A mouth full of train tracks used to be just another awkward sign of puberty. But these days, it's more common to see elementary school kids sporting a grin full of tin, as some orthodontic treatments are beginning at an earlier age.
With a price tag in the thousands, the need for braces is a pronouncement most parents dread, bringing to mind the geeky metal smiles and headgear of years past.
But experts say better materials and new treatment strategies are making braces work more effectively these days, while giving the patient more options as to how they look.
Here are the basics every parent needs to know:
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What's the difference between a dentist and an orthodontist?
An orthodontist has completed dental school, plus two to three years of study on how to move teeth, said Dr. Robert Bray, president of the American Association of Orthodontists.
When should a child be screened?
The American Association of Orthodontists recommends children be screened at age 7, around the time when their permanent upper teeth are coming in. "We are trying to pick up on things that may be way out of line and trying to find things that may affect their growth or smile," Bray said. But this doesn't mean every child will need to be treated that young, he said. It depends upon the patient.
How do braces work?
They apply gentle pressure to teeth to move them in a way that will improve their appearance and function.
Braces used to be for teens, why are kids getting braces at an earlier age?
The trend began about 15 to 20 years ago, when it was determined that early intervention could help in some cases, Bray said. For example, thumb sucking can create a functional problem that affects permanent teeth or the bone structure of permanent teeth. It is best corrected early, he said. Though some treatments are beginning earlier, the average age of treatment is about 12.
What is a two-phase treatment plan?
A first phase of treatment is sometimes recommended at an early age to correct the position and shape of the upper and lower jaws to help align teeth and give them room to fit better in the mouth. Then the braces come off, and there is a vacation of several months to several years before the next phase begins.
The second stage of braces helps refine and align the teeth.
Why would two phases be necessary?
There has been some controversy on the subject.
Studies by the University of Florida, University of North Carolina and in the United Kingdom looked at children with an overbite, in which the upper teeth were too far forward. They compared those who were treated in two phases with those who started later and wore braces only once. Researchers concluded there was no difference in the outcome.
Early intervention has been proven to work, however, in some cases.
Dr. Richard Mariani, a South Miami orthodontist in practice since 1983, said a first phase of treatment is necessary for situations such as a crossbite (when the upper teeth land on the inside of the lower teeth), an underbite (when the lower teeth are too far forward), thumb sucking or tongue thrusting, or if a tooth has been completely squeezed out of its designated spot.
"It's easier to correct those things at an earlier age," he said. "But I try to keep phase one under a year, then I try to keep phase two short, because you don't want the patient to burn out."
Mariani said the necessity of early treatment depends on the individual patient.
"Ninety percent of my colleagues will tell you that you need to do phase one treatment because it makes it easier for phase two, and in some cases, it does," he said.
How can a parent know for sure a child needs braces?
If you are seeing a problem in your child's mouth, such as overcrowding or a severe overbite, see a specialist and listen to what they have to say, Bray advises. Most orthodontists will take photographs and tell you what needs to be improved, he added.
"If you have doubts, or if something doesn't make sense, you can certainly get a second opinion," he said.
If your child is being made fun of or has low self-esteem because of the appearance of his teeth, that is also a valid reason to consider braces, experts say.
How have braces improved over the years?
Today, instead of the metal bands that wrap each tooth, orthodontists have a number of options. The most commonly used and least expensive are metal brackets that attach directly to the teeth. Wires that run through the brackets are held in place by tiny round rubber bands and apply gentle pressure to move the teeth. Different colored rubber bands and even metal brackets in the shape of hearts, footballs and flowers can allow the child to personalize their look.
There are several more expensive options that may used, depending on what needs to be corrected. Tooth-colored ceramic brackets lessen the look of braces. Self-ligating braces are metal brackets that do not require rubber bands to hold the wires. Lingual braces fit behind the teeth. Invisalign are clear brackets worn over the teeth.
How do new braces' materials affect treatment plans?
"The change is not so much in shortening treatment plans. You have to be careful with that because if the treatment is too short, there is danger of a relapse," Mariani said.
But new materials have changed treatments in other ways. For example, Mariani says, self-ligating braces can spare someone with a severely overcrowded mouth the necessity of having teeth pulled.
Mouths respond differently to these braces, which do not require rubber bands to hold the wires to the brackets, and work without stressing the tissue or bone or hurting teeth, he said. The downside is they cost 50 to 100 percent more than metal brackets.
What is risk of not getting treated?
If teeth are really crooked, they may be hard to clean around, eventually affecting the strength and durability of the teeth. It may make chewing food difficult or make the child at risk for jaw problems.
How much do they cost?
In South Florida, prices range from $3,500 to $6,500 per phase of treatment, Mariani said.
What can affect the rate of success?
The patients have to do what they are supposed to do -- take care of their teeth, follow instructions and avoid food that can break appliances. "What's hard about orthodontics is that there are facts you can't control," Mariani said. "You have to guess how the child is going to grow and guess how compliant they are going to be."
How can parents help the process?
"Parents must be behind you 100 percent or you're dead in the water," Mariani said. If a parent is feeding their kid Starburst and Blow Pops and wires are popping and breaking off left and right, then treatment is going to take longer, he said.
What is the average length of treatment?
About two years. But if the patient is not compliant, they're eating the wrong things, appliances are breaking or they're not taking care of their teeth, it can be longer. "You may have to cut the cord eventually, because there may be a danger of calcifications, gum problems, gingivitis," Mariani said.
What should a parent ask on a first visit to an orthodontist?
"First listen, and hear the person out, without worrying about the time or cost," Bray said. "Then ask, 'What absolutely needs to be done now, and what can be done later?' "