomal dominant 180500 RIEG1
Ellis van creveld syndrome Autosomal recessive 225500 EVG
Ectodermal dysplasia, cleft, and syndactyly Autosomal recessive 225000 PVRL1
 Hereditary defects of the teeth 213

trait is present in multiple generations of family during the mixed and early permanent
members and often demonstrates an autosomal dentition can be especially challenging and
dominant mode of inheritance. There are mul- can be managed in a variety of ways.
tiple genes that have been identified as being Frequently, these cases involve orthodontic,
causative of congenitally missing teeth including restorative, and prosthetic approaches to
MSX1, PAX9, WNT10A, AXIN2, and EDA resolve optimally.11 If implants are selected as
(Table 1). All of these genes, with the exception the ultimate treatment of choice for a patient,
of PAX9 have been associated be associated with there will be a need of years of transitional
syndromes that manifest missing teeth. The AXIN2 management before the implants can be placed.
gene is involved in the beta-catenin molecular
pathway and mutations in this gene are associated
Syndromes with missing teeth
with increased risk for developing intestinal cancer.7
Therefore, it is important to ask appropriate health There are many different syndromes and
history questions related to potential features that hereditary conditions that have missing teeth as a
could suggest the presence of a hereditary component of their phenotype. Management of
condition beyond just missing teeth (Table 1). If these conditions depends on the extent of
the orthodontist is being asked to consult on, or missing teeth, but oftentimes is determined by
undertake treatment of a patient with missing the extra-oral features associated with the syn-
teeth, the first order of business should be to drome or developmental defect. Cleft lip with/
determine the diagnosis and whether there are without cleft palate is frequently associated with
potential health issues beyond the missing teeth missing or extra teeth both at the cleft site and in
that should be evaluated and addressed. other areas of the mouth.12 Individuals with cleft
Management of non-syndromic missing teeth lip with/without cleft palate typically are best
often involves one or several teeth with the managed with a team approach that involves a
permanent maxillary lateral incisors and second variety of health care providers and oral health
premolars being the most common. It is not care specialists. Cleft lip with/without cleft palate
uncommon to have a peg lateral incisor be can be an isolated trait or it can be associated
associated with a contralateral missing perma- with a variety of syndromes.
nent lateral incisor.8,9 Missing lateral incisors can Several relatively common syndromes, such as
be associated with palatally displaced permanent Down syndrome (OMIM #190685), can have
canines requiring surgical and orthodontic congenitally missing teeth (Table 1).13 The app-
management.10 Initial diagnosis may occur roach to managing these conditions will depend
through routine radiographic examination of on the number and location of missing teeth in
the area in the primary or early mixed dentition addition to the character and severity of associated
or may not occur until there is asymmetric or features and manifestations. Severe neurological
failed eruption of a tooth. Due to the timing of or cognitive involvement can be the defining
tooth development, missing lateral incisors often determinant as to whether or not interventions
are diagnosed earlier than are missing second are provided for missing teeth. The ectodermal
premolars. It is typically a good idea for the dysplasias are group of conditions where missing
primary care dentist to consult with an teeth is often a primary feature. There are over 170
orthodontist at the time of diagnosis to begin genetically diverse conditions classified as
considering the different future treatment ectodermal dysplasias (ED) that are charac-
options. Initially, this may involve a phase of terized by abnormal development of tissues
monitoring growth of the dentition, alveolus, and derived from the ectoderm such as hair, teeth,
jaws to help establish the options and approaches sweat glands, salivary glands, mammary glands,
to be considered in developing a final treatment skin, fingernails, etc.14 Hypodontia associated with
approach. The degree of dental crowding, type ectodermal dysplasias often presents unique
of occlusion, alveolar development in area of treatment challenges due to the number and
missing tooth, possible need for restorative location of missing teeth and underlying
treatment to reshape teeth, patient desires, malocclusion (Fig. 1). Missing primary teeth is
and finances are all issues to be considered. commonly seen in hypohidrotic ED making it
Addressing the patient’s esthetic concerns necessary to provide management of missing teeth
214 Wright

Figure 1. Note the anterior end-to-end occlusion and missing, and malformed teeth in this young female with
incontinentia pigmenti.

from the early primary dentition throughout life recommended to occur prior to attending school
(Fig. 2A). and can occur as early as 2 years of age (Fig. 2B).
Management of severe cases of missing teeth Treatment for multiple missing teeth in patients
in the primary dentition often involves prosthe- with syndromes will typically be best managed
ses. Timing of this therapy is largely predicated through close collaboration of the primary oral
on the patient’s ability to cooperate with the health care provider, orthodontist, restorative
treatment and care for the appliances. This is dentist, and/or prosthodontist. Individuals with

Figure 2. (A) This 3-year-old child with hypohidrotic ectodermal dysplasia is congenitally missing all her maxillary
incisors and all mandibular anterior teeth. (B) Early treatment with removable prostheses provides improved
anterior esthetics and function as was well tolerated by this child.
 Hereditary defects of the teeth 215

ectodermal dysplasias often have Class III Non-syndromic supernumerary teeth

malocclusions due to mid face deficiencies
further complicating treatment.15 Effective team The most commonly occurring supernumerary
communication and developing treatment teeth are mesiodens, or teeth that develop in the
options early on will enhance the likelihood anterior midline of the maxillary arch.16 The extra
that the parents and patient will understand the tooth or teeth are often diagnosed during routine
goals and treatment plan and help align the radiographic examination or due to asymmetric
health care providers toward a unified goal. It is tooth eruption of a central incisor whose eruption is
typically helpful to develop short-term and long- being impeded by the supernumerary tooth (Fig. 4).
term goals to address the patient’s and parent’s There may be one or two teeth present, they
concerns and to understand that these goals are frequently have a conical or abnormal morphology
fluid and will change as the child and family and may be oriented to either erupt normally or be
change. inverted. Mesiodens are thought to be an isolated
Management in the primary and early mixed developmental anomaly and are not known to be
dentitions often involves reshaping teeth with a associated with syndromes or to be hereditary with
conical morphology and prosthetic treatment for an increased familial occurrence. Management is
missing teeth. Orthodontic therapy may be extraction, the timing of which should be planned
implemented in the mixed dentition to manage to prevent the supernumerary teeth from markedly
spaces and esthetics in the dentition due to altering the eruption of one or both central incisors.
missing anterior teeth (Fig. 3). Long-term plans Orthodontic management may be necessary to assist
may well involve implants, but it is critical to plan emergence and or alignment of the incisors due to
for this treatment approach so that natural teeth the presence of mesiodens.
are optimally positioned and alveolar ridge Complete gemination or twinning can result
development has to be considered with the long- in an isolated instance of a supernumerary tooth.
term goal of implants. Placement and location of Gemination is not known to have any familial
the natural teeth will be critical to developing an predilection or specific molecular etiology.
optimal final treatment plan regardless of the Management is typically an extraction of one of
approach taken. the teeth followed by orthodontic treatment to

Figure 3. Early treatment of this patient with X-linked hypohidrotic ectodermal dysplasia involved bonding
conical shaped incisors, and canines (A) followed by orthodontically positioning the teeth in a more ideal position
to help close spaces. (B) The retainer served as a removable prosthesis to replace the missing posterior teeth.
216 Wright

Figure 4. This child has tricho-dento-osseous syndrome that is characterized by thin enamel and taurodontism
had asymmetric eruption of the maxillary permanent central incisors as a result of a mesiodens present in the path
of eruption for the right permanent maxillary central incisor.

close spaces and align the remaining teeth as intestinal cancer (adenopolyposis carcinoma)
needed. Non-syndromic development of addi- making it critical to evaluate the family history for
tional premolars is not uncommon and is man- this associated clinical feature.
aged similarly to cases of germination.17 Cleidocranial dysplasia (OMIM #119600) is
Supernumerary teeth can commonly occur in a syndrome caused by mutations in the RUNX2
non-syndromic and syndromic cleft lip with or gene that is involved in bone and tooth for-
without cleft palate further complicating man- mation. Individuals having this condition are
agement of these patients. Careful evaluation by typically short in stature, can have frontal bossing
the craniofacial team to determine which teeth and delayed suture closure, multiple super-
are best kept and which will require extraction numerary teeth, and failure of the succedaneous
and the timing of treatments is essential. teeth to erupt.18 Although the condition is
inherited as an autosomal dominant trait,
there is often no family history because the
Syndromes with supernumerary teeth affected individual’s condition is caused by a de
There are multiple syndromes associated with novo mutation in the RUNX2 gene. The
supernumerary teeth that are caused by a variety orthodontist is likely to be called upon to help
of genetic mutations involving diverse devel- and manage the case due to the supernumerary
opmental pathways. Gardner syndrome (OMIM teeth that can occur anywhere in the dental arch,
#175100) is caused by mutations in the APC gene and/or for the failure of the succedaneous teeth
that is involved in the beta-catenin pathway (as is to erupt (Fig. 5). Management can be complex
the AXIN2 gene that is associated with con- and often requires orthodontic extrusion to
genitally missing teeth). Individuals with this bring the succedaneous into the oral cavity
condition are at increased risk for developing and gain proper alignment.19 The orthodontist

Figure 5. This 10-year-old female with cleidocranial dysplasia had numerous supernumerary teeth and failure of
eruption of most of the succedaneous teeth as illustrated in this panoramic radiograph.
 Hereditary defects of the teeth 217

will need to coordinate treatment with the The roots can be markedly decreased in girth
surgeon and primary care dentist for timing and are often described as being tent peg-like in
of supernumerary tooth removal and the appearance. One of the biggest issues in man-
placement of buttons or brackets on unerup- aging patients with DI is the propensity of the
ted teeth to allow mechanically assisted eruption enamel to fracture away from the dentin. Enamel
to be completed. loss is quite variable between individuals. The
primary care dentist often will place opaque
white resin veneers on the anterior teeth to
Conditions affecting tooth structure and
improve esthetics. If there is severe enamel loss
composition
then transition resin and/or stainless steel
The dental tissues have unique structures and crowns may be used in both the primary and early
compositions that impart their unique physical permanent dentition. Orthodontic treatment
properties allowing them to work in concert as a can proceed as needed with the understanding
functional unit. The enamel is the hardest tissue that brackets bonded to enamel or veneers can
in the body and provides a wear and fracture result in fracturing. Patients and their parents
resistant outer covering for the dental crown should be informed of this possibility as part of
while also serving as an excellent insulator from the consent process, but fear of enamel loss
thermal and chemical stimuli. The dentin, while should not preclude moving forward with
ridged, provides a stress absorbing supporting appropriate orthodontic care. It is prudent to
layer for the enamel and a mechanism for teeth have the restorative dentist prepared to help
to repair themselves through deposition of new manage a DI case when debonding in the event
dentin. The cementum on the root surface serves that enamel or veneers require treatment.
to anchor the periodontal ligament to the tooth Dentin dysplasias (DD) are associated with
thereby providing the dental attachment to the abnormal dentin development with dentin dys-
bone. There are numerous developmental plasia type I have short roots and type II being the
defects that can occur in each of these tissues. same as DI except that the permanent dentition
is much less affected. Both non-syndrome DI (DI
type II—OMIM #125490) and DD type II (OMIM
Developmental defects of dentin
#125420) are caused by mutations in the den-
While there can be environmentally induced tinsialophosphoprotein (DSPP) gene. A newly
alterations in dentin development, these described condition called molar incisor root
are typically not visualized clinically. Radio- malformation (Fig. 7) primarily affects root
graphically, dentin anomalies are commonly development of the first permanent molars, but
seen secondary to trauma and may include pulp can affect other teeth including the permanent
canal obliteration due to excessive dentin dep- incisors and second primary molars.20 The primary
osition and blunted or dilacerated root for- care dentist should coordinate treatment with the
mation. There are multiple hereditary conditions orthodontist as these cases may require extraction
affecting dentin formation (Table 2) with of the first permanent molars as their long-term
dentinogenesis imperfecta (DI) being one of prognosis can be quite guarded.
the more common. This group of disorders
can occur as an isolated dental trait or can
Developmental defects of enamel
occur with osteogenesis imperfecta (OMIM
#166200, #166210, #259420, #166220, and Enamel development can be altered by many
others) or as an isolated trait that does not different environmental influences and genetic
involved bone fragility (OMIM #125490). The alterations. Amelogenesis is a highly regulated
clinical phenotype is characterized by abnormal process and can be negatively influenced by
crown coloration due to the abnormally conditions such as fever, infection, trauma,
mineralized dentin that can be blue–gray to hypoxia, antibiotics, and many other factors.
yellow–brown (Fig. 6). The teeth tend to be Children having more frequent and serious ill-
small, have a bulbous crown with a marked nesses are more likely to have enamel defects.21
cervical constriction and radiographically have The phenotype resulting from different insults
pulp canal obliteration that increases over time. will vary depending on the type of stress,
218 Wright

Table 2. Amelogenesis imperfecta phenotype and genotype.

OMIM Gene/
AI Type and Inheritance Phenotype number Loci

X-linked type IE Hypoplasia/hypomaturation 301200 AMELX

X-linked hypoplastic–hypomaturation Hypoplasia/hypomaturation 301201 Xq22-q28
Autosomal dominant type IB Localized to generalized hypoplastic 104500 ENAM
Autosomal recessive type IC Hypoplastic 204650 ENAM
Autosomal dominant type III Hypocalcified 130900 FAM83H
Autosomal dominant type IV Hypoplastic hypomaturation 104510 DLX3
Autosomal recessive type IIA1 Hypomaturation 204700 KLK4
Autosomal recessive type IIA2 Hypomaturation 612529 MMP20
Autosomal recessive TYPE IIA3 Hypomaturation 613211 WDR72
Autosomal recessive type 1G (enamel renal Hypoplasitc, pulp calcifications, and eruption 611062 FAM20A
syndrome) abnormalities
Autosomal recessive type IIA4 Hypomaturation 614253 C4ORF26
614832
Autosomal recessive type IIA5 Hypomaturation 615887 SCL24A4
Autosomal recessive type IF Hypoplastic 616270 AMBN

Hypomaturation and hypocalcified phenotypes are characterized by a deficiency in enamel mineral content or
hypomineralization.

duration, and intensity of the influence. In the fluorotic enamel varies from mild to severe
general, the resulting enamel defects can be and is partially determined by the amount of
classified as defects in the amount of enamel fluoride in the individual’s serum. Extending the
(hypoplasia) or deficiencies in the mineral etching time of fluorotic enamel to 60 or 90 s
content or hypomineralization (Fig. 8). facilitates bonding of veneers for esthetics or
Dental fluorosis is a pathological condition brackets for orthodontic treatment. Fluorotic
characterized by hypomineralization of the enamel is less acid soluble, so extending the
enamel due to excessive exposure to fluoride etching time increases development of the
during enamel mineralization. The level of micro-porosities necessary for adequate bond
hypomineralization and clinical appearance of strengths.

Figure 6. Teeth with dentinogenesis imperfecta often have a blue–gray discoloration as seen in this affected
teenager (A) and can have markedly altered tooth morphology and eruption problems as seen in this child's
panoramic radiograph (B). (For interpretation of the references to color in this figure legend, the reader is
referred to the web version of this article.)
 Hereditary defects of the teeth 219

Figure 7. The condition known as molar incisor root malformation has only recently been identified and has an
unknown etiology and can affect the first permanent molars (arrows) and less frequently the incisors as seen in this
affected child. Abscess formation occurred in the maxillary right central incisor and the mandibular left first
permanent molar.

Molar incisor hypomineralization is a con- and difficult to anesthetize. The primary care
dition characterized by one or more of the first dentist should consider extraction as a possible
permanent molars having localized or general- treatment in these cases and should consult with
ized enamel that is poorly mineralized.22 The the orthodontist as to the implications of this
hypomineralized enamel is typically opaque approach and to coordinate optimal treatment.23
yellow to brown in color. In severe cases, the Recommendation for timing of extraction is
enamel is so poorly mineralized that it breaks variable, but there is consensus that outcomes
away from the dental crown during tooth related to positioning of the second permanent
eruption. These teeth can be hypersensitive molars are best when extractions are completed

Figure 8. Amelogenesis imperfecta types with poorly mineralized enamel typically have a yellowish-brown to orange
coloration and will typically have normal crown morphology if the enamel has not broken off during function (A). In
contrast, hypoplastic AI types may have small crowns as seen in this generalized thin hypoplastic case (B). (For
interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
220 Wright

Table 3. Conditions with abnormal tooth eruption phenotype.

OMIM
Condition Phenotype number Gene

Cleidocranial dysplasia Failure of succedaneous tooth to erupt 119600 RUNX2

Primary failure of eruption Failure of posterior teeth to erupt and not 125350 PTHRP1
orthodontically movable
Osteopetrosis Failure of eruption due to abnormal osteoclast 259700 TCIRG1
function
Cherubism Multilocular cystic changes in the jaws that interfere 11840 SH3BP2
with tooth eruption and facial growth
Mucopolysacharridosis Defective enzyme results in accumulation of material 309900 IDS
around dental follicles
Oculodentodigital dysplasia Small teeth with abnormal eruption 164200 GJA1
257850
Autosomal recessive AI and gingival fibromatosis Hypoplasitc enamel, pulp calcifications, and 614253 FAM20A
syndrome (enamel renal syndrome) eruption abnormalities

before eruption of the second permanent difficult to manage and require years of man-
molars. agement from the eruption of the primary den-
There are 100 hereditary conditions that are tition throughout adulthood.27 The orthodontist
associated with abnormal enamel formation.24 serves as a critical member of the treatment
These conditions may be isolated traits affecting team to help manage the common skeletal
primarily the enamel such as the amelogenesis malocclusions as well as impacted canines
imperfectas or they may be associated with that also are common in this population.
a syndrome such as Goltz syndrome (OMIM Early diagnostics and communication between
#305600), also known as focal dermal the oral health team members will facilitate
hypoplasia. Many of the genetic mutations efficient care timing for restorative, ortho-
causing these conditions are now known and dontic, and surgical interventions. Failure of
they are involved in diverse cellular functions. tooth eruption is common in some forms of AI
There are now more than 10 genes (Table 3) such as cases associated with FAM20A mutations
known to be associated with amelogenesis and can be very difficult to manage.28
imperfecta making it possible to provide a
definitive molecular diagnosis in the majority of
Conditions affecting tooth eruption
cases. Management of the individuals with
amelogenesis imperfecta (AI) or any enamel The molecular mechanisms controlling tooth
defect will depend on the clinical phenotype eruption are not as well understood as some
and associated features. For example, if the other aspects of tooth formation, but our
enamel is hypomineralized and discolored the knowledge in this area is advancing. Teeth typi-
teeth are frequently hypersensitive because the cally continue to have eruptive potential until
enamel lacks its normal insulating properties they meet opposition or a point of equilibrium in
(Fig. 8). These teeth are often treated by the eruptive and obstructive forces. Ankylosis arrests
primary care dentist with full coverage tooth eruption and is a relatively prevalent
restorations such as stainless steel crowns on the condition in the primary dentition (prevalence
posterior teeth and resin crowns on the anterior about 7–8% of children have one or more
teeth. Bonding restorations and orthodontic affected teeth).29 Ankylosis results from a loss of
brackets can be a challenge depending on the normal periodontal ligament resulting in the
enamel defect and presence of restorations. It alveolar bone attaching directly to the tooth root.
may be necessary to band many of the teeth in Ankylosis occurs more commonly in the siblings
order to complete comprehensive orthodontic of children who have ankyloses, is more common
treatment that is commonly needed for a variety of in the mandibular dentition, and more
reasons. Between 25% and 45% of individuals commonly affects teeth that do not have a
with AI also have open bite and or Class III permanent successor (often a primary molar
malocclusions.25,26 These cases can be very with no secondary dentition premolar).30
 Hereditary defects of the teeth 221

Ankylosed primary teeth tend to exfoliate nor- eruptive pathway is clear and free of obstructions.
mally leading to the general recommendation of Other conditions with cyst development
their not being extracted unless they are in severe and failure of tooth eruption, such as the
infraocclusion.31,32 mucopolysaccharidoses (OMIM #309900) with
Primary failure of eruption (PFE—OMIM severe growth inhibition and medical issues,
#125350), a non-syndromic condition affecting might be best managed by no treatment
tooth eruption, is caused in many cases by depending on the individual’s medical status.35
mutations in the PTHP1R gene that is a regulator Physical blockage of tooth eruption by excessive
of bone homeostasis. PFE is characterized by soft tissue or supernumerary teeth will require
having at least one affected first permanent the orthodontist to work with the oral surgeon,
molar; the teeth distal to the affected first per- periodontist, or primary care dentist to remove
manent molar also show failed eruption and the the obstruction. As mentioned previously in this
teeth tend to have a supracrestal position article the succedaneous teeth will frequently
meaning they have a completely cleared eruption require mechanical traction to achieve eruption
pathway, with no alveolar bone occlusal to the in individuals with Cleidocranial dysplasia
affected tooth.33 (OMIM #119600).36
Diagnosing the etiology of and type of con-
dition causing abnormal tooth eruption is
Conclusions
essential when considering appropriate treat-
ment options. Searching OMIM for tooth and Our understanding of the etiology of the
eruption reveals 119 conditions having tooth numerous and diverse developmental defects of
eruption issues ranging from natal teeth (OMIM teeth and their underlying pathological mecha-
#187050) to amelogenesis imperfecta (OMIM #s nisms has increased dramatically over the past two
130900, 204690, and 613211). Individuals with decades. Much of this knowledge has accrued as a
different forms of osteogenesis imperfecta can result of postgenomic advances including having
develop dentigerous cysts around forming teeth powerful molecular biological methods, animal
that can obstruct normal tooth eruption. Gin- models, and other resources and tools. Our ability
gival overgrowth, such as occurs in a variety of to diagnose many of these conditions and
conditions (e.g., gingival fibromatosis with delineate environmental and hereditary etiol-
hypertrichosis OMIM #135400) have disturbed ogies has advanced, as our approaches for
tooth eruption. Cleidocranial dysplasia (OMIM molecular diagnostics has improved and become
#119600) is thought to have abnormal cementum more robust. The importance of making a diag-
that, coupled with the role of the RUNX2 gene in nosis at the molecular level is increasingly
bone homeostasis, leads to abnormal tooth important as new therapeutics are now available
eruption. In osteopetrosis (OMIM ##259700), a to better manage conditions that previously had
syndromic condition characterized by dense no effective interventions. A recent addition to
bone due to defective bone metabolism, teeth fail such therapies is the fusion protein for tissue non-
to erupt due to the absence of an eruptive specific alkaline phosphatase that is now com-
pathway. mercially available in the United States to treat
As one might predict based on these very hypophosphatasia that is often first diagnosed
different mechanisms leading to tooth eruption due to premature exfoliation of primary teeth.37
abnormalities, the management of these con- In the future, clinicians will increasingly be
ditions will differ depending on the etiology involved in helping apply diagnostics and
making appropriate diagnosis critical. Con- therapeutics more strategically as precision
ditions such as Gorlin or basal cell nevus syn- medicine becomes a reality.
drome (OMIM #109400) that is characterized by
development of keratocystic ondontogenic
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The case for environmental etiology of
malocclusion in modern civilizations—
Airway morphology and facial growth
Anthony T. Macari, and Ramzi V. Haddad

The impact of nasal respiration impairment on craniofacial growth and

development remains a topic of interest for orthodontists in their daily
encounter with mouth breathing patients. The aims of this article are to
critically review the: (1) etiology of nasal obstruction, namely septal
deviation, turbinate dysfunction, lymphoid tissue hypertrophy, and soft
tissue alteration; (2) diagnostic methods to evaluate nasal obstruction; (3)
role of mouth breathing in the development of characteristic malocclusions
and associated patterns of facial growth (“adenoid facies”), with a focus on
recent research data; (4) indications of medical and surgical treatments with
the ongoing debate about removal of lymphoid tissues to avoid facial
dysmorphology; (5) diagnosis and treatment of obstructive sleep apnea in
growing subjects. Orthodontists play an important role in the early diagnosis
of airway impairment. Early clearance of the airways, whether medically or
surgically achieved, is gaining more ground between ENT specialists as they
became aware of the potential effect on craniofacial development. (Semin
Orthod 2016; 22:223–233.) & 2016 Elsevier Inc. All rights reserved.

Introduction In his seminal classification of malocclusion,

T
Edward Angle singled out the relationship
he study of the relationship between mal-
between mouth breathing and malocclusion.
occlusion and environmental factors has
He described the Class II division 1 malocclusion
been uninterruptedly updated in the ortho-
as “always accompanied and, at least in its
dontic literature during the last century. The
early stages, aggravated, if not indeed caused by
most evaluated aspect has been the potential
mouth breathing due to some form of nasal
effect of altered mode of breathing on dento-
obstruction.”1 Regarding the Class III maloc-
facial components. Orthodontists have focused
clusion, he stated that “deformities under this
on this association mainly because of daily
class begin at about the age of the eruption of
encounters with patients exhibiting complete or
the first permanent molars, or even much earlier,
partial abnormal respiration. They discovered
and are always associated at this age with
that aberrations in the nose, the neighboring
enlarged tonsils and the habit of protruding
anatomical entity to the mouth, created a variety
the mandible, the latter probably affording
of malocclusions and facial dysmorphologies
relief in breathing.”1 However, the excessive
because of the diversity of the adaptation
number of studies that assessed the direct
processes.
connection between nasal obstruction and
facial growth,2–14 failed to seal the debate on
Division of Orthodontics and Dentofacial Orthopedics, Depart-
the orthodontic implications of nasal respiration
ment of Otolaryngology—Head & Neck Surgery, American impairment.15–17
University of Beirut, Beirut, Lebanon. The aim of this article is to explore the various
Address correspondence to Anthony T. Macari, DDS, MS, aspects of the association between mouth
Division of Orthodontics and Dentofacial Orthopedics, PO Box 11-
breathing and dentofacial growth namely, the
0236 Riad El Solh 1107 2020, American University of Beirut, Beirut,
Lebanon. E-mail: [email protected]
etiology of mouth breathing, the relationship
& 2016 Elsevier Inc. All rights reserved.
between malocclusion and mouth breathing, the
1073-8746/16/1801-$30.00/0 medical treatment and the optimal timing of
http://dx.doi.org/10.1053/j.sodo.2016.05.009 lymphoid tissue removal.

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 223–233 223

224 Macari and Haddad

Etiology of mouth breathing by otolaryngologists to delay the removal of

the pharyngeal lymphoid tissues until after
The airway tube extends from the nostrils to the
puberty.
lungs. In between, the nose, nasopharynx, and
Parallel to the growth of lymphoid tissues, the
oropharynx are lined up with many important
general growth of the oropharynx complex and
organs and tissues that play an important role in
face maintain a normal functioning of the
filtering and humidifying the air before it reaches
nasopharynx.22 Nasopharyngeal obstruction and
the lungs, and in the immunity of our body.
subsequent change to mouth breathing may be
Conversion of nasal to oral breathing can be
induced if discrepancy in the growth of the
induced by different factors, whether partial or
lymphoid tissues and the nasopharynx occurs.22
complete airway obstruction may occur at any of
On the other hand, the tonsils known as the
those levels and can develop at any age.
“gate keepers” of the oropharynx, may also lead
Mouth breathing is classified into two groups:
to airway obstruction if hypertrophied (Fig. 1). In
habitual, with adequate nasal potency, and
the rare condition when tonsils touch or meet in
enforced, through nasal resistance or obstruc-
the midline, they are called “kissing tonsils.”
tion.18 The latter may occur in the anterior
Otolaryngologists classify the tonsillar hyper-
(maxillary) airway, in the posterior (pharyngeal)
trophy in a similar grading system to that of
airway, or both, since the two sections are not
adenoid hypertrophy. However, clinical exam-
completely independent. The maxillary section
ination for diagnosis is crucial.
has greater resistance in the nasal airway and
Although the adenotonsillar hypertrophy
therefore is more prone to obstruction.
constitute the main cause of airway obstruction in
growing individuals, other agents may contribute
Causes of nasal airway obstruction in increasing nasal resistance in the upper nasal
airways such as hard tissues: deviated septum,
Lymphoid tissues hypertrophy
turbinate irregularities and congenital, traumatic
Adenoids hypertrophy constitutes the primary or therapeutic asymmetries of the nasal cavity;
cause of upper airway obstruction, particularly in and soft tissues: catarrhal and allergic rhinitis,
children, inducing mouth breathing. The ade- and nasal polyps.
noids are located at the junction between the
nose and the oral cavity, at the roof of the
nasopharynx near the Eustachian tube that
connects the ear to the oropharynx. In few
instances, the hypertrophied adenoids can block
the Eustachian tube and limit the drainage from
the middle ear into the nasopharynx, which can
cause a middle ear effusion.
Interestingly, and unlike other tissue in the
body, the adenoids increase in size during
childhood to twice of their final adult size with a
particular pattern of growth,19 an observation
that Pruzansky20 denied. He suggested, in a
cephalometric study, that the lymphoid tissues
do not follow a specific growth curve, but
respond individually to different environmental
factors. Later, in a longitudinal study between
ages 3 and 16 years, Linder-Aronson and
Leighton21 studied adenoids growth behavior
on lateral cephalographs, and reported an
increase in adenoid size in preschool and
Figure 1. Lateral cephalometric radiograph of a
primary grade level years, followed by a decrease 6-year-old boy. The circle in yellow denotes the
during preadolescence and early adolescence. hypertrophied tonsils almost blocking totally the
These findings support a prevailing practice pharyngeal airways.
 The case for environmental etiology of malocclusion in modern civilizations 225

Septal deviation Similar to adenoids, turbinates’ hypertrophy

can be diagnosed on nasal endoscopy, but also on
The nasal septum, which is dividing the nose into
postero-anterior cephalographs. It can disclose a
two bilateral cavities, both formed by cartilagi-
possible extension of the posterior part of the
nous and osseous tissues. It remains one of the
inferior turbinates that would indicate an etiol-
most common causes of nasal airway impairment.
ogy for mouth breathing, particularly in the
A septal deviation to one side, caused by genetic
absence of septal deviation and/or large ade-
or environmental factors such as trauma, is a
noids and tonsils. When hypertrophied, inferior
major cause of airway obstruction. Trauma at
turbinates may extend posteriorly and constrict
birth is shown to induce septal deviation in new
the airways, showing a “foggy” image on lateral
born with different percentage of incidence.23–25
cephalograph above the posterior nasal spine
The deviation can be diagnosed clinically and
(PNS). This “tail” is often overlooked (Fig. 3).27
cephalometrically (Fig. 2). Upon clinical
The pathology may be associated with allergic
examination, a bulging mass is seen at the
rhinitis that is treated with either medication
opening of the nostrils unilaterally. Tracking
(nasal steroids) or surgery (reduction or
the midsagittal line on the postero-anterior
excision).28
cephalometric radiograph shows a deviation in
the radiopaque cartilage mass, usually assuming
an S shape. Soft tissues
Nasal obstruction may be cause by an overgrowth
Turbinates or alteration of the soft tissue mucosa lining the
The lateral walls of the nasal cavity are line up nasal cavity, in the presence of a local or general
with three pairs of turbinate: superior, middle, pathology. Catarrhal or allergic rhinitis is a
and inferior. The turbinates play a primary role common etiology for chronic mouth breathing.
in “filtering,” heating and humidifying the air A long period of treatment is usually necessary.
before it reaches the lungs. They undergo cycles When nasal polyps affect nasal respiration, sur-
of swelling every 3–7 h, with no change in the gical removal is mandatory to recover normal
total nasal airway resistance. The nasal cycle respiration.
occurs in nearly 80% of normal people with
alternate congestion and decongestion between
Nasal obstruction and mouth breathing:
right and left side.26 The cyclical hypertrophy
Relationship and diagnosis
should not be mistaken for a chronic condition.
Methods to diagnose adenoidal hypertrophy
include nasal endoscopy (NE) and radiological
imaging.
While nasoendoscopy remains a standard
mean to diagnose any nasal airway impairment,
cone-beam computerized tomography (CBCT)
has gained ground in the orthodontic science. It
is progressively used for diagnosis and treatment
planning on patients exhibiting complex
malocclusions.29
Studies have compared the accuracy of diag-
nostic methods, i.e., nasal endoscopy and lateral
cephalometric radiographs and have been found
to be similar, with endoscopy having the
advantage of three dimensional evaluation.30
In a recent study comparing CBCT with
nasoendoscpy the researchers found that
Figure 2. Postero-anterior cephalometric radiograph CBCT images were as accurate as NE in
of an 11-year-old girl. The nasal septum is deviated in evaluating adenoid size especially when used by
its lower half causing a shift to mouth breathing mode. trained orthodontists.31
226 Macari and Haddad

Figure 3. (A) Bilateral obstruction of the airway, in a 9-year, 4-month-old patient, by the hypertrophied inferior
turbinates (right and left arrows) shown on a postero-anterior cephalograph. (B) The patient’s lateral
cephalometric radiograph shows the posterior extension of the inferior turbinate toward the posterior wall of
the nasopharynx (arrow). This hypertrophy induced a narrowing of the airways and shift to mouth
breathing mode.

On lateral cephalographs, adenoid hyper- when the adenoids totally block air passage
trophy has been classified into three or four (Fig. 4). The subjective method in grading the
sizes or grades, ranging from small to large, as airway obstruction by adenoids corresponded
well as ratios between the size of adenoids and with the objective measurement of the airway
nasopharynx.32 The classification shown in clearance. In a study on 200 growing subjects,
Fig. 4 is based on the percentage of airway Bitar et al.32 found a high correlation bet-
obstruction, whereby the following grades ween the adenoids grading and the shortest
are assigned: 1 for less than 50% obstruction, distance between the adenoids and the soft
2 for more than 50% but less than 100%, and 3 palate (r ¼ 0.79).

Figure 4. Adenoid hypertrophy: lateral cephalographs of 3 mouth breathers showing different grades of airway
obstruction relative to adenoid size. (A) Grade 1 (less than 50% obstruction of airway) in a 8-year, 6-month-old boy
(B) Grade 2 (more than 50% obstruction but less than 100% airway obstruction) in a 6-year-old boy. (C) Grade 3
(total obstruction) in a 4-year, 9-month-old boy.
 The case for environmental etiology of malocclusion in modern civilizations 227

Mouth breathing and facial growth: lymphatic tissues on facial morphology, ortho-
Relationship and diagnosis dontists labeled faces with those reported char-
acteristics as “adenoid facies” (apparently at least
The impact of mouth breathing upon the 100 years ago), but has also been known as “long
development of malocclusion appears to be face syndrome” and “high angle” facial pattern
related largely to a low posturing of the tongue (Fig. 5).33
(and the subsequent adaptation of other facial Recently, we reported on data collected from
muscles) that may influence growth of the jaws, the cephalographs of 200 Caucasian children
and the occlusion. Mouth breathing has been (ages: 1.71–12.62 years, nearly 50% of them o5
associated with a narrow upper arch, but appa- years) that were diagnosed by a pediatric oto-
rently no high palatal vault11; posterior crossbite; laryngologist as being chronic mouth breathers,
anterior open bite, usually through excessive and referred them for cephalometric evaluation
eruption of posterior teeth; and a hyperdivergent of adenoid hypertrophy.34 Facial dysmorphology
skeletal pattern.11 was observed as early as the second year of life in
In parallel to the above descripors, children the youngest patient evaluated (1.71 years).
requiring adenoidectomy have been reported to Postero-inferior tilt of the maxilla (average
have longer facial height, steeper mandibular inclination of palatal plane to horizontal: 7.681
plane angle, and a more retrognathic mandible ⫾ 3.441; norm: 01 ⫾ 2.51,35 possibly the initial
than corresponding controls.2–7 Similarly, chil- response to functional alteration, occurred
dren with enlarged tonsils were found to have separately or together with one or all of the
more retrognathic and superior-posteriorly following modifications, compatible with a
inclined mandibles, greater anterior total and hyperdivergent vertical pattern: increased
lower facial heights, and larger mandibular plane palatal to mandibular plane angle; increased
angles.8 Moreover, retroclined mandibular lower face height, steep mandibular plane,
incisors, more anteriorly positioned maxillary mandibular antegonial notching, increased
incisors, decreased overbite, increased overjet, gonial angle, and elongated and thinner
increased incidence of lateral crossbites, shorter symphysis (Fig. 5B). The palatal tilt reached
mandibular arches, and narrower maxillary severe levels (81–91) between ages 4 and 5 years.
dental arches2–14 were related to chronic The occlusion ranged from normal with
mouth breathing. Acknowledging the impact of adequate overjet/overbite to malocclusions that

Figure 5. (A) “Long Face” syndrome characteristics in a 9-year, 3-month-old boy mouth breather: lip
incompetency, increased lower facial height, narrow width of the nose base and shadows under the eyes. (B)
Lateral cephalograph of same patient shows the hyperdivergent vertical pattern: increased palatal to mandibular
plane angle (PP/MP ¼ 361); increased lower face height (LFH/TFH ¼ 57%).
228 Macari and Haddad

contained one or more of these characteristics: depend on the underlying etiology of mouth
posterior crossbite, increased overjet, Class II breathing: the most common culprits in children,
molar relationship, open bite, and anterior allergic rhinitis and adenotonsillar hypertrophy,
crossbite. requiring two different approaches.40,42–44 The
In addition, when the study group was classi- management of allergic rhinitis lies in pharma-
fied by age into group 1: r6 years (n ¼ 124) and cological drugs utilized either orally or intra-
group 2: 46 years (n ¼ 76), airway clearance nasally. Medicaments include antihistamines,
distance (AD) was more decreased in the corticosteroids, antileukotrienes, nasal decon-
younger group and at a statistically significant gestants and intranasal saline douching.40 The
level (group 1: 3.19 ⫾ 2.32 mm; group 2: 4.78 ⫾ two drugs most effective in battling nasal
2.80 mm; p o 0.05). Furthermore, we stratified obstruction, intranasal corticosteroids and nasal
the study group into four subgroups on the basis decongestants, raise different safety and
of palatal to mandibular plane angulation to tolerability concerns when dealing with
reflect the facial divergence: group A: PP–MP r children. Stimulatory effects and cardiac-
27.51, n¼34; B: 27.51 o PP–MP r 321, n ¼ 68; C: related events generally contraindicate the use
321 o PP/MP o 36.51, n ¼ 67; D: PP–MP Z of nasal decongestants in children, not to men-
36.51, n ¼ 31. Statistically significant differences tion the risk of rebound nasal congestion. On the
(p o 0.05) occurred mainly between the most other hand, intranasal corticosteroids raise con-
hyperdivergent group (D) and the hypo- cerns for possible effects on growth velocity and
divergent (A) and normodivergent (B) groups in hypothalamic-pituitary-adrenal axis function.45
the AD distances, albeit the hyperdivergent Although generally regarded as safe in
pattern exhibited the narrowest airways.34 children when used in low doses, especially for
Authors have tackled the issue of differences compounds with low systematic availability, a
across age groups. Linder-Aronson et al.2 related small degree of risk cannot be excluded,
those potential differences to the effect of especially in light of the lack of studies
normal growth of the nasopharynx leading to evaluating the final height in children treated
increase in airway clearance. However, in our with intranasal corticosteroids.
study, both age groups included important Frequently, allergic rhinitis occurs con-
characteristics pertinent to hyperdivergence comitantly with adenotonsillar hypertrophy in
(MP–SN, PP–MP) and to long face syndrome children.46 Whether in association with rhinitis
in general, suggesting that this facial pattern on or as a separate entity, surgical intervention in
average would last once it was present. Thus, the the form of adenoidectomy, tonsillectomy or
severity and extent of these morphologic both becomes necessary if resolution of mouth
alterations depend on the timing, duration, breathing is to be expected. Currently, the
and rate of oral breathing. indications for adenoidectomy alone versus in
Despite the significant number of studies conjunction with tonsillectomy for the
relating association between mouth breathing management of airway obstruction are unclear.
and the development of malocclusion, the Despite the post-operative morbidity associated
association is not clear-cut.36–38 Recent studies with adenoidectomy, children are often able to
have confirmed the presence of mostly “vertical” return to normal activity the day after surgical
alteration of the dentofacial complex rather than intervention and the risk of post-operative hem-
a “sagittal” one.39 orrhage is less than 1%.47 However, combined
adenoidectomy/tonsillectomy increases the risk of
hemorrhage to 3% and may delay the recovery
Medical and surgical treatment
period to 14 days.47
The health-risks associated with by-passing the While the mean age of onset of allergic rhinitis
physiological protective mechanisms of the nasal is 10 years, adenotonsillary hypertrophy is often
airway in warming, humidifying and purifying diagnosed significantly before the age of 5 years,
inhaled air, in addition to the associated cra- potentially deterring normal craniofacial growth
niofacial dysmorphoses, often warrant medical at an earlier, more sensitive period and for a
and surgical interventions to resolve persistent longer number of years. Adenotonsillectomy,
mouth breathing in children.40,41 Treatment will and more commonly adenoidectomy, is
 The case for environmental etiology of malocclusion in modern civilizations 229

therefore among the most common surgeries possibly indicating a gradual adjustment or
performed in children.46,47 The post-operative compensation in growth32,56; dental compensa-
assessment of children undergoing such sur- tion is not uncommon and occlusion often shows
geries has highlighted the potential of normal- no signs of deterioration despite mouth breath-
ization of breathing towards reversing or ing34; research comparing the skeletal effects
stabilization the craniofacial dysmorphoses following adenoidectomy/adenotonsillectomy
associated with mouth breathing. Several authors does not support significant benefits when
have described a more anterior direction of performed early (o4 years or in the primary
symphyseal growth, reversal of the tendency to dentition) compared to later in childhood (44
mandibular rotation, increase in posterior facial years or mixed dentition).57,58
height and increased amount of mandibular It is noteworthy that the measures that have
growth following adenoidectomy or adeno- been shown to be affected by the timing of
tonsillectomy.2–4,48–51 Favorable changes in surgical intervention are the angular divergence
dental arches and dental positions have similarly between maxilla and mandible58 and anterior
been reported: increase in maxillary inter-canine lower facial height.57 Interestingly, when Bitar
width and normalization of upper and lower et al.32 looked specifically at children with nearly
incisor inclinations.6,44,49,51,52 Nevertheless, nor- complete adenoid obstruction, features relating
malization of growth and craniofacial patterns to hyperdivergence, increased lower facial height
has been reported to be partial, with the majority and other long-face syndrome characteristics
of children retaining features of the dolichofacial were present across all ages examined. The data
type of long face syndrome and variations in suggest that simply classifying children into
individual response.6,12,53 Similarly, limited mouth breathers and nasal breathers may
research on the potential for myofunctional impede the assessment of possible growth cor-
improvement suggests partial improvement in rections consequent to surgical intervention, and
tongue posture, facial muscle tonicity, mobility of calls for the investigation of the effects of early vs.
lips/tongue/mandible, deglutition and mastica- late treatment while controlling for the severity of
tion.46,54 When post-treatment changes were obstruction. Further longitudinal research is
followed through time, the incomplete imme- crucial for the development of prediction
diate recovery was not found to improve with equations and evidence based guidelines for
time and significant disability often remained, when early adenoidectomy and/or tonsillectomy
particularly in relation to masticatory function should replace pharmacological treatment and
and deglutition.46 Although it would be prudent close monitoring of growing children. Such
to avoid firm conclusions regarding this young guidelines would be based on the severity and
area of research, preliminary results on small persistence of nasophryngeal airway obstruction,
sample sizes may suggest the need for a the presence of early signs of malocclusion and
multidisciplinary approach involving speech individual risk for the long-face syndrome.34
therapy and myofunctional exercises for a
more optimal recovery.46,54,55
Obstructive sleep apnea in children
Mostly known as a frequent problem in adults,
Clinical implications
obstructive sleep apnea syndrome (OSAS) is also
The nature and timing of craniofacial growth common in children and adolescents, and it is
and the early morphological changes observed considered the severe aspect of the sleep dis-
with nasal airway obstruction support early sur- ordered breathing which includes as well primary
gical intervention to avoid a permanent setting of snoring and upper airway resistance syndrome.
skeletal dysmorphology that would be difficult to Originating from a different epidemiological
control orthodontically. However, the invasive- background, its diagnosis and therefore its
ness and potential morbidity of an elective sur- treatment approach can differ from adults.
gical intervention in a child necessitate a careful OSAS prevalence varies from 0.69–2.9% in chil-
cost-benefit analysis. Several factors favor the dren59–62 and is characterized by prolonged
delay in surgical intervention: the airway natu- partial upper airway obstruction and/or inter-
rally becomes less obstructed with increasing age, mittent complete obstruction that disrupts
230 Macari and Haddad

normal ventilation during sleep and normal as with their neck hyperextended or propped
sleep patterns.63 These episodes of obstructive upon multiple pillows.73
apnea or hypopnea can last for more than 10 s,
and are mostly terminated by arousals. Diagnosis
Considering the clinical history such as rate of
Etiology
growth, snoring, tendency to fall asleep during the
Predisposing factors that can lead to partial or day, sleep disturbances may lead to the diagnosis of
total airway narrowing can play a major role in OSAS in children. A clinical examination that
developing OSAS such as hypertrophied tonsils reveals the presence of enlarged tonsils and ade-
and enlarged adenoid,64 allergic rhinitis leading noids can be associated to the previously mentioned
to nasal obstruction because of nasal mucosal signs to confirm the presence of OSAS.68,71
edema and mucus secretion.61 Overnight polysomnography is recognized as
Obesity was related to the increase risk of the gold standard for diagnosis of OSAS. One of
snoring and in severe cases to OSAS65 where it the problems of polysomnography in childhood
appears to be more prevalent among overweight is that performance and interpretation of the
and obese children, as high as 60%66; it is results have not yet been standardized or eval-
suggested that the lateral pharyngeal walls uated for different age groups.
consisting of muscles, tonsillar tissues, and fat
pads, can increase in thickness due to the total Treatment
volume of fat and therefore limiting the airflow.67
Treatment of OSAS in children depends on the
Risk factors for OSAS also include medical
etiology and usually requires a multidisciplinary
conditions that involve craniofacial dysmor-
management involving the pediatrician, pedia-
phology (retrognathia), midface hypoplasia,
tric or adolescent psychiatrist, ENT specialist,
hypotonia, and syndromes that might affect the
maxillofacial surgeons, orthodontists, speech
tongue position such as Down syndrome.68
therapist, and neurosurgeons in some syndromes.
Smoking in adults was associated with sleep
breathing disorders where it leads to
– Adenotonsillectomy is considered first-line
obstruction and collapse of the pharyngeal
treatment if the child has adenoidal vegeta-
airway by inducing pharyngeal inflammation
tions and/or tonsillar hypertrophy.74
and mucosal edema, and therefore increasing
– Nocturnal masks for continuous positive air-
the risk of snoring.69 Similar results were
way nasal pressure (CPAP devices) may be
reported with passive parental smoking where
recommended. Some research indicates that
the risk factor for snoring in children was
such therapy may be helpful in weight loss.75
increased.70
– For some children, positional (nonsupine)
therapy may be indicated if their OSA is worse
Symptoms
in certain positions such as supine sleep,
Symptoms of OSAS include snoring accom- shifting their sleeping position to either prone
panied with choking or gasping during sleep or on their sides may be an important factor in
resulting in disturbed sleep and recurrent reducing the severity of OSA.68
awakenings which lead to daytime fatigue, – Treating obesity in children with OSAS and
headaches, dry or sore throat and excessive weight loss is also considered an effective
daytime sleepiness. treatment option.66
Neurobehavioral problems with impaired – Rapid maxillary expansion (RME): The pre-
concentration, daytime hyperactivity, anxiety and cise role of maxillary constriction in the
depressive symptoms, failure to thrive were also pathophysiology of OSA is unclear, but sub-
associated with OSAS.71,72 jects with maxillary constriction have
Parents may report loud and noisy breathing increased nasal resistance resulting in mouth
with an open mouth accompanied with snoring, breathing, similar to OSAS patients. The
and many children will sweat during sleep, tongue posture was found to result in retro-
especially around their head and neck. Children glossal airway narrowing in constricted palate.
might accommodate in unusual positions, such As RME treats maxillary constriction thereby
 The case for environmental etiology of malocclusion in modern civilizations 231

increasing the width of the maxilla and 2. Linder-Aronson S, Woodside DG, Lundstrom A. Man-
possibly reducing any nasal resistance thus dibular growth direction following adenoidectomy. Am J
Orthod. 1986;89:273–284.
modifying the breathing pattern in these 3. Kerr WJ, McWilliam JS, Linder-Aronson S. Mandibular
patients.76–80 This modification involves nasal form and position related to changed mode of breathing
cavities and, indirectly, the jaw which will be —a 5-year longitudinal study. Angle Orthod. 1989;59:91–96.
repositioned and this causes the root of the 4. Woodside DG, Linder-Aronson S, Lundstrom A, et al.
tongue to move forward and it changes the Mandibular and maxillary growth after changed mode of
breathing. Am J Orthod Dentofac Orthop. 1991;100:1–18.
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8. Behlfelt K, Linder-Aronson S, McWilliam J, et al. Denti-
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Eating disorders in children and
adolescents
Nina K. Anderson, and Olivier F. Nicolay

The incidence of eating disorders (ED) is increasing, not only in Westernized

societies, but developing countries as well. Individuals having EDs may
develop significant functional impairments across organ systems with
serious life-threatening consequences, leading to the highest rates of
mortality and morbidity among mental disorders. (Semin Orthod 2016;
22:234–237.) & 2016 Published by Elsevier Inc.

T he Diagnostic and Statistical Manual of

Mental Disorders (DSM-V) recognizes six
primary feeding and eating disorders including
a position to be the first healthcare provider to
detect and recognize the signs and symptoms of
an ED, and contribute to the early referral for
anorexia nervosa (AN), bulimia nervosa (BN) intervention/treatment. It therefore behooves
and binge-eating disorder, pica, rumination dis- them to become cognizant and knowledgeable
order, and avoidant/restrictive food intake dis- about the manifestations of ED.
order (ARFID). The residual category “eating The incidence of eating disorders (ED) is
disorder not otherwise specified” has been increasing, not only in Westernized societies, but
renamed “other specified feeding or eating dis- developing countries as well. Up to 30 million
order” and includes five disorders atypical ano- people suffer from an ED in the United States,
rexia, binge eating with low frequency and/or with worldwide estimates at 70 million1 affected
limited duration, purging disorder, and night by these disorders. Patients having EDs may
eating syndrome. develop significant functional impairments
At-risk children frequently present with sub- across organ systems with potentially serious
clinical, heterogeneous eating symptoms, tend to life-threatening consequences. The mortality
present premorbid psychopathologies (depres- and morbidity rates associated with EDs are
sion, obsessive-compulsive disorder, or other among the highest of any mental disorders. The
anxiety disorders) and are less likely to have mortality rate associated with anorexia nervosa
binge/purge behaviors associated with their ED (AN) is 12 times higher than the death rate
than adults. Childhood and adolescence are associated with any other causes of death for
critical periods of neural development and females age 15–24.1 Pediatric EDs are more
physical growth. The malnutrition and related common than type 2 diabetes mellitus.6 Between
medical complications resulting from ED such as 1999 and 2006, hospitalizations for ED rose by
AN, BN, and eating disorder not otherwise 119% for children under the age of 12.1,2 Female
specified may have more severe and potentially athletes (e.g., cheerleaders, gymnasts, dancers, and
more protracted consequences during youth skaters), males competing in weight class sports (e.
than during other age periods. g., wrestling and combat), or homosexual males
Given the frequency with which oral health are the highest risk groups for developing ED.
practitioners, particularly pediatric dentists and Given the frequency with which general practi-
orthodontists, see their patients, they might be in tioners, pediatric dentists, and orthodontists see their
patients, they are in a position to be the first
Department of Developmental Biology, Harvard School of Dental healthcare providers to recognize the signs and
Medicine, Boston, MA; Department of Orthodontics, New York symptoms of an ED, and contribute to the early
University School of Dentistry, New York, NY. referral for intervention/treatment.3,4 Thus, it is
Address correspondence to: Nina K. Anderson, PhD, Department important that dental professionals are knowledge-
of Developmental Biology, Harvard School of Dental Medicine, 188
Longwood Ave, Boston, MA 02115
able about the types of ED and their manifestations.
& 2016 Published by Elsevier Inc.
The Diagnostic and Statistical Manual of
1073-8746/16/1801-$30.00/0 Mental Disorders (DSM-V)5 recognizes six
http://dx.doi.org/10.1053/j.sodo.2016.05.010 primary feeding and eating disorders including

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 234–237 234

 Eating disorders in children and adolescents 235

anorexia nervosa (AN), bulimia nervosa (BN) specified may have more severe and potentially
and binge-eating disorder, pica, rumination dis- more protracted consequences during youth than
order, and avoidant/restrictive food intake dis- during other age periods. The Workgroup for
order (ARFID). The residual category “eating Classification of Eating Disorders in Children and
disorder not otherwise specified” has been Adolescents (2010) and The Society for Adolescent
renamed “other specified feeding or eating dis- Medicine recommend that the diagnoses and
order” and includes five disorders: atypical treatment thresholds for pediatric ED should be
anorexia, binge eating with low frequency and/ lower than for adults due to the potentially
or limited duration, purging disorder and night irreversible effects of ED including pubertal delay,
eating syndrome. growth retardation, short stature, structural brain
Many resources cover eating disorders in changes, low bone mineral density.6,7 In addition, it
adolescent and adult populations, but the has been reported that in young women suffering
research and data on pediatric patients and ED is from BN, unstimulated saliva flow rate was decreased,
scant. Children at risk present frequently with with frequent complaints of dry mouth.8 Moreover,
sub-clinical, heterogeneous eating symptoms, signs and symptoms of temporomandibular joint
tend to have premorbid psychopathologies disorders appear to be more prevalent in patient
(depression, obsessive-compulsive disorder, or populations with eating disorders.9,10
other anxiety disorders) but are less likely to have Avoidant/restrictive food intake disorder
binge/purge behaviors associated with their ED (ARFID), previously known as “feeding disorder
than adults.6 Childhood and adolescence are of infancy or early childhood,” refers to pediatric
critical periods of neural development and feeding patterns that are restrictive such aversion
physical growth. The malnutrition and related to or avoidance of certain foods which may relate
medical complications resulting from ED such to appearance, smell, texture, taste, and/or
as AN, BN, and eating disorder not otherwise temperature of food, lack of appetite, using

Table. DSM-V disorder, observable characteristics, questions.

DSM-V disorder Physical characteristics Questions

Anorexia nervosa Low body weight Hypothermia

If purging type see bulimian Fatigue Participates-organized sports
Carotenemia/dry skin
Nervosa purging type Baggy clothing Excessive exercise
Atypical tattoos/piercings Perfectionist
Vegetarian
History of dieting
Ritualistic eating behaviors
Self-injurious behavior
Amenorrhea
Teased/bullied
Depressed/moody
Bulimia nervosa purging type Swollen parotid glands Eats large meals
Petechial hemorrhages Drinks acidic fluids
Perimolysis Vegetarian
Chipped/notched maxillary Tooth sensitivity
incisors V-shaped lesions on labial aspects
Angular cheilitis Frequent tooth brushing
Halitosis Athletic
Esophageal tear Participates-organized sports
Downy facial hair (lanugo) Tooth sensitivity
Callouses on back of hands (Russell’s sign) Body dissatisfaction
Depressed/moody
Obsessive/compulsive
Avoidant/restrictive food intake disorder Delayed development Picky eater
Low body weight Avoids new foods
Speech problems Mealtime struggles
Lethargy Trouble pronouncing words
Trouble maintaining focus
236 Anderson and Nicolay

feeding behaviors to self-soothe (e.g., rumina- pubertal trajectory. Young adolescents and chil-
tion). It is estimated that up to 25% of infants and dren, males and females, may be equally affected.
young children have feeding problems.11 These During dental appointments any pediatric or
children may eat only foods of a certain color, young adolescent patient who presents with some
usually white/neutral such as bread, and plain of the physical characteristics of AN (Table)
pasta or foods of certain texture, nothing lumpy, should be checked more specifically for buccal or
no strong smells, a particular brand, or only cold facial surface erosion due to consumption of
or hot foods. Children who will only eat purees highly acidic foods, caries, halitosis, xerostomia
and smooth textures may have compromised/ or reduced salivary flow, orthostatic changes in
delayed oral motor skills, as they have not learned pulse, bloating.
to chew, which may also adversely affect their For both AN and BN, purging subtypes may
speech. Due to nutritional deficiencies, children exist. Dental problems resulting from the purg-
with ARFID can experience extreme lethargy, ing behaviors can appear as early as 6 months
difficulties of concentration, or delayed growth/ after onset. In addition to physical characteristics
weight gain for their age and gender. previously described (Table), common mani-
Dental providers who suspect that a patient festations of purging include dental erosion,
may have an ARFID (Table) should check for particularly on lingual surfaces of maxillary
physical signs including halitosis, early childhood teeth (perimolysis), chipped/notched maxillary
caries, speech problems, and trouble sitting incisors, angular cheilosis (Fig.), raised
through a dental exam. During the dental amalgams, gingival recession, V-shaped abfrac-
appointment, they should also ask parents if tion lesions on labial aspect of teeth as a result of
the child is reluctant to eat new foods, has trouble vigorous/frequent brushing, swollen parotid
gaining weight, eat only certain textures, has glands, trauma to mucosal membranes, pharynx
trouble chewing/swallowing food, avoids eating, and soft palate, petechial hemorrhages, lanugo
enjoys re-chewing food, misses school, or has hair, and sensitivity to hot/cold foods.
trouble making friends. If so, referral to a Unfortunately, the EDs are among the few
pediatrician specialist may be indicated. Children diseases for which support groups exist to
with ARFID have been found to have significant encourage the disordered eating behaviors, to
comorbidities including, an underlying medical endorse the condition, and represent the dys-
disorder (86%) oropharyngeal dysfunction (60%) morphic relationship with food as a life style
or behavioral problem (18%).11,12 choice and way to maintain control. Pro-ana for
AN and BN are diagnosed more frequently anorexia and pro-mia websites offer inspiration
between the ages of 16 and17. Recently however, and information for concealment of the eating
there has been a significant increase of eating disorders from others, or information on how to
disorders diagnosed in 10 years old children, and avoid eating.
boys.2,6 Secrecy and concealment are common
The defining characteristic of a non-purging behaviors in young people with EDs. They can be
type AN patient is low body weight due to so successful that many ED go unrecognized,
insufficient caloric intake. Low body weight is under-diagnosed or misdiagnosed by primary
relative to the expected weight based upon age, care physicians.13 This is rather unfortunate
gender, history of weight gain, and growth/ since, when asked about what could have

Figure. Examples of cheilosis, and damage to central incisors.

 Eating disorders in children and adolescents 237

facilitated their own recognition of having an ED nervosa among dentists and dental hygienists. J Dent Educ.
or their willingness to seek help, 60% of patients 2005;69(3):346–354.
5. American Psychiatric Association. Diagnostic and Statistical
reported that, had a healthcare professional Manual of Mental Disorders , 5th ed. Washington, DC; 2013.
recognized the signs of an ED it would have 6. Campbell K, Peebles R. Eating disorders in children and
facilitated their willingness to spontaneously adolescents: state of the art review. Pediatrics. 2014;134
disclose their behaviors. Eating disorders are (3):582–592.
associated with the highest rates of morbidity and 7. Shaughnessy BF, Feldman HA, Cleveland R, Sonis A,
Brown JN, Gordon KM. Oral health and bone density in
mortality of any mental disorders among adolescents and young women with anorexia nervosa.
adolescents. Early detection therefore increases J Clin Pediatr Dent. 2008;33(2):1–6.
the odds of recovery and of better long-term 8. Dynesen AW, Bardow A, Petersson B, Nielsen LR,
prognosis. As one of the first medical pro- Nauntofte B. Oral Surg Oral Med oral Pathol Oral Radiol
Endod. 2008;106:696–707.
fessionals to have an opportunity to detect
9. Akhter R, Hassan NMM, Nameki H, Nakamura K, Honda
ED in patients, it behooves dentists to become O, Morita M. Association of dietary habits with symptoms
cognizant and knowledgeable about the of temporomandibular disorders in Bangladeshi adoles-
manifestations of ED. cents. J Oral Rehabil. 2004;31:746–753.
10. Johansson AK, Johansson A, Unell L, Norring C, Carlsson
GE. Eating disorders and signs and symptoms of
temporomandibular disorders. Swed Dent J. 2010;34:
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 Seminars in Orthodontics
Future Issues
Vol 22 No 4 (December 2016)
MIND YOUR BUSINESS - THE BUSINESS OF ORTHODONTICS: GLOBAL TRENDS AND MANAGEMENT PROTOCOLS
Nikhilesh R. Vaid, Guest Editor

Recent Issues
Vol 22 No 2 (June 2016)
ENHANCING COMMUNICATIONS IN CONTEMPORARY ORTHODONTIC PRACTICE
Laurance Jerrold, DDS, JD, ABO, Guest Editor
Vol 22 No 1 (March 2016)
INTERACTIONS BETWEEN ORTHODONTICS AND ORAL AND MAXILLOFACIAL SURGERY
Jae Hyun Park, DMD, MSD, MS, PhD, Guest Editor
Vol 21 No 4 (December 2015)
ADVANCES IN CBCT DIAGNOSTICS WITH ORTHODONTIC TREATMENT: INTERPRETATION AND MANIPULATION
Onur Kadioglu, DDS, MS, Guest Editor
Vol 21 No 3 (September 2015)
ACCELERATED ORTHODONTICS
Mani Alikhani, DDS, MS, PhD, Guest Editor
Vol 21 No 2 (June 2015)
JUVENILE IDIOPATHIC ARTHRITIS AND TEMPOROMANDIBULAR JOINT INVOLVEMENT: AN INTERDISCIPLINARY APPROACH
Bjørn Øgaard, DDS, Dr Odont, Guest Editor
Vol 21 No 1 (March 2015)
INTERDISCIPLINARY MANAGEMENT OF THE ORTHODONTIC PATIENT
Pratik Kumar Sharma, BDS(Hons), MFDS, MSc, MOrth, FDSOrth, Guest Editor
Vol 20 No 4 (December 2014)
ALL ROADS LEAD TO ROME: NEW DIRECTIONS FOR CLASS II
S. Jay Bowman, DMD, MSD, FACD, FICD, Guest Editor
Vol 20 No 3 (September 2014)
PERIODONTAL-ORTHODONTIC INTERACTIONS
Ramzi V. Abou-Arraj, DDS, MS, Guest Editor
Vol 20 No 2 (June 2014)
AGE-APPROPRIATE ORTHODONTIC TREATMENT, PART II
Gerry Samson, DDS, and Elliott M. Moskowitz, DDS, MSd, Guest Editors
Vol 20 No 1 (March 2014)
AGE-APPROPRIATE ORTHODONTIC TREATMENT, PART I
Elliott M. Moskowitz, DDS, MSd, and Gerry Samson, DDS, Guest Editors
Vol 19 No 4 (December 2013)
THE VERTICAL DIMENSION IN ORTHODONTICS
Nada M. Souccar, DDS, MS, Guest Editor
Vol 19 No 3 (September 2013)
EVIDENCE-BASED ORTHODONTICS
Katherine Vig, BDS, MS, FDS, DOrth, and Greg Huang, DMD, MSD, MPH, Guest Editors
Vol 19 No 2 (June 2013)
PROGRESSIVE CONDYLAR RESORPTION AND DENTOFACIAL DEFORMITIES
Chester S. Handelman, DMD, and Charles S. Greene, DDS, Guest Editors
Vol 19 No 1 (March 2013)
INTERDISCIPLINARY TREATMENT OF ADOLESCENTS WITH MISSING ANTERIOR TEETH
Mark R. Yanosky, DMD, MS, Guest Editor
Vol 18 No 4 (December 2012)
UPDATES ON THE BIOLOGICAL FOUNDATIONS OF ORTHODONTIC TOOTH MOVEMENT
Vinod Krishnan, BDS, MDS, M Orth RCS D, PhD, and Ze’ev Davidovitch, DMD, Cert Ortho, Guest Editors