Medically Indicated Orthodontic Care: A Change in Concept

The Problem
Current health care policy in the U.S. has mandated that our children should be offered competent dental care as part of maintaining good general health. This includes orthodontic care only if it can be shown to be “Medically Necessary”.1 Even though only 16% of children can be easily recognized as requiring medically necessary orthodontic care2 (while 85% have malocclusion to some degree) as part of the aforementioned mandate, the definition of medical necessity as far as third party payors is concerned has been defined solely by the severity of the malocclusion being based on scoring systems that pile up points for deviations in the position of the teeth from the ideal. These scoring systems (indices) leave no room for subtlety. A malocclusion has to look really bad to qualify even though we know that small occlusal disharmonies can be the etiology of dysfunction and discomfort.
The position of this paper, however, is that traditional methods of orthodontic diagnosis and treatment planning fall far short of defining the true medical needs that can be – must be – addressed by orthodontics, and indeed, healthcare in general.  Mounting evidence that comes from outside the orthodontic literature suggests that the conditions that lead to malocclusion also lead to health issues far beyond just crooked teeth including problems with breathing and sleep.3,4,5,6
In his timely 2016 article, Joseph Ghafari describes his vision of “Medically Necessary Orthodontic Care”7, noting this topic is of understandable concern for the American Association of Orthodontists. He suggests that the time has come to forgo the distinction between medicine and dentistry, as we are finding it harder to justify paying attention to the teeth without consideration for the person to whom the teeth are attached.
Ghafari illustrates conditions that are directly associated with malocclusion including physical deficits (skeletal malocclusion, hindered growth potential), dental deficits (hygiene, alignment), and psychological deficits (self-esteem). These are the conditions that orthodontics does deal with even if they don’t show up in the occlusal indices.
However, there are also medical conditions that orthodontists tend to ignore by declaring them to be issues unsupported by the orthodontic literature;  these include TM disorders8, facial pain9, breathing dysfunctions including upper airway flow limitation10,11, facial morphology changes secondary to open mouth posture12, and larger whole-body issues related to cranial and spinal alignment, nutrition, breathing, and sleep. While there has been an ongoing thread of effort in other realms of dentistry and medicine to deal with these problems13, the orthodontic specialty has by and large seen fit to distance itself by claiming that orthodontic treatment has no direct role to play in either the causation or correction of these dysfunctions.
Historically, many within the orthodontic community have argued that orthodontics should grapple with issues like airway patency and respiratory health. For instance, Donald Enlow, the acknowledged “father” of craniofacial growth concepts, has been commonly quoted as saying, “the airway is the keystone for the face, implying a reciprocal relationship between breathing and facial development.”14 Also, Robert Ricketts stated that “respiration and deglutition is governed by the same set of muscles and the same set of nerve paths, we cannot separate the two”.15
The question that needs to be asked is whether orthodontic treatment can be responsible for either aggravating, reducing, or even curing certain systemic problems?  With the current focus in dentistry on breathing and sleep, the interest in evidence and research is becoming greater.16

The time has come to forgo the distinction between medicine and dentistry.

Responsible or Irresponsible?
Perhaps the disconnect in understanding occurs because many orthodontists don’t yet recognize that so many of the chronic non-communicable diseases of civilization (including but not limited to malocclusion and sleep apnea) that so plague us (and are breaking our collective healthcare bank) are already developing well before customary orthodontic treatment begins.17 Since traditional orthodontics is directed primarily at the jaws and teeth, any mitigation of chronic issues of breathing or posture by orthodontics is largely accidental or directed as only a small part of the problem (ie palatal width). While some orthodontists and other dental professionals are showing interest in improving aspects of health (for instance, by enlarging the airway and improving function), there is still no widely accepted, comprehensive approach for the medical conditions other than malocclusion.
For example, if a child has been mouth breathing since his/her ear aches began at 2 years of age (otitis media) and the TM joints have been strained by compensatory muscle patterns (mouth breathing and reverse swallow), and the shape of the face continues to elongate and the teeth are failing to erupt properly, by the time this child is of “braces age” the damage to the face and airway has already been done. The common assumption an orthodontist might make is that the condition is a “genetic” problem and erroneously uses the Angle classification to diagnose and treat the case as if the teeth were the only problem. Consequently, some children’s breathing related co-morbidities might be aggravated, or at least remain unaddressed, because the underlying medical problem was never recognized.
medically-indicated-orthodontic-careHowever, much can be done for the child starting as early as 2 years of age to prevent the long face syndrome and sequelae, soft tissue dysfunctions, strain on the TM joints and the craniofacial deficiencies if a proactive approach to screen and address early growth and development compensations is taken. Let’s consider just a few of the issues at hand:

  1. Posture: A recognition of the destructive influence that mouth breathing and open mouth posture have on the growing face is imperative. Without the scaffolding effect of the tongue resting on the palate, the maxilla deforms in three dimensions of space and changes the shape of the lower third of the face.18 This subject has been intriguing enough to inspire much research, even though most of the findings have been overlooked in clinical practice. Perhaps this has been due to the difficulty in clinical management and protocol. Moreover, it is well established that intramembranous bone growth – of which much of the splanchnocranium is derived – is driven by the soft tissue function or dysfunction.

Additionally, achieving proper tongue posture and function requires us to address the adequacy of nasal and pharyngeal airway patency first and foremost.  We need to add clinical protocols and appropriate referrals to address the need for proper nasal breathing and good lip seal as a primary goal of treatment in every case.19

  1. Nutrition: Current evidence both within and outside of dentistry shows that the foods we eat20 (highly processed and sugar-laden) and how we eat them21,22 (first from a bottle rather than the breast, and then highly processed and soft) are a major factor in the malocclusion epidemic. This has been known for over a hundred years and is amply verified in the anthropology literature. Malocclusion is a modern epidemic and needs be recognized as an epigenetic response to a changing environment.

By encouraging natural nursing, getting toddlers to eat foods that foster proper chewing, swallowing and breathing neural patterns early in development, we will help assure the promotion of proper function and structure. Society needs to recognize that the provision of nutrient-rich foods that do not challenge the immune system is a responsibility we have to future generations.

  1. Breathing: The influence of the modern environment on respiration deserves further study, too. We are literally breathing twice the rate we used to a hundred years ago as our bodies struggle to process the toxic burden of the things we breathe, eat, drink and put on our skin. Many of these industrially derived substances are so foreign to our body that it is a constant struggle to destroy, eliminate or sequester them mounting an exaggerated immune and metabolic response.

There are effective ways to change our biochemistry through breathing repatterning, which improves perfusion/gas distribution to make better use of oxygen and bring the sympathetic nervous system into better balance.23

  1. Sleep: The effects that all the previously described “daytime” problems have on our sleep cannot be overemphasized. Whether affecting the quantity or quality of our sleep, we – and our children – are suffering from a lack of proper rest and recuperation.

The behavioral and neurocognitive sequelae of poor sleep are well documented.24,25 The physical comorbidities of bad sleep are numerous and well documented. Sleepiness in adults and hyperactivity in children are well recognized and are, frankly, a menace to our society (How many train, boat, bus and car accidents could be prevented by good sleep?)
What readers of this article should know is that by the time a person succumbs to sleep apnea, it’s is way too late to do anything but mask (pun intended) the problem. CPAP and OATS are but crutches to relieve symptoms.  Making sleep and breathing a priority in our early treatment protocols will lessen the risk factors for sleep disorders well before we get to crisis management.26,27
Medically Indicated Orthodontic Care
There are other issues that could be addressed here, but these four are good illustrations of where we in dentistry and orthodontics need to begin to take action. Although orthodontic treatment plans will need to include collaboration with other healthcare professionals to be thorough, orthodontists can play a crucial role in controlling the conditions that create malocclusion.
First, we must intercept the compensations (read: bad habits) that lead to poor facial growth and airway development. Secondly, have to undo the damage to the face caused by those chronic habits. And lastly, we must make sure our patients have adopted the good habits and practices that will keep them healthy from then on. Then and only then can we take our place, not just as mechanics of the mouth, but as physicians of the face. As part of an interdisciplinary team, we can change the outcomes of bad breathing  for children so they need not get to the point where they can’t sleep well in adulthood.

It is time for dentistry, orthodontics and medicine to step up together.

Protocols are available that can be easily inserted into a pediatric and orthodontic practices to deal with these issues.28,29 While new learning and some retooling is needed, the biggest obstacles are the revision of orthodox beliefs about how it can’t be done. It can be done and is being done.
To summarize, medical indications for orthodontic care are when a child cannot breathe through their nose, cannot  hold their lips together without strain, cannot keep the tongue resting on the palate, or cannot swallow without having to recruit facial muscles to help. Similarly, the medical indications for overall health are when a child has poor body alignment, eats foods that are challenging to the body, does not breathe well enough to efficiently support proper metabolism, and does not get a good, restorative night of sleep. Note that none of these conditions are defined by how crooked the teeth are and might never show up in any index. This does not diminish the importance of these medical indications, but it does call into question the methods we have of defining them.
It is time for dentistry, orthodontics and medicine to step up together. When we, as a profession and as a society, take responsibility for these medical indications, we will be a much healthier people.

mark-a-cruzMark A Cruz graduated from the UCLA School of Dentistry in 1986 and started a dental practice in Monarch Beach, CA upon graduation. He has lectured nationally and internationally and is a member of various dental organizations including the Pierre Fauchard Academy, Pacific Coast Society for Prosthodontics and the American Academy of Restorative Dentistry. He was a part-time lecturer at UCLA and member of the faculty group practice and was past assistant director of the UCLA Center for Esthetic Dentistry. He has served on the National institute of Health/NIDCR (National Institute of Dental & Craniofacial Research) Grant review Committee in Washington D.C. as well as on the editorial board for the Journal of Evidence Based Dental Practice (Elsevier) and is currently serving on the DSMB (data safety management board) for the NPBRN (national practice-based research network.
barry-raphael-dmdBarry Raphael, DMD, is a practicing orthodontist in Clifton, New Jersey, for over 30 years. His transition to airway thinking came 25 years into practice so as he says, “I know what it takes to make the transition.” He teaches these concepts at the Mt. Sinai School of Medicine in New York City. He is the owner of the Raphael Center for Integrative Orthodontics and the founder of the Raphael Center for Integrative Education.

  1. AAO Leads Effort to Standardize Medically Necessary Orthodontic Care Criteria, Bulletin of the American Association of Orthodontists, MAY. 27, 2016
  2. Pediatr Dent, Spec Edition:Ref Manual 1995-96, 17(6)
  3. AMERICAN ACADEMY OF PEDIATRICS, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome; “ Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome’. PEDIATRICS 2002, 109:4, 704-712
  4. Marcus, C,, Diagnosis and Management of Childhood OSAS, PEDIATRICS, 2012,
  5. Sum, Fung, Association of Breastfeeding and Three-dimensional Dental Arch Relationships in Primary Dentition BMC Oral Health. 2015;15(30)
  6. Bonuck, K, Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years, PEDIATRICS 2012, 129: 4.
  7. Ghafari, Joseph,” “Medically necessary” Orthodontic Care: Challenges and applications.”, Sem Ortho, 2016, 22:3, 167-176.
  8. Kremenak, Charles R. et al, Orthodontic risk factors for temporomandibular disorders (TMD). I: Premolar extractions. American Journal of Orthodontics and Dentofacial Orthopedics , 1992, 101:1 , 13 – 20.
  9. Dibbets, Extraction, orthodontic treatment, and craniomandibular dysfunction. AJODO, 1991 ;99:210-9.
  10. Larsen, Ann, “Evidence supports no relationship between obstructive sleep apnea and premolar extraction”, J Clin Sleep Med 2015;11(12):1443–1448.
  11. Valiathana, M.,Effects of extraction versus non-extraction treatment on oropharyngeal airway volume.  Angle Orthod. 2010;80:1068–1074
  12. Seo-Young Lee , Christian Guilleminault, Hsiao-Yean Chiu,, Shannon S. Sullivan, Sleep and Breathing (2015), Mouth breathing, “nasal dis-use” and pediatric sleep-disordered-breathing, Stanford University Sleep Medicine Division, Stanford Outpatient Medical Center, Redwood City
  13. Kevin L. Boyd & Stephen H. Sheldon, Childhood Sleep-disordered Breathing: A Dental Perspective. Chapter 34 ISBN: 978-1-4557—0318-0;PII:B978-1-4557-0318-0.00034-6; Author: Sheldon & Kryger & Ferber & Gozal;00034 Elsevier 2013
  14. Enlow DH, Hans MG. Essentials of facial Growth. 2nd ed. Ann Arbor: Needham Press; 2008. p. 234–5
  15. JClinOrtho Interviews Dr. Robert M. Ricketts on Early Treatment, 1979, 13:1,23-38.
  16. Caroline Rambaud, Christian Guilleminault, Death, nasomaxillary complex, and sleep in young children,  Eur J Pediatr, DOI:  10.1007/s00431-1727-3
  17. Daniel E. Lieberman, The Evolution of THE HUMAN HEAD,  The Belknap Press of Harvard University Press Cambridge, Massachusetts, & London, England
  18. Mew, Mike, “Craniofacial Dystrophy, a possible syndrome”, Brit Dent J, 2014, 216:20, 555-558.
  19. Villa, M., Controlled Study of an Oral Jaw-Positioning Appliance for the Treatment of Obstructive Sleep Apnea in Children with Malocclusion, Am J Respir Crit Care Med 2002, 165, 123–127,
  20. Corruccini RS, et al. Genetic and environmental determinants of dental occlusal variation in twins of different nationalities. Human biology 1990, 62:3, 353-67.
  21. Sum, Fung, ibid.
  22. Legovic M, Ostric L. The effects of feeding methods on the growth of the jaws in infants. ASDC J Dent Child. 1991;58(3):253–5.
  23. Litchfield, Peter, CapnoLearning: Respiratory Fitness and Acid-Base Regulation, Psychophisiology Today, 2010, 7:1, 6-12
  24. Bonuck, ibid.
  25. Guilleminault, C,; A cause of excessive daytime sleepiness: The upper airway resistance syndrome.  Chest 1993;104;781-787.
  26. Singh, G.D,,  Biomimetic Oral Appliance Therapy in Adults with Mild to Moderate Obstructive Sleep Apnea, Austin J Sleep Disord. 2014;1(1): 5.
  27. Singh, G.D,, Evaluation of Posterior Airway Space following Biobloc Therapy; J. Craniomandibular Prac, 2007, 25:2.
  28. Raphael, Barry, “Airway Orthodontics, the new paradigm: Part 1 Addressing the Airway”, Ortho Pract US, 2016, 7:3, 35-39
  29. Raphael, Barry, “Airway Orthodontics, the new paradigm: Part 2 Vision for the Future”, Ortho Pract US, 2016, 7:4, 32-35.

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