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How do the IOTN scores compare with what parents and dentists think relative to orthodontic treatment need?Te vast majority of individuals who had orthodontic treatment feel that they benefted from the treatment and are pleased with the result.Today, medical and dental interventions that are intended to make the individual either "better than well" or "beyond normal" are called enhancements. Typical medical and surgical enhancements are drugs to treat erectile dysfunction, face lifts, and hair transplants. In dentistry, a good example of enhancement is tooth bleaching. In this context, orthodontics often can be considered an enhancement technology. It is increasingly accepted that appropriate care for individuals often should include enhancement to maximize their quality of life. If you really want it because you are convinced you need it, perhaps you really do need it--whether it is orthodontics or many other types of treatment. Medicaid and Medicare and many insurance companies now have accepted the reality that at least some enhancement procedures have to be accepted as reimbursable medical expenses. Similarly, when orthodontic benefts are included in insurance coverage, the need for treatment is no longer judged just by the severity of the malocclusion. Te bottom line: Enhancement is appropriate dental and orthodontic treatment, just as it is in other contexts. A key question, of course, is "Does orthodontic treatment really increase quality of life and self-esteem?"Dentists usually judge that only about one-third of their patients have normal occlusion, and they suggest treatment for about 55% (thereby putting about 10% in a category of malocclusion with little need for treatment). It appears that they include all the children in IOTN grade 3 and some of those in grade 2 in the group who would beneft from orthodontics. Presumably, facial appearance and psychosocial considerations are used in addition to dental characteristics when parents judge treatment need or dentists decide to recommend treatment. ******************************************* Who Seeks Treatment? Demand for treatment is indicated by the number of patients who actually make appointments and seek care. Not all patients with malocclusion, even those with extreme deviations from the norm, seek orthodontic treatment. Some do not recognize that they have a problem; others feel that they need treatment but cannot aford it or cannot obtain it. Both the perceived need and demand vary with social and cultural conditions. More children in urban areas are thought (by parents and peers) to need treatment than children in rural areas.Another way to put this issue is "Does having a less than ideal smile afect the way people act and live?" Tis question was examined by the American Dental Association's Health Policy Institute in 2015.31 An online survey was conducted by the Harris Poll, and nearly 15,000 responses from a randomly selected group of individuals age 18 and older were analyzed. Te study group was evaluated as a whole, by economic status (low, middle, and high household income), and by age (18 to 34, 35 to 49, 50 to 64, and 65 or older). Tis national data set tells an interesting story related to dental esthetics. Twenty-nine percent of low-income adults and 28% of young adults (18 to 34) believed the appearance of their mouth and teeth afected their ability to interview for a job. Tat is over one-fourth of these groups. Twenty-fve percent of all adults said they avoid smiling, 23% feel embarrassed, and 20% experience anxiety because of the condition of their mouth and teeth. But low-income and young adults felt the greatest impact, with a minimum of 30% in each of these two groups indicating that they experienced a problem related to the appearance of their teeth very often or occasionally. Finally, 82% of all responders agreed with the statement "It is easier to get ahead in life if I have straight, bright teeth."For instance, a Brazilian study showed that adults with ideal smiles are considered to be more intelligent and have a greater chance of fnding a job,37 and a systematic review documented patient satisfaction after orthodontic treatment combined with orthognathic surgery.38 Te data can be summarized succinctly: If your dental and facial appearance difers signifcantly from that of your group, you beneft socially from correcting this.A number of studies have documented improvement in quality-of-life scores and self-esteem in children and adolescents,33 and reports have shown quality-of-life efects after orthodontic treatment in children of African, European, and Asian descent.34-36 Multiple studies have shown that this is true for adults as well, and the range of improvements in quality of life extend further than one might have thought.In Switzerland, where high average incomes and supplemental social programs mean that essentially all citizens who want treatment can get it, 56% of the 2012 population aged 15 to 24 years were receiving or had received orthodontic treatment.32 Acceptance of treatment is at similar levels in the Scandinavian countries for the same reasons.Nevertheless, Medicaid and related programs support only a tiny fraction of the population's orthodontic care. 1.22). 1.23).

How do the IOTN scores compare with what parents and
dentists think relative to orthodontic treatment need? Te existing
(rather weak) data suggest that in typical American neighborhoods,
about 35% of adolescents are perceived by parents and peers as
needing orthodontic treatment. Note that this is larger than the
number of children who would be placed in IOTN grades 4 and
5 as having severe problems defnitely needing treatment, but
smaller than the total of grades 3, 4, and 5 for moderate and severe
problems.
Dentists usually judge that only about one-third of their patients
have normal occlusion, and they suggest treatment for about 55%
(thereby putting about 10% in a category of malocclusion with
little need for treatment). It appears that they include all the children
in IOTN grade 3 and some of those in grade 2 in the group who
would beneft from orthodontics. Presumably, facial appearance
and psychosocial considerations are used in addition to dental
characteristics when parents judge treatment need or dentists decide
to recommend treatment.

Who Seeks Treatment?
Demand for treatment is indicated by the number of patients who
actually make appointments and seek care. Not all patients with
malocclusion, even those with extreme deviations from the norm,
seek orthodontic treatment. Some do not recognize that they have
a problem; others feel that they need treatment but cannot aford
it or cannot obtain it.
Both the perceived need and demand vary with social and
cultural conditions. More children in urban areas are thought (by
parents and peers) to need treatment than children in rural areas.
Family income is a major determinant of how many children
receive treatment (Fig. 1.22). Tis appears to refect two things:
not only that higher income families can more easily afford
orthodontic treatment, but also that good facial appearance and
avoidance of disfguring dental conditions are associated with more
prestigious social positions and occupations. Te higher the aspirations for a child, the more likely the parents are to seek orthodontic
treatment for him or her.
Why do they seek treatment for their children? We have already
noted that psychosocial handicaps are the major reason. Another
way to put this issue is “Does having a less than ideal smile afect
the way people act and live?” Tis question was examined by the
American Dental Association’s Health Policy Institute in 2015.31
An online survey was conducted by the Harris Poll, and nearly
15,000 responses from a randomly selected group of individuals
age 18 and older were analyzed. Te study group was evaluated
as a whole, by economic status (low, middle, and high household
income), and by age (18 to 34, 35 to 49, 50 to 64, and 65 or
older). Tis national data set tells an interesting story related to
dental esthetics. Twenty-nine percent of low-income adults and
28% of young adults (18 to 34) believed the appearance of their
mouth and teeth afected their ability to interview for a job. Tat
is over one-fourth of these groups. Twenty-fve percent of all adults
said they avoid smiling, 23% feel embarrassed, and 20% experience
anxiety because of the condition of their mouth and teeth. But
low-income and young adults felt the greatest impact, with a
minimum of 30% in each of these two groups indicating that they
experienced a problem related to the appearance of their teeth
very often or occasionally. Finally, 82% of all responders agreed
with the statement “It is easier to get ahead in life if I have straight,
bright teeth.”
So, although the need for treatment and its assessments and
benefts are usually determined with carefully quantifed dental
morphologic and degrees of craniofacial deformity, poor dental
esthetics is enough to clearly impair people. Often, we lose track
of that simple truth by trying to justify orthodontic treatment at
a higher and seemingly more signifcant level. In fact, people value
straight teeth because it makes their lives easier and better.
Because it is widely recognized now that severe malocclusion
can afect an individual’s entire life, every U.S. state now provides
at least some orthodontic treatment for low-income families through
its Medicaid program. Nevertheless, Medicaid and related programs
support only a tiny fraction of the population’s orthodontic care.
From that perspective, it is interesting that even in the lowest
income group, almost 5% of youths and over 5% of adults report
having received treatment; 10% to 15% at intermediate income
levels have received treatment. Tis indicates the importance placed
on orthodontic treatment by families who judge that it is a factor
in social and career progress for their children.
Te efect of fnancial constraints on demand can be seen most
clearly by the response to third-party payment plans. When thirdparty copayment is available, the number of individuals seeking
orthodontic treatment rises considerably, but even when all costs
are covered, some individuals for whom treatment is recommended
do not accept it. It seems likely that under optimal economic
conditions, demand for orthodontic treatment will at least reach
the 35% level thought by the public to need treatment. In higher
socioeconomic areas in the United States, 35% to more than 50%
of children and youths now are receiving orthodontic care. In
Switzerland, where high average incomes and supplemental social
programs mean that essentially all citizens who want treatment
can get it, 56% of the 2012 population aged 15 to 24 years were
receiving or had received orthodontic treatment.32 Acceptance of
treatment is at similar levels in the Scandinavian countries for the
same reasons.
Orthodontic treatment for adults was rare until the latter half
of the 20th century. In the 1960s, only 5% of all orthodontic
patients in the United States were adults (age 19 or older). By
1990, about 25% of all orthodontic patients were adults (18 or
older) (Fig. 1.23). It is interesting to note that the absolute number
of adults seeking orthodontic treatment remained constant for the
next decade while the number of younger patients grew, so by
2000 the proportion of adults in the orthodontic patient population
had dropped to about 20%. By 2010 it had increased again to
over 25% of the total, and the most recent survey by the American
Association of Orthodontists (2014) indicated a further increase
to about 27%. In 2014 the average American orthodontist was
treating 125 adult patients. In 1989, the earliest year in which
that fgure was recorded, it was 41.
Many adult patients indicate that they wanted treatment earlier
but did not receive it, often because their families could not aford
it; now they can. Wearing braces as an adult is more socially
acceptable than it was previously, although no one really knows
why, and this too has made it easier for adults to seek treatment.
Recently, an increased number of older adults (40 and over) have
sought orthodontics, usually in conjunction with other treatment,
to save their teeth, and the majority of that oldest subgroup were
male (every other age group from childhood on has more females).
As the population ages, these older adults are likely to be the fastest
growing group who seek orthodontic treatment.
Many of the children and adults who seek orthodontic treatment
today have dentofacial conditions that are within the normal range
of variation, at least by defnitions that focus tightly on obvious
degrees of handicap. Does that mean treatment is not indicated
for those with lesser problems? Today, medical and dental interventions that are intended to make the individual either “better than
well” or “beyond normal” are called enhancements. Typical medical
and surgical enhancements are drugs to treat erectile dysfunction,
face lifts, and hair transplants. In dentistry, a good example of
enhancement is tooth bleaching.
In this context, orthodontics often can be considered an enhancement technology. It is increasingly accepted that appropriate care
for individuals often should include enhancement to maximize
their quality of life. If you really want it because you are convinced
you need it, perhaps you really do need it—whether it is orthodontics or many other types of treatment. Medicaid and Medicare
and many insurance companies now have accepted the reality that
at least some enhancement procedures have to be accepted as
reimbursable medical expenses. Similarly, when orthodontic benefts
are included in insurance coverage, the need for treatment is no
longer judged just by the severity of the malocclusion. Te bottom
line: Enhancement is appropriate dental and orthodontic treatment,
just as it is in other contexts.
A key question, of course, is “Does orthodontic treatment really
increase quality of life and self-esteem?” A number of studies have
documented improvement in quality-of-life scores and self-esteem
in children and adolescents,33 and reports have shown quality-of-life
efects after orthodontic treatment in children of African, European,
and Asian descent.34-36 Multiple studies have shown that this is
true for adults as well, and the range of improvements in quality
of life extend further than one might have thought. For instance,
a Brazilian study showed that adults with ideal smiles are considered
to be more intelligent and have a greater chance of fnding a job,37
and a systematic review documented patient satisfaction after
orthodontic treatment combined with orthognathic surgery.38 Te
data can be summarized succinctly: If your dental and facial
appearance difers signifcantly from that of your group, you beneft
socially from correcting this.
Orthodontics has become a more prominent part of dentistry
in recent years, and this trend is likely to continue. Te vast majority
of individuals who had orthodontic treatment feel that they benefted
from the treatment and are pleased with the result. Not all patients
have dramatic changes in dental and facial appearance, but nearly
all recognize an improvement in both dental condition and psychologic well-being.