Marc Bernard Ackerman, DMD, MBA

The American Association of Orthodontics Committee on Medically Necessary Orthodontic Care (MNOC) produced this statement in 2015 that is being promoted at the present time:

“Medically necessary orthodontic care is defined as the treatment of a malocclusion (including craniofacial abnormalities/anomalies) that compromise the patient’s physical, emotional or dental health.  This treatment should be based on a comprehensive assessment and diagnosis done by an orthodontist, in consultation with other health care providers when indicated.”

The Committee went on to recommend against the use of qualitative indices of malocclusion in determining treatment eligibility and instead use the following autoqualifiers for MNOC:

Overjet equal to or greater than 9mm

Reverse overjet equal to or greater than 3.5 mm

Posterior crossbite with no functional occlusal contact

Lateral or anterior open bite equal to or greater than 4 mm

Impinging overbite with either palatal trauma or mandibular anterior gingival trauma

One or more impacted teeth with eruption that is impeded (excluding third molars)

Defects of cleft lip and palate or other craniofacial anomalies or trauma

Congenitally missing teeth (extensive hypodontia) of at least one tooth per quadrant (excluding third molars)

(Records should include a panoramic radiograph, cephalometric radiograph, and intraoral and extraoral photographs.)

Correct me if I’m wrong but it seems to me that this rubric is antithetical to the emotional (psychosocial and social) component of orthodontic need and does not completely jibe with the Committees’ definition of MNOC? 

The crux of the issue is how orthodontists view what they do and why they do it.  Most orthodontists have been indoctrinated early in their professional education believing that they are treating a disease called malocclusion that always requires treatment and if they work hard enough they may just find a cure. Edward Angle’s point of view was that malocclusion is any deviation from ideal. His graduate, Robert H.W. Strang, modified the concept stating that malocclusion is any deviation from normal occlusion. I’ve been told that Strang used to say that all you needed was one crooked tooth to confirm your diagnosis of malocclusion!

Ideal and Normal are orthodontic fiction. These are words that defy description akin to explaining the taste the water. However, they are at the core of the modern orthodontic construct that governs how and why you should do orthodontics. It is this very mindset that precludes many orthodontists from offering consumers (patients in their mind) what they would term substandard treatment or in other words some limited intervention for any other reason than medical health. You can’t get to ideal if you only straighten the front six teeth and ideal keeps non-orthodontists from taking too large a slice of the orthodontic market.

Have you ever wondered about what the implications of the AAO Committee on MNOC recommendations might be? I would argue that by perpetuating the medicalized model of orthodontics, the specialty will give public and private third-party payers a greater justification for rationing orthodontic benefits to their subscribers and in the process, create larger barriers to access to care.  It will also give third-party payers license to require post treatment documentation that will be measured against ideal and potentially determine how the orthodontist is remunerated in the future. “Orthodontic insurance” is a misnomer and from the beginning has been a slippery slope. For years orthodontists encouraged each other not to participate in what used to be called prepaid plans and later to take direct reimbursement.  Today, only a minority of practices operate in the old model.  Orthodontic insurance has become a necessity for orthodontists to make a living and a necessity for the consumer to be able to afford the over-priced fees that most orthodontists charge.  Now I am not arguing that anyone should charge less than the free market will bear.  I am merely saying that if anything changes in the orthodontic insurance industry, it could have a profound effect on price.

With no valid corroboration of medical orthodontics as well as no consensus on what constitutes an orthodontic condition, what determines orthodontic need, what orthodontic treatment is required, and what orthodontic outcome is acceptable it is not inconceivable that there will be shift in thinking, particularly by private insurers on what kind and by whom orthodontics should be rendered. Let’s face it, orthodontics is a commodity and the price of commodities are market-driven.

In sum, I think that the traditional mentality regarding MNOC is a real danger to orthodontics’ bright future.  I would be really careful for what you wish for, especially if those wishes could have unintended consequences.