Uncertainty of Orthodontic Benefit and the

Questionable Ethics of Marketing

Bill Shaw

Despite increasing demand for orthodontics, research over several decades has
consistently failed to provide firm evidence of social or psychological benefit.
This article reviews work in the field, explores possible reasons for these
negative findings, and raises questions about current professional response
and the ethics of marketing. (Semin Orthod 2012;18:210-216.) © 2012 Elsevier
Inc. All rights reserved.

oncern about physical appearance is a com-
C mon feature of human activity, as we aspire
to culturally dictated norms and a desire to be
liked, respected, or accepted by those around us.
The drive to conform and be admired is perhaps
greatest for the teenager, but throughout adult
life, most individuals pay daily attention to their
appearance. It is not surprising that in today’s
appearance-preoccupied society, individuals with a
disfigurement that is visible to others may be sub-
ject to social difficulties, including negative im-
pacts on self-perception and self-esteem.1,2 Nick-
names, teasing, and harassment, as most of us will
recall, can be everyday occurrences in the hostile
environment of the playground. The long-term
effects of teasing on the development of personal-
ity are undetermined, but one may readily imagine
that, for some children, sustained ridicule and in-
sult may promote lower self-confidence and alien-
ation.
Evidence for Unfavorable Social
Response Related to Dentofacial
Variation
Conspicuous defects of dental appearance may
represent a particular social disadvantage be-
Professor of Orthodontics, Department of Oral Health and De-
velopment, University Dental Hospital of Manchester, Manchester.
Address correspondence to Bill Shaw, BDS, PhD, CBE, Depart-
ment of Oral Health and Development, University Dental Hospital
of Manchester, Higher Cambridge St, Manchester, M15 6FH, UK.
E-mail: bill.shaw@manchester.ac.uk
© 2012 Elsevier Inc. All rights reserved.
1073-8746/12/1803-0$30.00/0
http://dx.doi.org/10.1053/j.sodo.2012.04.006
cause they can never be hidden by clothing or
makeup. If defective dental appearance is a dis-
advantage for the individual, it will operate by
evoking an overtly unfavorable social response
such as teasing, by negative stereotyping, or by
impairing self-esteem.
Dental deviations may indeed become a tar-
get for teasing, and in one survey of children
between 9 and 13 years of age, 7% were teased
about their teeth once per week or more.3 Com-
ments about the teeth appeared to be more
hurtful than those about other features, with
60% of the group teased about teeth admitting
that they disliked or were upset by it. In a Danish
retrospective survey, 7% of adults also recalled
being teased about their teeth in childhood, and
every second individual with an overjet ⬎9 mm
could recall teasing.4 One point arising from the
childhood study was that those children who
were the victims of aggressive behavior were also
described by their teachers as introverted, and it
seems likely that teasing is attracted not only by
the presence of a defect but also where the
aggressor is confident of coming off best.
Negative attribution or stereotyping is more
subtle and covert in its operation. The research
on which current hypotheses are based has been
conducted by social psychologists investigating
the so-called physical attractiveness stereotype,
and it has been shown that, on the basis of first
impressions, society attributes to attractive indi-
viduals a series of desirable personality traits,
such as intelligence, honesty, and likeability. It is
then supposed, although as yet not convincingly
proven, that a self-fulfilling prophesy is subse-
quently invoked. In other words, the individual

210 Seminars in Orthodontics, Vol 18, No 3 (September), 2012: pp 210-216

 Uncertainty of Orthodontic Benefit
grows into the role that everyone expects of him
or her by having a privileged opportunity to
develop desirable social skills through favorable
response and encouragement.
The theory does have an appeal and probably
a degree of truth, but fortunately for the major-
ity of us, it seems that further extended knowl-
edge of an individual within the full complexity
of human interaction diminishes the impact of
physical attractiveness and allows other more
important qualities to assert themselves. A meta-
analysis of the “beautiful is good” literature sug-
gested that looks are relatively less important in
perceptions of friends, acquaintances, family
members, and coworkers than in perceptions of
strangers.5 More recently a study allowing just 3
minutes of interaction concluded that less at-
tractive individuals may not necessarily suffer
from being viewed inaccurately.6
Similar research approaches have confirmed
that stereotyping mechanisms do exist with re-
gard to dental appearance. In a series of such
investigations, facial photographs were modified
so that 5 different dentofacial arrangements could
be displayed within the same face.7 Judges, unin-
formed as to the true nature of the investigation,
were asked to view only one photograph and to
record their judgments of the viewed individual
along a series of scales. The results of these and
related studies showed 2 things—faces can evoke a
more favorable response when demonstrating nor-
mal incisors, but the level of background facial attrac-
tiveness asserts a significantly stronger influence on
viewer judgments than the dentition does.7,8
As noted earlier, however, an acknowledged
shortcoming of much stereotyping research is
the lack of real-life interaction. In one dentofa-
cial experiment, this weakness was addressed by
contriving face-to-face encounters, albeit ex-
tremely brief. Four actors, individually approached
different passersby in the street to request signed
endorsement of a petition concerning a topical
social issue of the period.9 With the assistance of
professional makeup artists, the actors, 2 male and
2 female, acting in a standardized manner, pre-
sented as normal or bearing 1 of the following 3
conspicuous facial anomalies: a port-wine stain, a
keloid, or extremely prominent maxillary incisors.
A total of 7200 confrontations were staged, and
one actor gained significantly more petition en-
dorsements than the others, confirming the influ-
ence of individual personality in social interac-
211
tions. Both female actors were significantly more
successful than the male actors. However, there
was no effect whatsoever detected for any of the
facial variations presented by the actors, including
the unsightly teeth.
Evidence for Impaired Self-esteem and
Other Psychosocial Disadvantage
Related to Dentofacial Anomalies
The psychological risk imposed by the less ex-
treme variations in the alignment of the teeth
that make up the everyday caseload of orthodon-
tists is uncertain. Negative personal perception
of the acceptability of one’s dentition may re-
flect experience of actual teasing or personal
comparisons with the teeth of other individuals
encountered directly or in media images. Cer-
tainly, there is considerable variability of adjust-
ment to unsightly malocclusion, from deep con-
cern to complete disregard.10,11
A multidisciplinary research program at the
University of Wales in Cardiff to address these
issues in a “real-life” manner was initiated with a
cohort of 1018, 11-12-year-old participants in
1981. Extensive assessment of dental health and
psychosocial well-being was recorded; facial and
dental photographs and plaster casts of denti-
tion were obtained and rated by a lay panel for
attractiveness; and an objective index of maloc-
clusion was applied. No recommendations about
orthodontic treatment were made to the chil-
dren and their families. Instead, an observa-
tional approach was adopted. A prospective lon-
gitudinal cohort design with 4 studies of the
effect of orthodontic treatment was performed
during a 20-year period. Secondary analysis of
outcome data incorporated orthodontic need at
baseline, and treatment was received in a 2 ⫻ 2
factorial design. At the third follow-up, 337, 30-
31-year-olds were re-examined in 2001.12
The early stages of this study provided little
support for the major hypothesis that children
with visible malocclusion were likely to be so-
cially and psychologically disadvantaged.13 Each
child’s popularity was derived from classmate
ratings, and the views of each child’s teacher
were recorded. Contrary to the “still-life” attribu-
tion studies conducted previously, the popular-
ity and friendship of participants were uninflu-
enced, even by extremes of facial and dental
attractiveness. No difference was detected in self-
212 Shaw
esteem or scholastic performance. The same
lack of effect was confirmed when the children
reached age 15-16 years, with no evident advan-
tage noted in having naturally straight teeth or
in having visible malocclusion corrected.
Several points of caution were made with re-
gard to these initial conclusions, one of which
related to the measures used in the early stages
of the study. The operational definition of psy-
chological well-being is heavily dependent on
the measures available to the health psycholo-
gist, and since the early 1980s, the number of
validated measures of psychological health in-
creased substantially. In 1981, however, self-es-
teem was considered to have a major causal influ-
ence on psychological well-being in children and
has stood the test of time as one of a limited
number of validated health measures previously
available. Over the years, a high level of self-accep-
tance or self-respect has been held to be an impor-
tant component of positive mental health.14-16
The concluding study in the longitudinal in-
vestigation12,17 acknowledged the fact that cur-
rent health psychology has deconstructed the con-
cept of psychological well-being, providing far
wider operational definitions and well-validated
outcome measures of psychological health, emo-
tional health, and quality of life in a number of
domains including health, as well as measures of
life events, perception of stress, and general health
status. Accordingly, a wide range of measures were
applied in the appraisal of the 30-31-year-olds in
this concluding study. However, even in a sub-
group whose orthodontic change had been sub-
stantial and stable, no significant effect on psycho-
logical health, life satisfaction, quality of life, or
health status could be detected.
The findings demonstrated that analyzing the
long-term effects of orthodontic treatment on
psychological health without considering inter-
vening factors may lead to invalid conclusions
regarding the efficacy of such treatment. The
finding that participants who received orthodon-
tic treatment had significantly higher scores on
some psychological health variables than those
who did not receive treatment appeared to be an
artifact. When previous need for treatment 20
years earlier was taken into account, there was
little objective evidence to support the belief
that orthodontics improves psychological well-
being in adulthood. In addition, lack of orth-
odontic treatment when there was a previous
need for treatment did not lead to psychological
difficulties in later life in the form of nonpsy-
chotic mental disorder, depressive disorder, so-
cial anxiety, or social phobia. The observed ef-
fect of previous need and orthodontic treatment
on self-esteem at outcome was accounted for by
self-esteem at baseline. This finding emphasizes
the need for longitudinal analysis of baseline
and outcome data when evaluating the effect of
treatment on psychological variables. Partici-
pants’ self-esteem increased during a period of
20 years, but not because of receiving orthodon-
tic treatment, and regardless of whether an ear-
lier need for treatment existed at baseline.
These findings concur with those of an earlier
comparison of a group of US adults who had
received orthodontic treatment and a (nonran-
domized) control group who had not.18 In a
randomized control group design, it was found
that treatment did not affect self-esteem in an
American sample of 93 participants aged 11-14
years.19 However, in a randomized controlled
trial of 174 British children aged 8-10 years with
Class II division 1 malocclusion, children who
received early treatment were found to have an
increase in self-esteem compared with control
subjects, but only in the short-term.20
Some investigators have narrowed the focus
in studies concerning malocclusion and quality
of life by collecting subjective data, with mea-
sures specifically developed to determine oral
health-related quality of life. However, recent
reviews of these studies confirm that although
patients commonly seek orthodontic treatment
to improve psychosocial well-being, malocclu-
sion and orthodontic treatment does not appear
to affect general or oral health quality of life to
a measurable degree.21,22
Factors Influencing the Receipt of
Orthodontic Treatment
Possession of a definite malocclusion is by no
means the only factor that determines whether
an individual will receive orthodontic treatment.
Indeed, the presence of a malocclusion may be
hardly necessary at all. The eventual decision to
embark on orthodontic treatment reflects the
interaction of factors on the side of the consum-
ers (patient and parent) and providers (the in-
dividual dentist or orthodontist and the health
system generally).
 Uncertainty of Orthodontic Benefit
Among consumers a key motivating factor in
the desire for orthodontic treatment is the op-
portunity for an improved appearance, with im-
proved dental health and function often second-
ary in the individual’s personal priorities. Indeed,
in one study, most respondents reported that they
would rather have straight teeth than healthy
ones.23 Concern with body image is fostered by the
grooming behavior that most children learn from
their parents, the advertising industry, and the intu-
itive knowledge that achieving success with the oppo-
site sex is a competitive business. Just as the media
impose pressures on female and male adolescents
to conform to idealized body types, the prevailing
idealistic media image of the face includes a white
well-aligned anterior dentition.24
Discrepancy between one’s ideal body image
and one’s perceived body image leads to discon-
tentment and possible remedial action: a change
in hairstyle, going on a diet, or getting a tan. Being
able to delegate the task of such self-improvement
to a third party, such as the orthodontist, may be
particularly attractive.
The primary elements in the motivation for
an aesthetic improvement in the dentition is the
extent of the discrepancy between perceived
normal occlusion and the self- (or parent-) per-
ceived malocclusion, and how well the perceived
discrepancy can be tolerated or accepted. In as
many countries as have been studied, consumers
agree that the orthodontist’s ideal occlusion
looks best, and that the desirability of treatment
increases with the extent of deviation from this.
It is also evident, however, that a fairly wide
range of variation is regarded as acceptable or
normal. A predictable, fairly strong relationship
between the objective severity of the visible ir-
regularity and the desire for orthodontic treat-
ment has been confirmed, but equally clear is
the frequency with which individual subjects will
act inconsistently. Studies both in Britain and
North America have shown that a large propor-
tion of children with objectively good occlusion,
in one case as many as 50%, are dissatisfied with
their teeth.10
The explanation may lie partly in the impre-
cise way in which individuals have viewed or per-
ceived their own teeth before visiting the ortho-
dontist. In one study, for example, children’s and
parents’ descriptions of the child’s dentition from
memory were generally inaccurate, and further-
more, almost one-third of children and parents
213
were unable to identify a photograph of the
child’s teeth.10 However, when given the oppor-
tunity to examine the child’s teeth in a mirror,
both child and parent could place the dentition
on a scale of dental attractiveness at a point that
reasonably coincides with the orthodontist’s ob-
jective rating.25
Although we have seen that having a maloc-
clusion appears to have little bearing on self-
esteem, effects in the opposite direction have
been found. Variations in self-esteem can influ-
ence personal judgments of the severity of the
malocclusion. Thus, it was found that children
who underrate their own dental appearance
have, on average, lower self-esteem.26
In a sense, it would seem reasonable in arriving
at a decision on treatment need for the “underra-
ters” to be given the benefit of doubt, in other
words, to accept their rating as being more impor-
tant than the objective one. Unfortunately, their
lower self-esteem would be likely to persist after
treatment, and a careful balance would be neces-
sary in discouraging entry to treatment that might
be harmful by other criteria.
General Trust in the System (Conveyor
Belt Orthodontics)
The remarkable faith that consumers have in the
services they receive was emphasized in a survey
of the expectations that patients and parents in
the United Kingdom and United States believed
their orthodontic treatment would yield, which,
in the light of evidence of the effects of maloc-
clusion, is rather optimistic.27 It is unlikely that
this represents the reiteration of convincing
sales talk but rather that the dentist’s referral to
orthodontic care carries with it a strong implicit
message that it is both necessary and worthwhile.
Nearly 50% of patients referred to a suburban
orthodontic practice in the United States were
there because their dentist said they needed
braces or because they were under the impres-
sion that orthodontics was essential to the health
and longevity of their oral cavity.28 Patterns of
referral from one dentist to the next are likely to
be highly varied, and thresholds of referral will
reflect the rigor of examination (especially with
regard to unerupted teeth), the dentist’s subjec-
tive perception of need, and the possible appli-
cation of a formal priority index in the local
system of treatment provision.
214
Unless treatment is rationed or governed by a
priority index, referral to the orthodontist will
generally initiate a conveyor belt of entry into
orthodontic treatment, with little or no reflec-
tion or discussion even when the level of treat-
ment need is low. Studies in Britain and The
Netherlands have shown that at least in the past,
dentists and orthodontists are rather more crit-
ical than the public about the range of dental
irregularity that is acceptable.11,29 Most devel-
oped countries have seen a steady increase in
the number of courses of orthodontic treatment
provided annually.30,31 The capacity of any
country’s dental system for orthodontics reflects
the number of dentists in the country, the propor-
tion who undertake some orthodontics, the pro-
portion who are in full-time orthodontic practice,
whether they are permitted to employ dental assis-
tants in an extended role, and the number of cases
a single orthodontist is judged able to treat. (The
last statistic is probably the main determinant of
treatment standards.) When all barriers to care
including cost are removed, the uptake of orth-
odontic treatment may be as high as 60%, such
that children who do not receive orthodontic treat-
ment are in a minority.32
Professional Ethics and Veracity in
Promoting Orthodontics
After an increase in the provision of orthodon-
tics by general and pediatric dentists, it has been
noted that orthodontists have been mass market-
ing the speciality and their particular expertise,
and although treatment used to be promoted
under the guise of oral health improvement, it is
now being promoted to patients as life enhanc-
ing.28 This approach to enlisting patients has
been criticized on the grounds that it lacks ve-
racity, and as such is in conflict with one of the
principles enshrined in the American Dental
Association code of ethics. Certainly misleading
English language examples of the likely benefits
of orthodontic treatment can readily be found
in the Web pages of individual practices and
official Web sites:
Why should I have my teeth straightened?
Orthodontic treatment improves your smile and
your health. Your smile is the most striking part of your
face. Look in the mirror. Do you like your smile now?
Can your smile be improved? Think about how you
Shaw
react to someone with a pretty smile. Do you find them
more attractive? Will you be more attractive with an
appealing smile? Orthodontic treatment will make your
smile look fabulous. The fabulous smile can last for the
rest of your life. Think about how a fabulous smile will
improve your life. Orthodontic treatment will also make
your face look delightful. Wouldn’t a delightful face be
wonderful?
Your health is also affected by poorly arranged teeth
that can break easily and trap food particles that cause
tooth decay and gum disease. They can also lead to
poor chewing and digestion, which can be bad for your
overall health, such as:
● Dental problems. Crooked teeth are hard to clean
so that people with crooked teeth tend to have more
cavities and gum problems than people who have
orthodontic treatment. Crooked teeth wear in ways
that they should not. This puts extra stress on your
teeth, gums, and jaw, which can lead to problems
later on.
● Breathing problems. As you get older, the roof of
your mouth can sometimes partially block the air
passages in your nose. If you have orthodontic treat-
ment you may avoid this possibility.
● Statistically, people who have had braces as
children have lower incidence of cardiovascu-
lar disease as adults. Children who get braces learn
to take care of themselves and that translates into a
reduced risk for cardiovascular disease. There are
also some recent data that indicate oral bacteria
might play a direct role in cardiovascular disease, by
dissolving calcium in your mouth and depositing it
into your arteries. Orthodontics helps prevent oral
infections that may have a direct effect on heart
disease.
Why Is There No Evidence of
Significant Social or Psychological
Benefit From Orthodontic Treatment?
It has been demonstrated that individuals with a
significant malocclusion have a more favorable
perception of and higher satisfaction with their
teeth after treatment.12,17 However, self-esteem
does not improve, and visible malocclusion has
no discernible negative effect on social and psy-
chological well-being. It has been suggested that
this reflects the operation of what psychological
research describes as a “hedonic treadmill.”22
Longitudinal studies across a wide range of hu-
man experience infer that good and bad events
 Uncertainty of Orthodontic Benefit
affect happiness, but only in a transient way.
Each individual has a “set point” for happiness,
and even major life experiences bring about
relatively little long-term change.33
It would seem especially unlikely that individ-
uals who find themselves on the “orthodontic
conveyor belt” with little previous concern about
a visible malocclusion, or a malocclusion that is
not visible, will find their lives much affected by
orthodontics.
What Is the Responsibility of the
Orthodontic Profession at This Time?
The volume of research in this area, especially
longitudinal research, is remarkably scant for a
profession that aspires to a great deal of research
on the methods and technologies of treatment.
This complacency may reflect the fact that the
current demand for orthodontic treatment is
high, almost regardless of geography and health
systems.31 Thus, one might reasonably regard
the benefits of orthodontic treatment as self-
evident. Certainly, prospective patients (and par-
ents) seem confident of the gains they expect to
achieve when commencing orthodontic treat-
ment.27,34
In recent decades, however, health profes-
sionals have come under increasing pressure to
demonstrate their worth with factual evidence of
benefit. For example, dentistry has been urged
by the US Institute of Medicine to “improve our
knowledge of what works and what does not
work” in the advancement of oral health objec-
tives. The report noted: “a focus on health out-
comes is essential for dental professionals and
dental services in achieving desired health out-
comes for individuals and communities, and
cannot simply be assumed, but must be demon-
strated to patients, other purchasers of dental
services and policy makers.”35
If indeed there is no significant oral health
benefit or quality of life benefit for a large pro-
portion of routine orthodontic treatment, then
there is a compelling need for collective effort
by the orthodontic profession to confront this
uncomfortable situation in an ethical and open
manner. It seems a highly inappropriate time for
national bodies to embark on mass marketing
campaigns to stimulate orthodontic demand
(such as the NOW campaign of the British Orth-
odontic Society,36 that appear driven by a “need
215
for more lucre”28 rather than a concern for the
well-being of young people). Instead, a collective
investment in high-quality research would seem
more timely and honorable.
What Research Is Needed Now?
The first research priority must be to develop high-
quality, multidisciplinary, prospective research
studies. Random allocation, by far the preferred
option for minimizing bias in treatment versus
nontreatment comparisons, is difficult to achieve in
orthodontics because individual patients with the
common range of malocclusion will themselves de-
cide whether they desire treatment, whether they will
comply with treatment, or whether they will accept
nontreatment as an option. Randomization is
more achievable when treatment is deferred,
rather than denied, as in several recent Class II
division 1 trials. This approach, however, obviously
precludes long-term comparison of treatment ver-
sus no treatment.
An opportunity for random allocation to treat-
ment or nontreatment, rather than treatment or
delayed treatment, arises in the context of social-
ized services, where cases below a fixed level of
severity are ineligible for free or subsidized treat-
ment. In these circumstances, sample sizes would
require adjustment to achieve sufficient power to
detect significant difference in outcome.
A second line of investigation that is urgently
required is an exploration of alternative inter-
ventions for managing patients who are referred
for treatment in the absence of a clear likeli-
hood of health gain but because of a strongly felt
subjective need. These might include the devel-
opment of candid age-appropriate information
packages and self-rating exercises to allow a
clearer grasp of the cost/benefit implications of
active treatment. Along with this should be the
development of clearer evidence-based guide-
lines for dentists who initiate most referrals and
for orthodontists to use in their crucial role in
explaining cost/benefit balance.
The third issue may be less easy to resolve.
The over-representation of ideal occlusion in
magazines for young people has parallels with
the negative influence produced by the com-
mon appearance of models with “ideal” body
images. If good quality research continues to
cast doubt on the long-term benefits of orth-
odontic treatment, then the profession’s role
216
will be to take a lead on developing an ethical
public health message.
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