For many special needs patients, orthodontic care may seem out of reach due to physical and developmental challenges. However, new technologies in treatment, and the availability of advanced education in caring for special needs patients, are making a surprising and welcome difference in the lives of many patients with disabilities. The American Association of Orthodontists (AAO) reports that many of its members are able to successfully address the orthodontic treatment needs of those with physical, cognitive and developmental disabilities.
"In particular, the orthodontic challenges seen in patients with cerebral palsy, autism, Asperger's and Down syndrome are being addressed with positive outcomes," say David R. Musich, DDS, MS, and Matthew J. Busch, DDS, Chicago-area orthodontists with a long history of treating special needs patients.
New technologies are opening new doors for special needs patients seeking treatment for tooth alignment issues and complications specific to a patient's disability. These include temporary anchorage devices that help move specific teeth, minimally invasive surgical procedures, clear aligners that can be removed for hygiene purposes, implants, self-ligating brackets, and improved oral hygiene measures. In addition to overcoming the oral health challenges created by disabilities, these special patient populations, just like others, benefit from the boost of confidence that comes with a healthy, beautiful smile.
"As recently as ten years ago," Dr. Musich continues, "many orthodontists lacked the education and experience to work with patients with disabilities, and, as a result, patients and caregivers were frustrated." Now, organizations like the American Association of Orthodontists (AAO) offer continuing education for doctors and their staff on the nuances of treating patients with disabilities. Case studies with examples of successful outcomes are shared to help further education for orthodontic teams. Some practices work with special education teachers in the community who can share valuable information on how to work with specific disabilities. These resources are changing the culture of many orthodontic offices. "Both patients and caregivers report life-changing experiences and a greatly improved quality of life," says Dr. Musich. "And thanks to technology, orthodontists have a whole new range of options to treat special needs children and adults."
Clear Possibilities: A range of technologies usher in new possibilities for patients
Ken Fischer, DDS, an orthodontist in Orange County, CA, has extensive experience working with cerebral palsy patients. He says that in each case, his patients achieved a level of progress with clear aligners that never would have been possible with traditional braces. Cerebral palsy patients struggle with increased saliva flow and problems with muscle control. Dr. Fischer often sees patients with an open bite with protruding front teeth, which is marked by tongue thrusting. A patient's inability to close the lips because of an open bite also contributes to excessive saliva flow. Many of these issues can now be addressed by treating the patient with removable clear aligner trays or other options such as temporary anchorage devices or simple surgeries to help manage more complex tooth size discrepancies and growth pattern imbalances.
Dr. Fischer gives an example of a cerebral palsy patient who struggled to eat a sandwich on her own. She continually faced a choking hazard due to dental and facial imbalances and needed supervision at every meal. "By straightening the patient's teeth and aligning the jaw, she is now able to eat on her own. This is a huge lifestyle change for both patient and caregiver."
"In the past, traditional braces have been a distraction for some patients with cerebral palsy," Dr. Fischer continues. "Having something affixed in their mouth can trigger an increased sense of anxiety, and patients may have the urge to tug at the brackets and wires. But with the removable aligners, patients and caregivers are more in control, especially when it comes to taking them out for flossing and brushing. Oral hygiene is much easier for cerebral palsy patients who are treated with removable aligners." Clear aligners aren't the only option for cerebral palsy patients, however. Self-ligating brackets require less time to change wires and can simplify oral hygiene. "These new options have enabled us to treat many types of special needs patients, especially those with complex problems," says Dr. Musich.
Dr. Fischer emphasizes the importance of an improved self-image for people with disabilities. "Many of my patients with special needs are going through adolescence, a time when their peers are also seeing an orthodontist," he explains. "Just being in treatment helps kids feel like they fit in, and it's reflected in a more positive demeanor."
There are multiple options for patients with autism spectrum disorder or Asperger's syndrome, according to Jean McGill, DDS, MS, of Easton, PA. "As specialists, we look at the many various orthodontic options and customize a plan that works for each patient. Generally speaking, kids with autism and Asperger's are extremely tactile and experience things through `touch.' They may have a tendency to take clear aligners in and out. For that reason, sometimes traditional braces work better for them, as they remain in place and there is nothing removable to 'play' with." The goal for these patients when they visit her office is to provide a quiet environment and limit their time in the chair, which works well with their short attention spans. Dr. McGill typically sees these patients at the end of the day or right before lunch to give them individualized care in a quiet environment.
Accessible Paths to Hygiene
Oral hygiene is of utmost importance for the disabled patient and their caregivers. There have been advances here, too. Dr. Musich and Dr. Busch typically treat Down syndrome patients with traditional braces because their cases are frequently too complicated for clear aligners. In these cases, they use new tools like protective sealants or smaller hygienic brackets to make oral hygiene much easier for patients and caregivers.
Cerebral palsy patients often have complications because teeth that are crowded or poorly aligned make flossing and brushing a struggle for the patient and their caregiver. The ability to take out the aligners and brush the patient's teeth is a plus. New electronic and ultrasonic tooth brushing systems are also a great option for all patients. "Once teeth are straightened, maintaining good oral hygiene is easier for all," says Dr. Busch.
An Outlook to Smile About
A final tip: special needs children should see an orthodontist no later than age seven, a recommendation that the AAO makes for all children. Many times early or interceptive treatment can be done to reduce the severity of the problem. If the decision is made to wait for additional maturity of the patient or the development of the teeth, the early appointments may serve nicely to condition the special needs patient to the "positive environment" of the orthodontic office, which reduces the anxiety for future care.
"After consulting with a dentist, parents of special needs kids typically seek out the expertise of an orthodontist," says Dr. McGill. Patients with disabilities can take longer to treat and the process requires the patient's diligent adherence to the orthodontist's recommendations on diet and oral hygiene. (Not all orthodontic practices treat special needs patients, but the number that do is growing.) "Asperger's and autism spectrum patients tend to be very good about following the rules, they really want to do the work and help in the success of their treatment by maintaining oral hygiene," says Dr. McGill.
Dr. McGill encourages orthodontists who see special needs patients to reach out to primary care dentists to spread awareness. "Many dentists think these cases are just too hard and don't want to give false hope to families," she says. "But the truth is, some special needs patients can be successfully treated, and all kids, and even young adults, should be evaluated by an orthodontist. When it comes to treatment, an orthodontist can make recommendations to help parents come to a decision that's in their child's best interest."
As medicine improves, so does the life expectancy and quality of life for many patients with disabilities. Down syndrome patients, for example, live twice as long as they did just decades ago. Laws such as the Americans with Disability Act (ADA)and the 1997 Individuals with Disabilities Education Act (IDEA) have helped, too. "Parents want to see their kids mainstreamed and have the opportunity to live a full life. If their peers have braces, they want their child to also have the confidence that comes with a healthy, beautiful smile," says Dr. McGill.
The American Association of Orthodontists (AAO) is a professional organization for 17,000 member orthodontists in the United States, Canada and abroad. Orthodontists are uniquely qualified to correct improperly aligned teeth and jaws. They are specialists in the diagnosis, prevention and treatment of dental and facial irregularities. Orthodontists receive an additional two-to-three years of specialized education beyond dental school in an accredited orthodontic residency program to learn the proper way to align and straighten teeth. Only those who have successfully completed this formal education may call themselves "orthodontists," and only orthodontists are eligible for membership in the AAO.
Visit www.mylifemysmile.org for information about orthodontists, orthodontic care and to find an AAO-member orthodontist near you.