Written evidence submitted by the British Orthodontic Society (COH0015)

Executive Summary

• Every year hundreds of thousands of young people in England benefit from a NHS orthodontic intervention. The diagnosis and treatment available to Under 18s from NHS orthodontic providers in primary care, community clinics and secondary care plays an important role in improving oral health and well-being; benefits which endure for a lifetime.
• Conversely, those children who could benefit from treatment and do not get access to an orthodontic opinion are more likely to be bullied and are at risk of a lifetime of disadvantage.
• Orthodontic consultants and specialists treat a wide range of complex conditions, from rare developmental abnormalities and missing teeth to crossbites, reverse bites, impacted or protruding teeth or cases resulting from trauma.
• Treatment to correct a malocclusion - straightening teeth - provided by specialists and dentists with an interest in orthodontics is available to children and young people under 18 who meet criteria based on clinical needs, aesthetics and with good dental health. The most recent Child Dental Health Survey found 44% of parents of 12-year-old children reported problems with either crooked or protruding teeth.
• There are significant waiting lists for treatment in some areas.
• Orthodontic treatment delivers important health and well-being benefits, such as:
  Straighter teeth are easier to clean - children who have received orthodontic treatment have been shown to have lower plaque scores and individuals with only minor dental problems or no problems at all have a better Oral Health-related Quality of Life, particularly in relation to emotional and social well-being allowing them to function well in society.
• BOS echoes the concerns expressed by the Faculty of Dental Surgery of the Royal College of Surgeons of England in The State of Children’s Oral Health in England. It is indeed lamentable that in today’s society tens of thousands of children need to be admitted to hospital for multiple extractions of decayed teeth. Children who have decayed teeth extracted at an early age are likely to experience crowding and other orthodontic problems requiring more complex treatment as they advance into adolescence followed by further dental interventions throughout their lives. The many thousands of children undergoing general anaesthetics annually are already disadvantaged and while NHS dental and orthodontic services are available to mitigate the damage, the fact is that the initial disease is preventable.

1.0              Introduction

The British Orthodontic Society is a UK charity, which promotes the study and practice of orthodontics, acts to maintain and improve professional standards in orthodontics and encourages research and education in orthodontics (http://www.bos.org.uk). The Society has over 1900 members in the UK and internationally, and is the largest specialist dental group in the UK, composed of consultant orthodontists, university teachers in orthodontics, specialist orthodontic practitioners, and dentists with an interest in orthodontics. A further 900 dental health professionals with an orthodontic interest, including orthodontic nurses, therapists and technicians belong to affiliated organisations.

This submission provides information relating to the work that orthodontists routinely carry out in the UK, focusing on problems seen in children during the development of their dentition and providing evidence where available, with regard to the scope and effect that this treatment can have in relation to child dental health.

2.0              What is orthodontics?

Orthodontics is the branch of dentistry concerned with the treatment of malocclusion or an improper bite, often in combination with disproportion of the relationship of the jaws and bite. Orthodontic treatment can focus on the teeth only, or can deal with the teeth in combination with the control and modification of facial growth. The most recent Child Dental Health Survey found that 44% of parents of 12-year-old children reported problems with either crooked or protruding teeth [1]. There were 209,072 NHS-funded orthodontic case starts in England and Wales in 2012/13 and 201,977 in 2013/14.

Orthodontists play a key role in managing the developing dentition in children, and are often involved with interceptive treatment in the child at various stages of their development: during the transition from primary to adult dentition; during adolescence for the correction of an aberrant bite and definitive treatment with fixed braces as the adult dentition becomes established. In more severe cases, orthodontists in secondary care work closely with maxillofacial surgeons to manage individuals with significant jaw discrepancies, who require combined orthodontic and surgical correction.

In 2013, there were 698,512 live births in England and Wales [2]. The approximate numbers of affected children have been included in this document by extrapolating from these figures, based upon known prevalence of the varying features of malocclusion that are described.

2.1 Issues around access to orthodontics

The optimum time for orthodontic treatment is normally between the ages of 10 and 14. In some parts of the country, long waiting lists have formed resulting in many young people facing delays in starting their treatment. Options for treatment can be limited when treatment is not carried out during the optimum developmental timeframe, leading to a more complex treatment or compromising a good outcome, or both. There are extreme variations in waiting list lengths around the country.

3.0              Common problems encountered during development of the dentition

3.1              Enforced extraction of teeth

The most common reason for the enforced and premature loss of teeth in children is dental decay. The most recent data suggests that 43% of five-year olds have obvious decay experience in their baby teeth [1] and tooth decay remains the most common single reason why children under the age of ten years in the UK are admitted to hospital [3]. Early tooth loss can have a significant influence on subsequent development of the dentition and if left untreated, these effects can be life-long.

3.1.1              Early loss of baby teeth: Adult teeth replace the baby teeth between the ages of 6-12 years (excluding the wisdom teeth) in a sequential manner, with the baby teeth all acting to preserve space and symmetry within the dentition prior to their adult replacement. The early loss of baby teeth in a developing child can have significant implications for subsequent dental development: producing dental crowding, tooth impaction and asymmetric eruption of the adult teeth [4]. Data from the NHS Dental Epidemiology Programme Survey of 12-year-old Children (2008-9) [5] has shown a positive association between the premature extraction of baby teeth and a subsequent increase in orthodontic treatment need [6]. Orthodontic intervention through the appropriate use of extractions and space maintenance within the developing dentition can help prevent more serious problems with the teeth and bite, and avoid the need for complex orthodontic treatment in the adult dentition.

3.1.2              Early loss of first permanent molars: The first permanent molar is the adult tooth most commonly affected by caries and can be susceptible to progressive and rapid decay in the developing dentition. Around one third of UK 15 year-olds have experience of decay into dentine in at least one of their permanent teeth [7] and most first permanent molars are extracted because of dental caries [8]. In addition, combined first permanent molar–incisor hypomineralization (MIH) is a recognized condition of unknown aetiology where there is poor-quality enamel, seen in around 15% of Caucasian children [9] [which equates to >100,000 children in the UK]. MIH is a frequent compromising factor for adult first molars, resulting in decay and rapid breakdown, with conventional fillings generally failing and their maintenance throughout adulthood requiring full-coronal restorations, which can condemn these patients to the morbidity and expense of dental treatment throughout their lifetime.

In the right circumstances, premature loss of first permanent molars can be followed by successful eruption of the second permanent molars to replace them, and ultimately the wisdom teeth to complete the molar dentition [10]. However, treatment planning for first permanent molar extraction is complex and depends upon a number of factors [11]. Significant occlusal complications can result if they are removed at the wrong time. Appropriate management of these teeth requires specialist input from specialist paediatric dentists and orthodontists.

3.2              Dental crowding

Dental crowding commonly manifests in the developing dentition. Space maintainers can be used in the late mixed dentition to prevent movement of both upper and lower molars as the primary second molars are lost and the second premolars erupt. This can provide enough space to allow mild crowding to be treated without the need for permanent tooth extraction in the adult dentition; or useful additional space in very severely crowded cases that require more space than four premolar extractions can provide.

Interceptive extractions to alleviate incisor crowding are also undertaken during the mixed dentition. Extraction of the primary canines can be useful in preventing maxillary lateral incisors erupting into crossbite, helping to align an instanding lower incisor and preventing any gingival recession; providing space for alignment and crossbite correction associated with a crowded maxillary incisor; and as a potentially interceptive procedure to prevent impaction of the maxillary canine.

3.3              Tooth impaction

Tooth impaction can occur at any stage of dental development and affect many different teeth within the developing dentition.

3.3.1              Impacted upper adult central incisor: An impacted upper adult central incisor can have a major negative impact on dental and facial aesthetics and is a problem that often manifests in the 5-12 year-old age group, occurring with an incidence of around 3% [12] (>20,000 children per year in England and Wales). A propensity for crowding, and the formation of additional teeth or tumours to develop in this region of the mouth, can often cause impaction of the adult incisor tooth in this region. Orthodontic management often involves surgical removal of the additional teeth and exposure or the impacted front tooth; in many cases, followed by prolonged orthodontic traction to the impacted incisor, often in relatively young children [13].

3.3.2              Impacted upper adult canine tooth: The adult canine tooth usually erupts in the upper jaw between the ages of 11-12 years. In Northern European populations up to 3% of these teeth fail to erupt into the mouth because of deviation in their normal eruption path [14] [>20000 children per year in the UK]. Impaction of these teeth can have detrimental effects over the long-term: if left untreated, the baby canine tooth rarely lasts beyond a few years, which can result in spaces at the front of the mouth; the impacted canine can undergo cystic change in around 8% of cases [15]; and damage to neighbouring teeth can occur in up to 48% of cases [16]. In severe cases, this can result in loss of adjacent teeth. Orthodontic management of impacted upper adult canines is time-consuming, expensive and requires multidisciplinary intervention [17, 18]. Commonly, surgical uncovering of the adult canine tooth is required, followed by fixed orthodontic braces to move this tooth into its correct position within the mouth. Almost 90% of surgical exposures are performed under day-stay general anaesthetic and once surgically uncovered, the average time required to move it into the correct position with a fixed orthodontic brace is 2.8 years [19].

Early orthodontic assessment and interception can prevent impaction in the right circumstances, although this is not entirely predictable in all cases [20].

4.0              Common problems associated with the developing bite

4.1              Prominent upper front teeth

Around 40% of European children [21] (>250,000 per year in England and Wales) have some prominence of their upper front teeth and this can make them vulnerable to trauma. Indeed, systematic review has estimated that globally, over 200 million episodes of upper front tooth trauma have occurred as a result of prominence associated with these teeth [22]. Traumatic loss of an upper front tooth (central incisor) is seen in around of 3% of children and usually occurs unilaterally, in the developing dentition and in boys with prominence of these teeth [23]. In addition, these teeth can be damaged following trauma, which can range from simple enamel fractures of the crown to more complex fractures of the crown and root.

Orthodontic treatment in the developing dentition can very rapidly correct upper front tooth prominence [24] and reduce the incidence of incisor trauma; children with prominent upper front teeth who are treated earlier are less likely to traumatise their upper incisors and this is a significant benefit of treatment [25].

4.2              Prominent lower front teeth

Around 3% of European children [21] (around 21,000 per year in England and Wales) have prominent lower front teeth or a ‘reverse bite’. In the most severe cases, management requires complex multidisciplinary treatment involving orthodontics and jaw surgery. In the right circumstances, early orthodontic intervention can be effective in correcting the dental and skeletal features of this type of problem, with recent evidence from a UK-based multi-center RCT demonstrating maintenance of the beneficial effects of this treatment [26].

4.3              Crossbites

Teeth can erupt into a position of crossbite during development of the dentition, which is a transverse discrepancy in the position of either the back or front teeth. Around 8% of European children have a crossbite in the developing dentition [21] (around 56,000 children in England and Wales per year). Early correction is indicated, particularly as a crossbite can cause a jaw displacement on biting or damage to the gums, and this can be achieved relatively easily in the child, which reduces the risk of this problem being perpetuated from the primary into the mixed and then adult dentition [27].

4.4              Digit sucking

A prolonged digit sucking habit in a developing child can affect the eruptive position of the teeth, often giving rise to a number of characteristic features as part of a malocclusion, which are frequently seen in the developing dentition. In a minority of cases the habit can persist into the teenage years and can be the main contributing factor in the etiology of significant problems associated with the bite, which can ultimately require surgical correction. Occasionally a simple removable or fixed orthodontic appliance may be required to break the habit.

5.0              Missing teeth

In some circumstances one or more of the adult teeth can fail to develop, a condition termed Hypodontia, which is seen in up to 7% of European children (excluding the wisdom teeth) [28]. The exact cause of why certain adult teeth can fail to develop is not fully understood, but genetic and environmental factors are thought to play a role. Children with missing teeth often require complex and long-term multidisciplinary treatment. They can have numerous oral problems in addition to the obvious gaps that exist between their teeth, including delayed development and eruption of the teeth that are present, smaller teeth, tooth impactions and reduced bone support in regions where the teeth have not developed. Missing teeth have been shown to have a negative impact on the psychological status of a child, affecting both emotional and social well-being [29]. The bite can also be affected, producing fundamental problems, such as difficulty in chewing and eating [30, 31].

Orthodontists play a key role in ensuring that space is appropriately distributed within the jaws to allow appropriate restoration of the gaps. However, definitive management of these children can involve multiple clinical specialties including children’s dentists, restorative dentists and oral surgeons; it is expensive, extends from an early age into adulthood and requires life-long maintenance [31].

6.0              The impact of malocclusion and orthodontic treatment within society

6.1              Oral Health-related Quality of Life (OHQoL)

OHQoL is a standard of health of the oral and related tissues, which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being [32]. There is evidence from many global populations that individuals with significant malocclusion have a worse OHQoL than those with only a minor or no malocclusion, particularly in relation to emotional and social well-being [33-36].

6.2              Social well-being

The social impact of a malocclusion can be observed through the judgements that are made by people when interacting with affected individuals. There is evidence of more positive characteristics being associated with a normal set of teeth and bite, as opposed to a malocclusion [37-40] and these can manifest in many ways, including the prospects of obtaining employment [41]. Therefore, an ideal occlusion provides social benefits to the individual through the association with more positive character judgements amongst society. Indeed, qualitative research has shown that young people with malocclusion who seek orthodontic treatment are dissatisfied and have a sense of shame about their teeth [42, 43]. Children with a malocclusion are more likely to be bullied [44], and furthermore where children are bullied about the appearance of their teeth, orthodontic treatment of the malocclusion leads to reduction in the experience of bullying [45].

6.3              Oral health

There is some epidemiological evidence to support the notion that the presence of dental crowding or prominent upper front teeth can make cleaning more difficult [46, 47]. In addition, children who have received orthodontic treatment have been shown to have lower plaque scores [48].

The presence of a malocclusion can also reduce chewing (masticatory) efficiency, particularly if this is associated with an absence of tooth contacts, as is seen in an open bite [49].

7. Recommendations

• The BOS supports the Royal College of Surgeons’ recommendations for reducing tooth decay in children.
• The BOS believes that paediatric restorative and orthodontic specialist services should be accessible to children and young people in all parts of the country to help reduce inequalities.
• The BOS calls on the Department of Health to carry out a review of orthodontic waiting lists and to provide funding for treatment in areas where lists are unacceptably long.
• The BOS urges the Commissioners of dental health care to direct more funding to areas of deprivation not only to deal with dental decay in young children, but to ensure that their dental development is not blighted by this early problem. Total dental care including orthodontic treatment at a later stage must be provided for this vulnerable group of patients to give parity to their life chances.

Authors on behalf of BOS:

Martyn Cobourne, Professor of Orthodontics, King’s College London

Jadbinder Seehra, Consultant Orthodontist, King’s College London Dental Institute

Tim Newton, Professor of Psychology as Applied to Dentistry, King’s College London

References

[1]              National Children’s Dental Health Survey, 2003.

              Note: The Health and Social Care Information Centre ran a survey of children’s dental health between               October 2013 to March 2014 in England, Wales and Northern Ireland. The results of the survey are due               to be published as a National Statistics report in February 2015.

[2]              Office for National Statistics: Statistical bulletin: Births in England and Wales (2013).               http://www.ons.gov.uk/ons/rel/vsob1/birth-summary-tables--england-and-              wales/2013/stb-births-in-england-and-wales-2013.html

[3]              Hospital Episode Statistics (provisional). Health and Social Care Information Centre,               (2013). Data provided to the Faculty of Dental Surgery after a FOI request.

[4]              Rock WP (2002). UK National Clinical Guidelines in Paediatric Dentistry. Extraction of primary teeth – balance and compensation. Int J Paediatr Dent 12:151-153. http://www.bspd.co.uk/LinkClick.aspx?fileticket=1rurkCokla0%3D

[5]              NHS Dental Epidemiology Programme Survey of 12-year-old Children (2008-2009)               http://www.nwph.net/dentalhealth/reports/Report_NHS_DEP_for_England_OH_Su              rvey_12yr_2008-09.pdf.

[6]              Bhujel N, Duggal M, Munyombwe T et al (2014). The impact of premature extraction               of primary teeth on the subsequent need for orthodontic treatment. Eur Arch Paed               Dent. ISSN 1818-6300. http://dx.doi.org/10.1007/s40368-014-0128-x.

[7]              Pitts NB, Chestnutt IG, Evans D et al (2006). The dentinal caries experience of               children in the United Kingdom. Br Dent J 200: 313-320.

[8]              Albadri S, Zaitoun H, McDonnell ST et al (2007). Extraction of first permanent molar               teeth: results from three dental hospitals. Br Dent J 203: E14; discussion 408-409.

[9]              Crombie F, Manton D, Kilpatrick N (2009). Aetiology of molar-incisor hypomineralization: a critical review. Int J Paed Dent 19: 73-83.

[10]              https://www.rcseng.ac.uk/fds/publications-clinical-              guidelines/clinical_guidelines/documents/a-guideline-for-the-extraction-of-              first-permanent-molars-in-children

[11]              Cobourne MT, Williams A, Harrison M (2014). National clinical guidelines for               the               extraction of first permanent molars in children. Br Dent J 217: 643-648.

[12]              Di Biase DD (1971). The effects of variations in tooth morphology and               position on               eruption. Dent Pract Dent Rec 22: 95–108.

[13]              Management of unerupted maxillary incisors (2010). RCS England Clinical Guidelines              https://www.rcseng.ac.uk/fds/publications-clinical-              guidelines/clinical_guidelines/documents/ManMaxIncisors2010.pdf

[14]              Thilander B, Myrberg N (1973). The prevalence of malocclusion in Swedish               schoolchildren. Sc J Dent Res 81: 12–21.

[15]              McSherry PF (1998). The ectopic maxillary canine: a review. Br J Orthod 25:               209-216.

[16]              Ericson S, Kurol PJ (2000). Resorption of incisors after ectopic eruption of               maxillary canines: a CT study. Angle Orthod 70: 415-423.

[17]              Pearson MH, Robinson SN, Reed R et al (1997). Management of palatally               impacted canines: the findings of a collaborative study. Eur J Orthod 19: 511-              515.

[18]              Management of the impacted maxillary canine (2010). RCS England Clinical               Guidelines.

[19]              Iramaneerat S, Cunningham SJ, Horrocks EN (1998). The effect of two alternative               methods of canine exposure upon subsequent duration of orthodontic treatment.               Int J Paediatr Dent 8: 123-129.

[20]              Parkin N, Furness S, Shah A et al (2012). Extraction of primary (baby) teeth for               unerupted palatally displaced permanent canine teeth in children. Cochrane               Database Syst Rev 12:CD004621.

[21]              Tausche E, Luck O, Harzer, W (2004). Prevalence of malocclusions in the early               mixed dentition and orthodontic treatment need. Eur J Orthod 26: 237-244.

[22]              Petti S (2015). Over two hundred million injuries to anterior teeth attributable to               large overjet: a meta-analysis. Dent Traum 31: 1-8.

[23]              Jarvinen S (1978). Incisal overjet and traumatic injuries to upper permanent incisors. A retrospective study. Acta Odontol Scand 36: 359–362.

[24]              O’Brien K, Wright J, Conboy F et al (2003). Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicentre, randomized, controlled trial. Part I: dental and skeletal effects. Am J Orthod Dentofacial Orthop 124: 234-243.

[25]              Thiruvenkatachari B, Harrison JE, Worthington H et al (2013). Orthodontic treatment for prominent upper front teeth (class II malocclusion) in children. Cochrane Database of Systematic Reviews. Issue 11. Art No: CD003452. DOI: 10.1002/14651858.CD003452.pub3.

[26]              Mandall N, DiBiase A, Littlewood S et al (2012). Is early class III protraction facemask treatment effective? A multicentre randomized, controlled trial: 3-year follow-up. J Orthod 39:176-185.

[27]              Harrison JE, Ashby D (2008). Orthodontic treatment for posterior crossbites. Cochrane Database Syst Rev, CD000979.

[28]              Khalaf K, Miskelly J, Voge E et al (2014). Prevalence of hypodontia and associated factors: a systematic review and meta-analysis. J Orthod 41: 299-316.

[29]              Kotecha S, Turner PJ, Dietrich T et al (2013). The impact of tooth agenesis on oral health-related quality of life in children. J Orthod 40: 122-129.

[30]              Laing E, Cunningham SJ, Jones S et al (2010). Psychosocial impact of hypodontia in children. Am J Orthod Dentofacial Orthop 137: 35-41.

[31]              Garnett MJ, Wassell RW, Jepson NJ et al. (2006). Survival of resin-bonded bridgework provided for post-orthodontic hypodontia patients with missing maxillary lateral incisors. Br Dent J 201: 527-534.

[32]              Health Do, An Oral Health Strategy for England. In: Issue 1994. London.

[33]              de Oliveira CM, Sheiham A (2003). The relationship between normative orthodontic treatment need and oral health-related quality of life. Community Dent Oral Epidemiol 31: 426-436.

[34]              Marques LS, Filogonio CA, Filogonio CB et al (2009). Aesthetic impact of malocclusion in the daily living of Brazilian adolescents. J Orthod 36: 152-159.

[35]              Johal A, Cheung MY, Marcene W (2007). The impact of two different malocclusion traits on quality of life. Br Dent J: 202:E2.

[36]              Masood Y, Masood M, Zainul NN et al (2013). Impact of malocclusion on oral health related quality of life in young people. Health Qual Life Outcomes 11: 25.

[37]              Henson ST, Lindauer SJ, Gardner WG et al (2011). Influence of dental esthetics on social perceptions of adolescents judged by peers. Am J Orthod Dentofacial Orthop 140: 389-395.

[38]              Jesani A, DiBiase, AT, Cobourne MT et al, (2014). Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. J Dent 42: 1135-1142.

[39]              Shaw WC (1980). The influence of children’s dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am J Orthod 79: 399-414.

[40]              Verdecchia F, Bee M, Lombardo L, et al (2011). Influence of anterior tooth alignment on peer perception in 8 to 10-year-old children. Eur J Orthod, 33: 155-160.

[41]              Pithon MM, Nascimento CC, Barbosa GCG et al (2014). Do dental esthetics have any influence on finding a job? Am J Orthod Dentofacial Orthop 146: 423-429.

[42]              Josefsson E, Lindsten R, Hallberg LR (2010). A qualitative study of the influence of poor dental aesthetics on the lives of young adults. Acta Odontol Scand 68: 19-26.

[43]              Taghavi Bayat J, Hallberg U, Lindblad F, et al (2013) Daily life impact of malocclusion in Swedish adolescents: a grounded theory study. Acta Odontol Scand 71: 792-798.

[44]              Seehra J, Fleming P, Newton JT & Dibiase AT (2011) Bullying in orthodontic patients and its relationship to malocclusion, self-esteem and Oral Health Related Quality of Life. J Orthod, 38: 247-256.

[45}              Seehra J, Newton JT, DiBiase AT (2013) Interceptive orthodontic treatment in bullied adolescents and its impact on self-esteem and Oral Health Related Quality of Life. Eur J Orthod, 35: 615-621.

[44]              Addy M, Dummer PM, Griffiths G, et al (1986). Prevalence of plaque, gingivitis and caries in 11-12-year-old children in South Wales. Community Dent Oral Epidemiol 14: 115-118.

[45]              Davies TM, Shaw WC, Addy M, et al (1988). The relationship of anterior overjet to plaque and gingivitis in children. Am J Orthod Dentofacial Orthop 93: 303-309.

[46]              Davies TM, Shaw WC, Worthington HV, et al (1991). The effect of orthodontic treatment on plaque and gingivitis. Am J Orthod Dentofacial Orthop 99: 155-161.

[47]              Magalhaes IB, Pereira LJ, Marques LS et al (2010). The influence of malocclusion on masticatory performance. A systematic review. Angle Orthod 80: 981-987.

18 February 2015