Answering Your Questions About Orthodontia

As we continue to navigate these unprecedented times, KCBS Radio is getting the answers to your questions about the coronavirus pandemic. Every morning at 9:20 a.m. Monday-Friday we're doing an "Ask An Expert" segment with a focus on a different aspect of this situation each day.

Today we’re looking at orthodontic treatment with Dr. Dave Johnson, assistant clinical professor at the UCSF School of Dentistry, practicing orthodontist in Alameda and the Bunger family orthodontist.

Let's start by talking about the differences between dentistry and orthodontia, because we did answer dental questions a couple of days ago on "Ask an Expert".

Dentistry and orthodontics are actually quite different. When you go to the dentist generally what's going to happen is, you're going to go in, having a cleaning done, you go in and leave. You may need a filling or something like that and if you go in for the procedure, you leave. 

But orthodontics is really quite different. It's really more of a journey. So think of it almost like a plane flight. You get on a place and you're in transit from one place to another and essentially what the orthodontist is doing is providing a whole bunch of these journeys all at once. So each of my patients are sort of on a journey like you'd be on a plane and my job is to land them on the runway way out in the distance. So it's a process unlike just going in for a procedure.

So right now with orthodontia being told "stand down" so to speak, unless it's an emergency, how is that affected?

Aside from the emergencies, essentially what I have is a lot of planes in a holding pattern. So these people that are out there are kind of midway through their flight patterns, to keep using that analogy.

What's interesting though about orthodontics is a lot of times those people that aren't seeing orthodontists may still be proceeding towards their eventual finish or runway even though they're not going into the office. So they could actually still be in transit. The issue here though is that for some patients, if they don't go in and see their orthodontist they may get off course a little bit. So that's something that we as orthodontists need to check in on a little bit. And I know a lot of my colleagues are doing that, checking in with their patients just remotely - there's a lot of remote teledentistry going on right now as well.

We've been shut down for, coming up on six weeks now. What's the typical cycle for appointments in orthodontia these days?

It's about six weeks. So essentially what's happened is that a lot of people have missed one cycle. So that may be okay, that may not be. I'll bring up one thing which is that there are some appliances that orthodontists use that will continually keep working and they do need to be checked in on otherwise they can actually go too far. And so that is something where, if you're in process with your orthodontist you may want to check in and see what the next step is.

What is the typical length of treatment these days? I'm sure that varies but from seeing an orthodontist for the first time to being patted on the back on your way out with shiny new straight teeth, what does it typically take?

You're right it really does vary, but right now the average times are probably more than a year, less than a year and a half. Right around that 18 month mark is fairly typical for full orthodontic treatment. 

And treatment nowadays is across the board, there's so many different things that we do. We do treat children but a lot of adults are having treatment now too with what's called clear aligner therapy, or Invisalign is probably what a lot of people have heard of. So a whole different style of treatment.

And that treatment, believe it or not, can be done a little bit more remotely in that patients wear clear aligners that are changed each week. And essentially it's that same sort of flight pattern to get them to the runway at the end. And sometimes those clear aligners can be distributed - and I know in our practice some patients have gotten to the end of the series that they had and we were able to mail or give them the next set of the series. So some people are still progressing forward.

Well let's get to some questions then and let's stay with Invisalign because one of the questions says: I'm using Invisalign. I'm not sure how long I'm supposed to keep using the same one.

That really depends and I would say they should check in with their orthodontist because it may be possible to give them the next series. But also there are some points in the treatment where the patient would have to come in and have some in-office procedure done in order to progress to the next series. So those two things could be in play and so what they should do is check with the orthodontist - usually a phone call or even email, I know a lot of us do things virtually now - and they should check in with them because it may be possible to keep progressing.

My daughter is in middle school and she's getting anxious about her braces since we've now missed two appointments. What can I tell her?

Unfortunately we've been directed by both the California Dental Association and the California Association of Orthodontists to not see any patients unless it's a true emergency. And a true emergency is really defined as something that's either painful or it's an infection. Or the other one that's a little less common or understood is if not providing treatment would cause harm to the patient in some way. So I know for my practice there are lots of patients who are ready to get their braces off but we can't actually see them. These are kids or adults that are just biting at the bit to come in to finish their treatment.

Is there any harm to having the braces stay on longer while we wait for this opportunity to re-open?

Probably not. In most cases, really what's happening is - again it's sort of like that airplane that's in the holding pattern waiting to land. It's unfortunate in the sense that I know people are eager or anxious to get things removed or move to the next step. But probably as long as you're practicing good oral hygiene, keeping braces or teeth and aligners clean during this time there's probably not a lot of harm as long as they don't have one of those appliances in that I mentioned earlier where it is actually moving teeth in a way that it won't stop when you get to a certain point, so spring appliances and things like that.

I assume if somebody has something like that, their orthodontist would be in touch with them to say "this is something we need to talk about."

Yes, and that actually has happened for us. We've had to call some people in who have these devices in and actually in several cases had to remove them so they didn't go too far. And they should know that. These are spring devices that a lot of orthodontists use to correct overbites and things like that.

Are you doing anything different in the office now than you might have been before, given the nature of this pandemic?

Well the answer to that is, a little bit yes. And so I will go back and say that dentists and orthodontists alike have practiced what we call "universal precautions" for many many years. We were probably really the first profession to really adopt this in a very big way. And so we've always used gloves and masks, disinfected and sterilized everything that comes in contact with patients.

What I think we're doing a little bit different now and preparing for as we hope to reopen is a little more social distancing, which hasn't been done before. So our waiting rooms are looking really different. There's probably some splashguards in front of the receptionists for example, we're not using touch screens anymore, we're putting up barriers. But we're still practicing the same universal precautions that dentists have always practiced. So I think we are actually at the forefront of that. 

And along that line, as the governor talks about when it's time to reopen that there won't be a switch that's going to get switched, in fact it'll be sort of like a dimmer where we turn it up a bit - we as dentists and orthodontists are really hoping that we're in that first wave as the dimmer switch gets turned a little bit.

On March 3rd I had a temporary crown put on. Since then it's come off and I re-cemented it myself. How long can I go without having the new crown put on?

That's a very good question. Again, not knowing the specifics of it I would say he should contact his dentist and ask that very same question. Depending on how well he temporarily cemented it, if food or plaque can get underneath that temporary crown it can actually cause harm. And that's one of those things that we have been directed we could attend to. So I would have him check with his dentist about that.

Exactly what is an emergency? My son says it feels like something is loose but we don't see anything obvious, and he's not in pain.

Looseness is probably not something that is an emergency. Really again, it's defined as pain, swelling, infection - something like that. And so you know again with orthodontics every once in a while something does come loose. I'll be honest and say we use fairly fine and delicate appliances in a place that is really brutal, if you think about what happens in the mouth as far as chewing and food and huge forces are generated. Sometimes things do break. It's just part of what we deal with.

If it's just broken and it's hanging in there and not causing any pain or anything like that, then I would say it's probably not a true emergency yet. Probably the best thing to do would be to contact the orthodontist, describe the situation. What I have been doing is I have been having my patients send me a picture. Nowadays with our digital photography on our phones I can get a very clear picture of what's going on. As a matter of fact, just recently I had a mom who sent me a picture of her daughter with a wire sticking out and I described to her over the phone how to actually take that wire and re-insert it into the slot. And she did a perfect job and sent me a picture afterwards. So this is kind of like teledentistry. This is such a great ability to be able to visualize that for us and then be able to give you good guidance as to what to do.

Will this gap in appointments and/or adjustments mean my treatment will take longer to finish?

That's a good question. The answer is probably a little bit but probably not a lot. Again those planes that are in flight - as long as they're still going down that road towards that eventual landing, the treatment times actually may not increase. One of the things that makes orthodontics take so long is not how we deliver the forces to the teeth, but we actually have to wait for the bones to remodel around those teeth to be able to move. So we're really waiting for the patient's response to what we've done. So if that response is still taking place then there's actually no slowing of the treatment that's in effect.

Anything you'd like to pass on to people in orthodontic treatment to ease their minds or give them some quick tips?

I will say this, that we as orthodontists and dentists alike - we want to get back to work as much as these patients want to get back in to see us. So we're all hoping that as soon as we can, that we can get back to work. And I want to reassure the patients that are listening that we're always practicing universal precautions, always taking great care in our offices and all of the orthodontists and dentists are on that path. You'll be safe in the dental office.