StraightSmile Solutions®

Yes, some periodontal patients can indeed get orthodontic treatment but it isn’t without risks.

My preference for these patients is always Invisalign over fixed braces for hygiene and also because the forces are slower and lower. This leads to less tissue breakdown over time during treatment.

Also, you need to differentiate between ACTIVE periodontal disease and past periodontal disease.

Patients with ACTIVE disease shouldn’t be treated until it’s resolved and you’ve finished the 1 month evaluation documentation and all pockets are <4mm without BOP. You also don’t want to treat patients who have more than half of their attachment gone. They should have at least 50% of crown to root ratio. Of course you need excellent, recent xrays as well.

I am also NOT a periodontist and neither are general dentists.
I punt every severe patient to perio and have them sign off in writing that they support and advise ortho Tx.
Without that signature, you’ll potentially be liable if something happens, even if you put that disclaimer in writing.

I also let them “baby sit” my patient during ortho Tx ( for PMTs) and let them put on the perio splint at the end for retention ( and I’ll do essix over)

It might be an additional out of pocket fee for the patient, but it’s standard-of-care and any patient who refuses and asks you to cut corners, shouldn’t be a patient you want in your practice.

I know some people think I am contradicting myself, but I am indeed a fan of Invisalign. For a young, healthy, class 1 patient, there are many alternative aligner options for treatment that are just as good as Invisalign and can save you or the patient a lot of money.

That being said, orthodontics isn’t only for kids anymore and for our senior patients, in my professional opinion, Invisalign is the only way to go. Here’s why:


1. The abfractions. Invisalign has the most gentle plastic and the most forgiving trimline- I’ve seen other systems crack teeth with abfractions and extensive fillings..

2. Their pontics are nicest

3. Lowest/slowest forces for perio

If you’d like more information on clear aligner options besides Invisalign or if you’d like help with any aligner or orthodontic case, please contact us at www.straightsmilesolutions.com

First of all, I want to preface this blog that I’ve avoided writing this blog because I am emphatically against premolar extractions for a zillion reasons. Most of the time it’s overkill and not necessary, especially with early intervention. That being said, I want to give my “rules” for extractions:

1. Always, always get a ceph and ceph numbers before even considering any extractions. Watch our content on cephs to learn why and how to interpret or schedule a session with us at www.straightsmilesolutions.com/services for hands-on help with a case.

2. Consider alternatives like IPR, expansion, proclination and distalization (which is SO easy with invisalign and elastics for anchorage as long as the 8’s are extracted!)

3. Always, always screen for OSA and never initiate extractions on any patient who might be at risk for OSA. That means, asking questions, doing an exam and referring as needed if you don’t know. Document, too! If you don’t do OSA and refer and collaborate with a sleep MD in your practice, you aren’t qualified to make this decision. This is a liability. Don’t skip this step!

4. There is ABSOLUTELY NO reason to extract on a growing kid. This isn’t standard of care IMPO. That’s my opinion and the opinion of many orthodontists and likely also a dental board, if questioned. Why risk your license because a parent is pushing you? Extractions are always last resort and growing kids shouldn’t be guinea pigs for sloppy ortho. Refer to someone who can treat properly.

If you’ve done all of the above and you still think the patient is a candidate for extractions, here’s my cookie-cutter approach:


1. You only take out upper bi’s when you are full step class II and only if and only if you’ve exhausted other options above. Use a TPA or nance for anchorage.

2. You only take out 4 bicuspids when the patient is class 1 with severe crowding. If you are worried about profiles, do 5’s but to me those are bigger teeth so extract closer to the crowding.

3. If the patient is slight class 2 with severe crowding, do upper 4’s, lower 5’s but consider a TPA or nance or anchorage.

4. If the patient is slight class 3 (less than 2mm) with severe crowding do upper 5’s, lower 4’s but consider additional, lower anchorage like a LLHA.

5. If there’ is asymmetry, you’ll need to get creative and/or if one premolar is has a less favorable prognosis (eg- perio/endo/caries..etc). It makes the mechanics a bit tricky but it’s doable and the patient will appreciate it.

Oral habits like thumb-sucking and using a pacifier use can be normal, soothing reflexes from birth to one year of age. The majority of children naturally outgrow their habit easily on their own. However, habits that persist after the age of three or four risk oral complications:

• Crooked teeth
• Narrow arches
• Proclined teeth (AKA buck teeth)
• Longer and more complicated orthodontic treatment, possibly including surgery or extractions
• Posterior crossbites (the upper arch fits inside the lower arch)
• Anterior open bite
• Smaller airways
• Impacted teeth
• Long facial height by changing the growth pattern

Eliminating Habits

The first step to eliminating habits is to examine the patient and take limited, orthodontic records. Panos, cephs, and uncomfortable intraoral photos aren’t needed at age 3-5 but may be needed in older children. For children ages 3 and 4, I recommend making the exam fun by having the child use his own fingers to retract his teeth and make a “funny” face while biting his teeth together like an alligator. I used to save a few of these photos to show the child how other kids did it and offer a copy of the photo home as a souvenir.

I also recommend getting a baseline SDB/Habit Questionnaire for documentation. Many pediatric oral trainer companies have their own version of this form, or you can purchase one from our store.

For kids under age 5, often all you need to do to correct the malocclusion is to eliminate the habit. Positive reinforcement is the best step to start:

• Children may suck their thumbs when they feel insecure. Work on correcting the cause of anxiety, instead of the thumb-sucking habit. Stress in the home often needs to be corrected before you can address the habit.
• Reward children when they refrain from sucking. Use a Sticker Chart on a calendar.
• Give verbal praise to the child. Encouragement from siblings also helps. Success with habit cessation is a win for the whole family, and the siblings should also get a reward or a family celebration, like a trip to the ice cream parlor!
• If these methods fail, remind the children of their habit by bandaging the thumb or putting a sock on the hand at night. One of my favorite tricks is to take a large, men’s, long-sleeve T-Shirt and tie knots in the ends of the arms. You can let the child decorate it with fabric pens or tie-die it so that it’s less like a punishment and more like a fun adventure!

If that method isn’t successful, I recommend a soft, removable habit correction appliance which I call a “Tooth Pillow”. These are stock (not custom), so taking an impression isn’t necessary. Fees start at $50 and go up depending on what company you use. Some companies do require you to take a certification course to order these appliances.

For more information, check out our top-selling eBook or watch our YouTube video where I discuss U Concept® U Kiddy, Pacifiers, and Binky help for ages 2-4 years old.

For kids, older than age 5, often more aggressive treatment might be necessary beyond the removable appliances, including fixed or removable palatal cribs and/or palatal expanders. These will require full orthodontic records and an impression or scan.

These custom appliances usually stop thumb sucking immediately. They are used for 6-12 months, at least.

“please fabricate u/l schwartz with no occlusal acrylic, lab please pick best clasps”

This is pretty standard for fixed if you want to archive the script for future patients.

Only variation would be one of the following:

1. Please add anterior bite plate
2. Please add sagittal to distalize tooth _____

3. Please add sagittal screw to advance tooth ____

4. Please add tongue/thumb crib

Ultimately this is pretty easy. Not too many variations.

“please fabricate u/l fixed expander with buccal tubes”

or 

“please fabricate u/l fixed expander”


This is pretty standard for fixed if you want to archive the script for future patients.

Only variation would be one of the following:

1. Please solder anterior bite plate
2. Please solder facemask hooks

3. Please solder tongue/thumb crib

1. Educate Yourself
From my 20 years in the orthodontic industry, I’ve compiled my top tips for selling that ortho case. For more detailed clinical tips and tricks, I recommend my book: https://www.straightsmilesolutions.com/store/ebook/
2. Non-Surgical and Non-Extraction
Advertise yourself as a 99% non-extraction and non-surgical orthodontist in kids under age 10. This can be a very lucrative statement. No one wants to have teeth taken out and nobody likes jaw surgery, so give your customers what they truly want for the parents who are willing to accept Phase 1 treatment! Of course, there are occasional pathology and one-offs who have skeletal asymmetries, hence 99% rather than 100%,
3. Complimentary Panoramic Xray for Screening
Panoramic Xrays are the gold standard for screening kids aged 7 and up for orthodontics. Don’t charge and don’t be stingy – it will pay off in the long run. When parents can visualize potential impactions, the argument for early treatment is all the more powerful.
4. AirwayDontics
Screen every. Single. Patient for airway issues. Use a SDB screening form. Good airways are directly correlated with Phase 1 orthodontics and also better behavior and grades in school, and most parents are unaware of the connection. Educate them with YouTube videos and blogs. For more information, check out our YouTube page, which has hundreds of videos on the subject: https://www.youtube.com/c/Straightsmilesolutionsortho
5. Get Social!
Now that you are loaded with invaluable new knowledge, we have come to the last and the most important step – go and put the knowledge into practice! Start with social media: regularly post some of the claims above to your social media accounts: use Facebook, YouTube, Instagram, and TikTok. Thousands of practitioners are doing this already!

Ultimately, you’ll need to consult your dental practice act in your state or country for the answer on this question.

For me, I only take cephs if there’s a benefit from the cephs. I take cephs on growing kids who need AP or vertical changes and on adults where we are contemplating making drastic AP or vertical changes.

If you are just starting orthodontics in your practice and you don’t want to invest in a ceph arm or module, you can always refer out for the ceph. There are many oral and maxillofacial radiologists in urban areas who often have free-standing xray only practices. https://www.aaomr.org/find-an-omr2#/

If you don’t have a center near you, you can also consider a dental school.

Lastly, find a friend nearby who you can outsource the xray too, who will be professional and not poach your patient.

Allergies are real in orthodontics. The first step is a comprehensive medical and dental history.

The most common allergies are:

1. Latex (Gloves, Braces Elastomerics)
2. Nickel (Metal braces and Wires)

I find most real allergies are usually only in adults. Whenever a patient declares that they have a latex allergy, the first question I ask is, “tell me what happens”. True allergies can manifest just as mild itching all the way to anaphylaxis. If a patient mentions anaphylaxis or swelling of the mouth or tongue or throat, I’ll often request a medical clearance from the patient’s allergist or PCP in order to proceed with treatment with braces.

Although it’s possible to reduce latex or nickel exposure with self-ligating, ceramic braces or aligners vs traditional metal braces with elastomeric ties, it often can add to the patient expense. These products are often more expensive. Treatment is often slower with non-latex elastics vs latex elastics.

I’ve never seen an allergy to clear aligners, but reportedly in the literature it does happen albeit, very rare.

Discomfort is real in orthodontics. I’ve had both braces and aligners as a patient several times and I’ve also treated tens of thousands of orthodontic patients. I can tell you that the pain IS real and management of discomfort is critical to patient trust and compliance.

I always address the elephant in the room at the “start” appointment. Usually, the younger patients have very little discomfort but teens and adults often do. There are two kind of discomfort in orthodontics:

1. Related to rubbing of the new appliances

2. Related to the moving of teeth


All patients should be given wax and orabase at delivery appointment. I usually instruct the patients to use the wax liberally on any area that is bothering them. Take a small piece of wax the size of a pea and press it on any area that is causing irritation. Always use wax before bed as well. Some patients may go through many packages of wax just the first week alone so remind patients they can always buy more at their local drug store or stop by the office for more. Wax should be removed for brushing and flossing but can be worn while eating.
Usually after a few weeks, the lips and cheeks will become more resilient (like wearing new shoes) and the wax will no longer be needed.

Teeth movement is another kind of discomfort. This can express just as a dull aching or a very real, sharp pain that throbs. Usually this will kick in about 24-48 hours after a change of aligner trays or after an orthodontic “tightening” and will last several days. It’s important to get ahead of the pain with OTC painkillers like Motrin and Tylenol. Follow the direction from your MD if you have any questions.

Aligners usually have much lower discomfort than braces but that all depends on the type of thermoplastic material that is used and how the treatment is staged. Aligners that are changed every 3-5 days have much lower discomfort than ones that are changed every 2 weeks because the forces are lower and more gradual.

Occasionally, you’ll have a patient who is having severe discomfort and having trouble managing the pain. I recommend the “pulse” method for short-term, severe, acute discomfort. Have the patient contact their MD with dosages and questions. This involves taking BOTH NSAIDS (like motrin) AND Tylenol but not at the same time. Normally Motrin is taken every 6-8 hours and tylenol is taken every 4-6 hours. Never exceed the recommended maximum dose of either medication. I have the patient start with Motrin at breakfast and make sure they are eating it with a meal. 2-3 hours later they take the first dose of Tylenol just to “stay ahead” of the pain. You don’t wait until you feel discomfort to take the next dose. Stay on a schedule. Every 3 hours or so during the day you are taking a dose of the pain relievers, alternating NSAIDs and Tylenol. The last dose before bed should be the NSAID because it’s longest acting.

I wouldn’t do pulse for more then 24-48 hours and then stop. They may no longer need it after that. Some patients will start pulse BEFORE their aligner change or orthodontic adjustment.

Make sure your patient contacts their PCP or MD with questions about dosages and medications.