Are Palate Expanders One Of Orthodontia’s Biggest Scams?

Want to see parents of school-aged children get riled up? Simply bring up the topic of orthodontics — crooked teeth, crossbites, braces, retainers and more. Whether they’ve got children in the midst of wincingly expensive dental ministrations, or their monthly D.D.S. payments are still on the horizon, the subject brings up a soupcon of feelings: dread, nostalgia, wariness, or straightforward financial panic. Often a mix of all of the above. And if you really want to get them going, ask them if they have any familiarity with the phrase “palate expander.”

“I had one as a kid! Hurt like hell!” says one mom, in a recent Facebook post about the topic. “It feels like alllll my friends’ kids are getting them these days,” chimed in another. “All three of my kids had one! Hated it. I couldn’t bring myself to turn the key— my partner had to do it,” said a third parent. And “My husband is convinced it’s a medieval torture device used to get more money out of vulnerable parents and orthodontists undersell the complications and parent responsibility!”

Palate expanders, for those lucky enough to not know, are small metal devices that have been in use since the late 19th century, and they look and function like they haven’t been updated since. Temporarily anchored to the back top teeth of a child’s upper jaw, and meant to literally crank open said jaw a few extra millimeters before the palate is fused in late puberty. Expense aside (orthodontia is only very rarely covered by insurance), expanders are a team effort. An adult has to insert a tiny tool and literally turn the screw to open the device wider, millimeter by millimeter, day by day. Everyone is affected — and complicit.

And if you listen to parent chatter in the pick-up scrum, they seem increasingly common. But are they necessary? According to some experts, these devices — while effective — are being vastly overused, especially in younger children. Sometimes being installed in kids as young as 3 or 4. So much so that last year, Dr. Neal Kravitz, D.M.D., editor-in-chief of the Journal of Clinical Orthodontics and a faculty member of the Harvard School of Dental Medicine, published a paper from Seminars in Orthodontics, titled “Everybody Gets an Expander.” (Kravitz tells me the title is meant to be read in the style of Oprah’s “You get a car!”)

In the paper, Kravitz explains that there has been a movement since the 1990s years toward two-phase treatment: a first phase during preadolescence (around age 8) with expanders and then braces on just a handful of teeth in the front of the mouth, followed by a second phase during adolescence with full-mouth braces. “But there is no evidence that this approach is more effective or more efficient,” says Kravitz. “It is, however, much more expensive for the family. In the vast majority of cases, children can wait until middle school during peak pubertal growth and receive a single phase of comprehensive orthodontic treatment.”

So, it’s both being done too early and too often, he notes. In fact, only about 10% of kids will truly have the skeletal constriction that demands an expander, and using a palatal expander without this has limited indications and questionable benefit. For many parents, it feels like that 10% number is too low, simply based on what they’re hearing and experiencing.

The hope behind all of these expensive ministrations is a widening of the upper jaw. This is the primary reason orthodontists should prescribe expanders, says Dr. Olivier Nicolay, D.D.S., clinical professor and chair of orthodontics at the New York University School of Dentistry. The jaw size discrepancy obviously leads to the appearance of crowded teeth but can also lead to what’s known as a crossbite, malocclusions (i.e., your teeth or bite doesn’t line up), and other possible problems in the long run. Those include trouble chewing and eating, as well as uneven tooth and gum wear and tear, says Dr. John Callahan, D.D.S., the president of the American Association of Orthodontists and an orthodontist in central New York.

Once the palate has been widened (called Phase 1 at some orthodontic practices), the teeth ideally have more room to get into a more comfortable and desirable alignment — which then becomes the work of braces to make permanent. (What, you thought you were done?) Braces typically come soon after the expander has been removed. Welcome to Phase 2.

I’ve had my own Phase 1 fun, so to speak. A few years ago, my daughter, now 15, had an expander in her mouth, for what was described to me as a narrow upper jaw — and subsequent crowding of her teeth, which were all overlapping, especially in the front. We managed not to lose the tiny, precious tool — called a swivel key — but we did manage to find ourselves back in the office for a redemonstration when our (my) first attempts to insert and turn led to gagging (her) and crying (both of us).

Only about 10% of kids will truly have the skeletal constriction that demands an expander, and using a palatal expander without this has limited indications and questionable benefit.

With braces and other orthodontia, the line between health and aesthetics has always been fuzzy. “It’s really hard to tell what is really necessary,” says Lyla, a mom of two in Upstate New York. “And you sort of have to take the doctor’s word for it. With my son, it was obvious that his teeth were crooked, but then they started suggesting all these other things, like extractions, and I wasn’t sure. It’s all sort of a mystery — and a fine line between vanity and necessity.” Plus, doctors often talk about how a bad bite or crooked teeth can “cause problems later,” but those can feel vague and not that substantiated. Those problems tend to be jaw-related or alignment related, but doctors don’t often elucidate what those problems really are.

Perhaps that’s because we put such social and emotional weight in smiles — for those who can afford it, paying to improve them is a given. According to a study by the American Academy of Cosmetic Dentistry, 48% of people say a smile is the most memorable attribute people remember, regardless of age. In a survey conducted by the American Academy of Cosmetic Dentistry (AACD), 74% of people said they believe an unattractive smile can hurt a person’s career. According to a survey from the American Dental Association’s (ADA) Health Policy Institute, 82% of respondents believe that “straight, bright teeth help you get ahead in life.” For parents trying to give their kids every opportunity in life, this could be one of those things you just can’t skimp on — even if it means getting into debt for a few years of braces.

“We have a real problem with overmedicalization in the pursuit of added revenue. No matter the field of medicine or dentistry, when treating children, you can achieve more by doing less.”

Kathy, a mom of three in North Carolina, has had many friends “who let their orthodontist talk them into making their kids get braces twice. Once in third or fourth grade and then again, later on in middle school or later. When I asked why have it done twice, they really didn’t have an answer for me, just that ‘We recommend it…’ I think they prey on the fact that you don’t really know anything, and most people won’t push back.”

Some orthodontists are also suggesting expanders for kids who have airway and breathing problems that affect their sleep — i.e., obstructive sleep apnea (OSA). This must be done as part of a team effort with a child’s physician and ear, nose, and throat doctor (ENT) and be done after other testing and treatment, says Dr. Shankar Rengasamy Venugopalan, D.D.S., an associate professor at Tufts University School of Dental Medicine. Unfortunately, some orthodontists and other dentists are going straight to expansion to help with breathing and sleep issues, and a number are doing so based more on anecdotes rather than good science, says Dr. Mitchell Levine, D.M.D., a spokesperson for the American Academy of Sleep Medicine and associate professor of orthodontics at St. Louis University. The research on whether expanders can help is mixed,” says Levine. “There is no correlation between airway dimensions and OSA. Many patients who undergo [expander] treatment have not had an actual sleep study.”

There are actually some studies that have shown that expansion has made apnea worse, notes Venugopalan, who says that the first and best treatment for kids who have sleep apnea is typically to be checked by an ENT for enlarged tonsils and adenoids, which can require surgical removal.

Translation: If your orthodontist goes straight to expander because your child snores, take a big step back. “We have a real problem with overmedicalization in the pursuit of added revenue,” says Kravitz. “No matter the field of medicine or dentistry, when treating children, you can achieve more by doing less.”

So what should ambivalent parents do when faced with so much money and discomfort — not to mention the fate of their child’s smile — on the line? First, you should know that in large part, most orthodontists aren’t trying to pull a fast one, says Callahan. Yes, unfortunately, there are some more profit-hungry ones who are sort of spoiling it for everyone else. To find someone you can trust, make sure that you’re seeing a certified orthodontist, and Callahan suggests finding someone who is a member of AAO.

Parents should listen carefully when their orthodontist suggests an expander and ask questions about why it’s being recommended, especially since technically “crowded teeth” is not in and of itself enough reason. And definitely consider getting a second opinion if you’re unsure. In some cases, extractions or even a “watch and wait” approach is better. It certainly costs less.

And finally, if after a lot of soul-searching you do end up getting an expander for your child, just be sure to ask for a spare swivel key.

Liz Krieger is a writer and editor whose work has appeared in Good Housekeeping, Health, The Cut, Travel + Leisure, and many more. She lives in Brooklyn with her husband, two daughters, two inscrutable cats, and one exceedingly scruffy rescue dog. You can follow her on Instagram and Twitter.