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Who Needs Braces? Socially-Necessary vs. Medically-Necessary Treatment

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Every day I am asked by many of the parents I meet whether or not their child needs braces. Many of these parents are seeking a simple and straightforward answer of yes or no. Often times a parent may inadvertently reveal their desired answer by the way in which they pose the question. Those seeking an unequivocal yes may ask, don't you agree that my child definitely needs braces? Those seeking an unequivocal no will probe, are braces medically necessary in this case? Unfortunately, an honest answer to this seemingly clear-cut question is a real challenge for an orthodontist.

Unlike treating a disease with a known cause and having the ability to select a therapy that cures that disease, orthodontics is limited to managing the irregularity of teeth. In simple terms, we orthodontists are able to straighten your teeth, but we really have little idea how or why they went crooked in the first place. In fact, many of the dental traits that have been labeled orthodontic problems are merely examples of normal human variation.

It has been near impossible for the orthodontic specialty to gain consensus on what defines a healthy bite and consequently who needs braces. In the 1970s the National Institute of Dental Research and the National Research Council of the National Academy of Sciences convened three independent panels of orthodontic experts to examine research related to variation in dental bite and handicapping orthodontic conditions. Their conclusion was twofold: A precise and clinically meaningful definition of a healthy bite does not exist and the degree of handicap to function or appearance that might result from an imperfect bite can only be determined in relation to symptoms, not morphologic variation. Nearly 40 years later the American Association of Orthodontists on its consumer-facing website, mylifemysmile.org, still argues that the primary goal of orthodontic treatment is to achieve a "good" or "healthy" bite.

How do we orthodontists expect to maintain our status as an esteemed specialty of health care when we can't achieve consensus on what we actually do? A century into modern practice, orthodontics is in the midst of a teenage identity crisis. Do we carry on portraying ourselves as "bite fixers," or do we acknowledge that the vast majority of our patients may be seeking our services to achieve a detectable improvement in their appearance in order to expand their scope of social possibility?

The ethical principle of veracity requires that the health professions be honest and trustworthy in all their dealings with the public. The act of selling orthodontic treatment to a patient or parent without objective evidence of a functional, appearance or psychosocial problem is contrary to the ethical tenets of respect for patient autonomy, non-maleficence, beneficence, justice and veracity. Although the question of who needs braces can create a significant tension between professional ethics and business practice for the orthodontist, it really shouldn't.

In the absence of incontrovertible data on the medical benefits of straighter teeth, it's probably time to level with the public and loudly proclaim that bite alone doesn't determine orthodontic need. So what is the best index of treatment need in 2013?

When a parent thinks their kid needs braces then they probably do, and when a parent doesn't think their kid needs braces then they probably don't, it's as simple as that.

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