An occasionally irregular blog about orthodontics

A new dental disease: Orthodontosis and orthodontitis

A new dental disease: Orthodontosis and orthodontitis

Orthodontosis and orthodontitis

Since I started this blog I have confined my reviews and comments on papers in the mainstream orthodontic journals. However, I came across a paper and a letter in the British Dental Journal that I found so extraordinary that  I’ve decided to change my blogging practice. This blog is about my academic interpretation of these sources.

crooked-teethThe concept of a New Dental Disease: Orthodontosis and orthodontitis

Viazis D, Viazis E and Pagonis T

Journal of Dental Health, Oral Disorders and Therapy 2014, 1,(5) DOI: 10.15406/jdhodt.2014.01.0030


This paper was published in the Journal of Dental Health, Oral Disorder and Therapy.   This is a new open access journal so you can have a good look at this paper.

What did they do?

This paper is an opinion piece that derived from the analysis of thousands of non-extraction orthodontic treatments by the authors. They then used this analysis to develop a new orthodontic classification. This is based on the premise that the traditional methods of orthodontic classification are not valid or reproducible and a new classification is required. They propose the following;

Orthodontosis: none inflammatory deficiency of alveolar bone caused by the displaced roots of teeth.

Orthodontitis:  excess soft tissue manifestation and chronic inflammation.

Their theory arises from an assessment of the clinical morphology of the alveolar bone and they expand this concept in the paper. I thought that this was a difficult paper to follow, but this is my interpretation.  The proposed new classification is:

Localised orthodontosis: This is class I crowding and they suggest that there is a non-inflammatory deficiency of the bone where there is crowding caused by displaced roots. This results in excess soft tissue and chronic inflammation called orthodontosis. They illustrate this with pictures. But this just looks like chronic gingivitis caused by poor hygiene to me!

Pre-maxillary Orthodontosis: This is Class II malocclusion. They suggest that this has occurred because the roots of the incisors are not upright and by stripping uprighting the roots then the problem is cured.  More severe problems can be corrected by orthognathic surgery.

Mandibular Orthodontosis: this is Class III malocclusion  and as they suggest again that this condition can be alleviated by uprighting roots along with interproximal reduction.

They illustrated these new concepts with pictures of fixed appliances straightening teeth and correcting the orthodontosis.

They then move on to the theories of tooth eruption and introduce the concept of “ortho eruption” and suggest that uprighting of the roots of the teeth from the beginning of orthodontic treatment and using light forces stimulates bone remodelling around displaced roots. Importantly non-extraction treatment is achieved through bone growth.

They finally conclude that using an appliance system that uprights the roots from the start of treatment and adopting this new classification may lead to more non-extraction treatment.

What did I think?

I cannot help thinking that all they have done is simply describe orthodontic tooth movement and remodelling of alveolar bone.  As a result, I could see nothing new here at all.  It was interesting that their classification is concerned with correcting the position of the teeth within the alveolar bone. However, I could not  think  how this is going to help orthodontic treatment planning. I also wonder if this was an attempt to turn malocclusion into a disease that can be “cured” by non-extraction treatment?

They also seemed to suggest that because this classification is related to a new disease of the alveolar bone and teeth, then the “disease” can be cured by moving the teeth using a system of orthodontic appliances that moves the roots of the teeth.  I have always been under the impression that all fixed orthodontic appliances move the roots of the teeth. As a result, this paper, its hypothesis and conclusions are a complete mystery to me.

I then moved on to the letter by Pagonis in the British Dental Journal. In this letter he repeated the main message of the paper. But he specifically mentioned the concept that

“ If orthodontic disease presents as a deficiency of alveolar bone around malpositioned roots, treatment should mimic the continuation of natural eruption thereby restoring the architecture of alveolar bone and eliminating soft tissue inflammation. This new technology of orthodontic tooth movement (Fastbraces) contemplates that light forces may possibly stimulate bone remodelling around the area of displaced roots”

Now I understand, this is all probably about Fastbraces. I suggest that you have a look at their website for more information on this treatment system.

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  1. Dai Roberts-Harry says:

    Its just more nonsense de jour

  2. Naphtali Brezniak says:

    I wonder how come you missed this editorial:
    Defining and framing orthodontitis: A new term in orthodontics
    Naphtali Brezniak; Atalia Wasserstein
    Angle Orthodontist, Vol 84, No 3, 2014

    Defining and framing orthodontitis:
    A new term in orthodontics
    Naphtali Brezniak; Atalia Wasserstein
    It is well known that orthodontic force application
    induces aseptic local inflammation due to necrosis in
    the periodontal ligament (PDL) and that there is no
    tooth movement without this inflammation process. It is
    also well known that the inflammation process is
    important for both the bone as well as the cementum
    remodeling processes.1–5 If we consider these wellknown
    phenomena together, we can name the process
    related to orthodontic tooth movement, as well as the
    Inflammatory Root Resorption Concurrent with Orthodontics
    (IRRCWO),6 as ‘‘Orthodontitis’’. Orthodontitis,
    then, is the inflammation behind tooth movement,
    where the prefix is our profession and the suffix ‘‘itis’’7
    is used in medical terminology to describe inflammation
    of an organ or a tissue. The combination,
    Orthodontitis, is therefore a term we would like to
    introduce along with a classification system to describe
    the inflammation resulting from orthodontic force
    Orthodontitis is an aseptic local inflammation in the
    PDL induced by orthodontic forces. Orthodontitis can
    be divided into 2 groups: Instrumental Orthodontitis
    (IO) and Instrumental-Detrimental Orthodontitis (IDO):
    Instrumental Orthodontitis (IO): IO initiates controlled
    bone modeling,8 as well as bone and cemental
    remodeling (reversible changes).8,9 IO enables tooth
    movement to occur due to frontal and undermining
    alveolar bone resorption and apposition on the
    pressure and tension sides, respectively.10 The roots
    next to IO areas also undergo surface resorption,11
    mainly by cemental remodeling. This biological process
    ceases when orthodontic forces are removed.
    The periodontal ligament that surrounds the roots is
    fully regenerated. IO symptoms include mild to
    moderate tooth mobility and/or sensitivity, and pain
    during the first days following force application. IO
    signs include mild to moderate tooth mobility and
    radiographic PDL widening. Signs and symptoms
    disappear following orthodontic force cessation.
    The mechanism behind the process is that orthodontic
    force enables normal blood flow, but induces
    local electrical current and pH changes as well as
    release of different biological materials from the
    damaged cells (e.g. cytokines and prostaglandins).
    These events trigger local inflammatory activity in the
    area surrounding the roots and is limited to the PDL,
    alveolar bone and cementum. The inflammation in the
    pressure area induces mainly a bone modeling
    process by resorbing the alveolar bone while the
    inflammation in the tension area induces bone
    modeling by apposition; new bone is being laid down
    on the affected surfaces. Surface cemental remodeling
    is induced in both areas as well.
    The inflammation mechanism is genetically controlled.
    It is activated regularly during our lifetime and
    it remains behind the normal remodeling/modeling
    Regarding treatment, analgesics are sometimes
    prescribed during orthodontic treatment. No further
    action is needed.
    Instrumental and Detrimental Orthodontitis Grade
    1 (IDO1): IDO1 is similar to IO. However, the
    inflammation in IDO1, for unknown reasons, changes
    its character on the cemental side (the effect on the
    bone on the pressure and tension sides is similar to
    that of IO) and the remodeling process becomes a
    modeling process; the resorption process goes
    beyond the cementum into the dentin. IDO1 causes
    minor to moderate root shortening12 as well as
    scattered lacunae on other root surfaces. Both of
    these are irreversible changes. The results are
    usually diagnosed using X-rays during, close to the
    end, or following orthodontic treatment. The symptoms
    and treatment are similar to IO. After orthodontic
    treatment is completed, there are only radiographic
    signs (root shortening or peripheral surface resorption)
    but no symptoms.
    Instrumental and Detrimental Orthodontitis Grade
    2 (IDO2): IDO2 is very similar to IDO1. However, in
    this case, the inflammation results in severe root
    shortening. The symptoms are tooth mobility and
    sensitivity during or following orthodontic treatment.
    The signs include tooth mobility/sensitivity and severe
    G 2014 by The EH Angle Education and Research Foundation,
    Angle Orthodontist, Vol 84, No 3, 2014 568
    root shortening12 as viewed on X-rays. The consequences
    of IDO2 require treatment. The treatment for
    IDO2 depends on the time that it is discovered. If
    IDO2 is diagnosed after debonding, we suggest that
    fixed retention be used to splint the affected teeth
    together with unaffected teeth. In rare situations,
    fused crowns can be a good treatment solution.
    Extractions and implant replacements should be
    considered only in extremely rare cases, if ever.
    The mechanism for both IDO1 and IDO2 is similar to
    that described for IO. However, the level of the
    resorptive activity on the root surface is different, and
    it is probably individually genetically determined.13–16
    The remodeling process is being disturbed in the
    transition between the resorption and the reversal
    stages.8,9 The coupling between resorption and apposition
    disappears or is delayed and, therefore, resorption
    continues into the dentin.
    Furthermore, we suggest that IDO should be
    regarded as a self-defense mechanism of the body
    to an extreme local condition (similar to the body’s
    reaction or behavior in hypovolemic shock)17 which
    occurs in the PDL following force application. By
    shortening the roots, the body decreases the current or
    future moments developed in the apical areas of the
    teeth due to the orthodontic force being applied at the
    crown. In addition, we suggest that the irreversible
    lacunar resorption along the roots’ surfaces is a
    mechanism that may defend against the loss of teeth
    with resorbed short roots by increasing their surface
    areas, thereby keeping the damaged teeth in a stable
    condition. It has been demonstrated that those teeth
    can remain in the mouth for many years.18,19
    We believe that the profession should adopt this new
    terminology and use it to explain the actual process
    underlying tooth movement and IRRCWO during consultation
    with the parents/patients/guardians. If patients
    and parents can understand this process better, the
    number of lawsuits against orthodontists in this matter
    would decrease tremendously. IRRCWO can be considered
    one of the body’s self-defense mechanisms.
    Even today, it has not been determined conclusively the
    level of force and/or the duration of force application at
    which this reaction will be expressed.
    1. Bletsa A, Berggreen E, Brudvik P. Interleukin-1alpha and
    tumor necrosis factor-alpha expression during the early
    phases of orthodontic tooth movement in rats. Eur J Oral
    Sci. 2006;114:423–429.
    2. Garlet TP, Coelho U, Silva JS, Garlet GP. Cytokine
    expression pattern in compression and tension sides of
    the periodontal ligament during orthodontic tooth movement
    in humans. Eur J Oral Sci. 2007;115:355–362.
    3. Tzannetou S, Efstratiadis S, Nicolay O, Grbic J, Lamster I.
    Comparison of levels of inflammatory mediators IL-1beta
    and betaG in gingival crevicular fluid from molars, premolars,
    and incisors during rapid palatal expansion. Am J
    Orthod Dentofacial Orthop. 2008;133:699–707.
    4. Surlin P, Rauten AM, Silosi I, Foia L. Pentraxin-3 levels in
    gingival crevicular fluid during orthodontic tooth movement
    in young and adult patients. Angle Orthod. 2012;82:
    5. Kim SJ, Park KH, Park YG, Lee SW, Kang YG. Compressive
    stress induced the up-regulation of M-CSF, RANKL,
    TNF-a expression and the down-regulation of OPG expression
    in PDL cells via the integrin-FAK pathway. Arch Oral
    Biol. 2013;58:707–716.
    6. Brezniak N, Wasserstein A. Orthodontically induced inflammatory
    root resorption. Part 1: The basic science aspects.
    Angle Orthod. 2002;72:175–179.
    7. Accessed
    November 15, 2013.
    8. Roberts WE. Orthodontics Current Principles and Techniques.
    [5th ed.] Vanarsdall RL Jr, Vig KWJ, Graber LW. St
    Louis: Mosby; 2012:386–453.
    9. Viecilli RF, Katona TR, Chen J, Hartsfield JK Jr, Roberts
    WE. Orthodontic mechanotransduction and the role of the
    P2X7 receptor. Am J Orthod Dentofacial Orthop. 2009;135:
    10. Brudvik P, Rygh P. The initial phase of orthodontic root
    resorption incident to local compression of the periodontal
    ligament. Eur J Orthod. 1993;15:249–263.
    11. Andreasen JO. Review of root resorption systems and
    models. Etiology of root resorption and the homeostatic
    mechanisms of the periodontal ligament. In: Davidovitch Z,
    ed. Biological Mechanisms of Tooth Eruption and Root
    Resorption. Birmingham, Alabama: EBSCO Media; 1988:
    12. Levander E, Malmgren O. Evaluation of the risk of root
    resorption during orthodontic treatment: a study of upper
    incisors. Eur J Orthod. 1988;10:30–38.
    13. Al-Qawasami RA, Hartsfield JK Jr, Everette ET, Flury L, Liu
    L, Foroud TM, Marci Jv, Roberts WE. Genetic predisposition
    to external apical root resorption. Am J Orthod Dentofacial
    Orthop. 2003;123:242–252.
    14. Low E, Zoellner H, Kharbanda OP, Darendeliler MA.
    Expression of mRNA for osteoprotegerin and receptor
    activator of nuclear factor kappa beta ligand (RANKL)
    during root resorption induced by the application of heavy
    orthodontic forces on rat molars. Am J Orthod Dentofacial
    Orthop. 2005;128:497–503.
    15. Bastos Lages EM, Drummond AF, Pretti H, et al. Association
    of functional gene polymorphism IL-1beta in patients
    with external apical root resorption. Am J Orthod Dentofacial
    Orthop. 2009;136:542–546.
    16. Iglesias-Linares A, Yan˜ ez-Vico R, Ballesta-Mudarra S, et al.
    Postorthodontic external root resorption is associated with
    IL1 receptor antagonist gene variations. Oral Dis. 2012;18:
    17. Rhee P. Shock, electrolytes and fluid. In: Sabiston Textbook
    of Surgery. 19th ed. Philadelphia: Elsevier; 2012:66–119.
    18. Becker A, Chaushu S. Long-term follow-up of severely
    resorbed maxillary incisors after resolution of an etiologically
    associated impacted canine. Am J Orthod Dentofacial
    Orthop. 2005;127:650–654.
    19. Marques LS, Chaves KC, Rey AC, Pereira LJ, Ruellas AC.
    Severe root resorption and orthodontic treatment: clinical
    implications after 25 years of follow-up. Am J Orthod
    Dentofacial Orthop. 2011;139(4 Suppl):S166–S169. doi:
    Angle Orthodontist, Vol 84, No 3, 2014

    • ross hobson says:

      Better get thy asbestos suit on quick!

      I too have read the various papers on this subject and they are adopting well trodden pseudoscience techniques (read Ben Goldacre ” Bad Science” and “Bad Pharma) and invented a disease so they can sell a solution (well known in the Pharmaceutical industry), Using misinterpretation of papers with selective quotes to support the claims.
      I am amazed people buy this snake oil, especially evidence based, highly educated dental colleagues. Maybe this is a failure of us as academics not to instill the skills of critical reading? However I digress. The speed of the obviously well rehearsed response telling you how incorrect you are is again an example of pseudoscience. You and i have participated in this debate before… and the authors were resoundingly silent when challenged to participate in a RCT.

      ps Please keep up the good work of passing a critical evaluation of all thing orthodontics and i have a spare fire extinguisher if you need one

    • Lawrence J. Levens, DDS, MSd, MScLO says:

      Dr. Brezniak,
      I read your article previously and it was an excellent discussion of the remodeling process including root resorption. I have to guess that Dr. O’Brien discussed the editorial and letter from the British Dental Journal because they have hijacked your new terminology and redefined it for commercial purposes. In the case of FastBraces your terms are and to define something less descriptive and not at all as clever to validate their proposition that non-extraction treatment is the solution to these two conditions (Orthodontitis and Orthodontosis). They are also claiming to be the only practitioners smart enough to have figured out that using nickel-titanium wires is technological advantage. They also have cleverly suggested that moving the roots gently towards the targeted position as soon as possible is a great idea too. Unfortunately, they are using an appliance that is not technologically advanced (the bracket was proposed by Viazis in the 1980s and NiTi wires have been around since the same time) and not at all clever (using a terribly undersized wire in a rectangular slot to torque roots and also only offering one wire for the entire treatment). I think the point of Dr. O’Brien’s comments was to show how non-sense is often proposed as science.

  3. Anne Marie Kuijpers-Jagtman says:

    Hi Kevin,

    I came across this topic several months ago through a letter to the Editor in the BDJ (2015;218;22-3) of Dr. P. Huntley, who wrote a good commentary. He mentioned the Fast Braces University so I couldn’t resist the temptation to see that on the web. I read the same article as you are mentioning. However, it has been published in an open access journals. I don’t know if you paid attention already to Beall’s list of potential, possible, or probable predatory scholarly open-access publishers on This is the best resource available at the moment to check about the reliability of an open access journal. It is very worthwhile to spend time on this website to understand the world of open access publishing. You can hardly believe what you read there. By the way Medcrave, who is the publisher of the journal you mentioned, is on that list.

    Best wishes, Anne Marie

  4. Tony Kilcoyne says:

    Thanks for highlighting this paper and the new CONCEPTS of Orthodontosis and Orthodontitis.

    I agree it IS a Paradigm-Shift for those steeped within older Traditional concepts of Angle’s classification and other historical ‘textbook’ approaches.

    As you know, these are now totally discredited in the Scientific literature and were based upon a mythical greek god and arbitrary assumptions 😮

    For those who have taken an adversarial position against FastBraces systems that enable the average GDP to do proper fixed Ortho using rectangular wire in a rectangular slot for 3D corrections from day 1 ( the optimum approach surely?),
    Please please please keep an open mind.

    This is good for patients and is progress of science conceptually which, if we are being brutally honest, has been lacking in Traditional Ortho. for too long!

    One is feeling like Florence Nightingale, pointing out the ‘traditional’ flaws but being castigated for introducing a new Concept which has demonstrated consistant results.

    How did a mere female who didn’t even have a vote, stand up to the powerful God-like Male medics of the time, despite their power and their constant derision & ridicule, I really don’t know.

    But thank goodness she didn’t buckle under such prejudice – the outcomes spoke for themselves and the growing evidence showed the old-traditional medical approaches were based upon many flawed assumptions, whilst Florence Nightingale’s new Concepts grew in credibility, but it took MANY decades to overcome the inherent prejudices and disempowerment of women/nurses compared to the socially revered men/medics too!

    The great news is more GDPs are doing and referring more Ortho than ever before – the progressive Specialists are welcoming Orthodontics being ‘normalised’ back into everyday dental practice, like every other dental discipline.

    Yours also progressively,


    • Kevin O'Brien says:

      Tony, thanks. This discussion is opening up. Just a quick question. Do you have a financial interest in Fast Braces, I know that you speak on their courses?

    • Monica says:

      Don’t most of the other dental disciplines form a substantial and vital part of the undergraduate curriculum, and therefore are of course ‘normalised’ in everyday dental practice, whereas Orthodontics is a specialty which requires the attainment of further competencies following undergraduate training in order to understand planning and treatment fully.
      As an orthodontic trainee, I don’t see the specialty as being patriarchal or prejudiced, rather a group who seek to treat patients with methods that have the strongest evidence base, the best results and the greatest patient satisfaction, no matter how straight-forward of complex the case.

      • Tony Kilcoyne says:

        Dear Kevin,

        I lecture and get paid lecture/education fees as I do for other topics/advances in Dentistry also.
        Obviously patients pay me for treatment and again as they do for other advanced/progressive options.

        As you know I speak as I find!

        Dear Monica,

        There’s no reason Irtho can’t be taught to Undergraduates – it is no more ‘Special’ than Endo, Perio, Oral Surgery, Paedodontics etc, so why don’t ‘Specialists’ teach Ortho and give good value for students £9k fees over 5 years ???

        If there’s a dental school that would like to offer FastBraces toit’s undergrads, so they can complete several fixed Ortho cases safely, competently and fast, just let me know – I’m sure something can be arranged.

        It’s not Brain-Surgery OR more difficult than any other Dentistry Discipline for Undergrads – why keep them in ignorance and produce a cohort of ortho-ignorant applicants for future ‘Specialist’ training too???

        Orthodontics IS Dentistry – there’s no need to Monopolise or restrict it at undergraduate & GDP level, by neglect or design !!!!!!!

        Yours inclusively,


        • I’m not currently involved with undergraduate training but I’m sure the reason orthodontics is not taught in more detail comes down to time within the curriculum. I’ve heard how clinical teaching time is being squeezed and undergraduates barely have time to complete all the rest of their clinical training, let alone add in fixed appliance therapy. Dental graduates are leaving dental school with much less clinical experience and lower ‘totals’ than I did over 20 years ago.

          Back to the point in hand, there is no talk of restricting orthodontics to specialists, but anybody involved in orthodontics should take the time to properly research and understand the available science and mechanics. Fastbraces make a lot of claims about their appliance, but mostly they are no different from any other fixed appliance. For example root movement occurs with fixed appliances, torqueing could occur early if a rectangular wire was inserted at first vist, but it isn’t always desirable. As for ‘growing bone’, doesn’t it sound similar to claims by Damon a few years back? I’ll believe it when I see a well-planned and executed non-biased study.

          My biggest gripe with the current STO culture is the aggressive marketing by the firms which make their product seem somehow magical and different compared to non-branded systems (Stephanie sums it up very nicely). Worse are the dentists who are taken in by the marketing, become evangelical about their pet product, and refuse to engage in reasoned discussion with those trying to understand and educate.

  5. Dear Kevin,
    Great analysis!
    Fastbraces, Damon system you name it….
    It’s outrageous that they have access to publish this kind of information.
    Some young orthodontist can think: “if Its published, Fastbraces can create bone” exactly what happened with Damon system not so many years ago.

    I truly enjoy reading your blog.

  6. Fastbraces, 6 months smile, Acceledent, Propel, and the soon to come “O’Begg brackets” 😉 Are we in the business of fastodontics now? Some years ago, SLB was suppose to revolutionnize treatment time. Well, it appears it didn’t. Nowadays everybody seems to be doing orthodontic treatment in 3, 6 months. I just can’t. There is something I must have missed (probably more than one would say my ex-wife!). A very wise Professor once wrote: “The most important thing is not the braces, wires, techniques, philosophy and paradigm. The most important thing is THE TREATING DOCTOR. We tend to forget this in our search for improved efficiency.”
    Braces do not treat the patient. The doctor does. Teeth respond to one thing only: pressure. Apply a force on a tooth and it will move (or not!). And teeth are not selective as when they will move or not. The difference with us doing ortho and other doctors who dont is that we understand how the tooth will react to a force. That’s it!
    So what are you comfortable with, when comes the time to treat your patients? What works well in your hands? How would you treat your kids? How would you treat yourself? With what do you achieve the best results?
    Thinking that a new technique or appliance will do all the work in faster time than what the human body can bear, for me is magic thinking. Biology will stay the same, the teeth will still move because of cell reactions. And even if I love new technilogies, I love learning new ways to do things, I can not perceive how we could cut time in half in our treatment time, regardless of the technique we use. Believe me, I hope I am wrong. But for now, fastodontic isn’t just my thing. To all you fastodontist out there: be careful not to cause any fastodontitis to your patients!

  7. Nicky Stanford says:

    This six and a half minute video on fastbraces, orthodontitis and orthodontosis is well worth a watch

  8. Spyros Papageorgiou says:

    Dear Kevin,
    out of curiosity, isn’t this blog 14 days too late?

    Anyways, even if it was theoretically the best treatment option in the world, I would not even consider mentioning it to a patient of mine until at least 4-5 formal RCTs or prospective well-controlled blinded non-RCTs (from independent research groups) have emerged.
    Just my opinion, but if we want to be regarded as health care providers, we should start acting like it.


  9. I instinctively distrust any new way of describing techniques that are wrapped up in mysticism and need to invent all sorts of new words.
    The alveolar bone is there to support teeth, it resorbs after extraction. All bone remodels under the correct tension/pressure. As orthodontists we should attempt to mimic natural developmental processes. The maxilla is a membrane bone and requires stimulation to grow. The mandible is fixed in size but the alveolar bone adapts to the tooth position to match maxillary width. The mandibular teeth can be moved within the alveolar bone and the bone will move along with the teeth. Modern conditions do not provide the correct stimuli. (Look at ancient skulls – most have broad arches and evenly arranged teeth in the absence of disease). If we stimulate natural development to the correct arch width and shape we can then carry out corrections (if needed) for root angulation.
    All else is what works for the orthodontist and the patient. Inventing new words and describing variations of known techniques to get papers published is vanity. Good orthodontics requires minimal retention. If the archwidth is established to the correct dimensions during the appropriate part of the growth period extractions are rarely called for. All orthodontics requires some long-term retention. If someone does not think this they have not monitored their patients for long enough (25 years will reveal the truth).

  10. Seong-Seng Tan says:

    To label crooked teeth as a disease is a clevery ploy to instill guilt in the parent for the purpose of enrolling the patient for treatment. Why didn’t specialist orthodontists think of this before? Seriously, as a community, although not necessarily all its practitioners, specialist orthodontists also engage in questionable marketing practices. Just attend the motivational and marketing lectures at the AAO meetings and you will know what I mean.

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