Its Like Pulling Teeth Case Study Answers

This is something that, as a Boise dentist who is certified to practice orthodontics, I am passionate about! Pulling teeth is NOT the right way to go about straightening your smile.

Why Are Teeth Getting Pulled?

In dental school, I did a research project on orthodontia about pulling teeth for orthodontic treatments. We needed cases of adults with orthodontic work where teeth hadn’t been pulled. But as we were gathering case studies, we didn’t find enough! The huge majority of patients had teeth pulled as part of their treatment plans.

This is shocking, especially considering it hasn’t changed very much, even in recent years. The problem is that many orthodontists get stuck in a “one plan fits all” mentality that requires pulling teeth. In many of these cases, the patient could easily use alternative methods, achieve the same positive outcome, and keep all their teeth to boot!

Why Should You Look At Alternative Options?

There’s no real reason to pull teeth. Here are some of the many reasons to keep all your teeth right where they belong!

1) New Technology

There is technology available that will create space in a patient’s mouth, allowing for all of their teeth to fit safely and smoothly in place. In nearly all cases, surgery and extractions are no longer necessary to achieve good results. Low-friction brackets and nickel titanium wires are two of the most incredible innovations in orthodontia.

2) Joint/Jaw Pain

There is a frightening correlation between having teeth pulled and experiencing Temporomandibular Joint Disorder. You change the dynamics of the musculoskeletal system that is used for chewing when you are missing some of your teeth. This creates a situation where joint pain is far more common. Nearly all of the patients who come in with jaw pain also have tooth extractions in their past for orthodontic work.

3) Aesthetics

Having teeth pulled creates a sunken face because the fullness of the jaw and tooth structure isn’t there. Taking out the premolars really changes the profile from pre-treatment at 13 or 14 to post treatment. Fortunately for this patient, the jaw was pulled forward which dramatically improved facial structure.

4) Less Pain

With the new technology, there is also significantly less pain. The changes that the braces make to correct misalignment are gradual and consistent, rather than abrupt and intense. Typically my patients say that they don’t have days of soreness after they come in to see me, as many normal orthodontic patients have.

5) Save Time and Money

The time it takes to accomplish results for patients using newer orthodontic technology is significantly less than traditional methods. Because it doesn’t take as long, there are fewer appointments to see me and that saves you both time and money. The average price at an orthodontist’s office is around $5,000, while most of my patients pay under $4,000.

Orthodontics at Modern Dental

I can preserve aesthetics, maintain structural integrity of the jaw, and still accomplish the orthodontic work that you need to have straight teeth and a correct bite.

And this is not to say that many orthodontists aren’t doing a great job and meeting the needs of their patients with the latest technology and methods. There are some who have the same values that I have. I’m grateful that they exist. And I hope that their influence can be felt more broadly across their field.

I look forward to the day when I no longer get treatment plans with pulling teeth as a first step. If you need some orthodontic work done and don’t want your teeth pulled, please talk to me today and we’ll do everything we can to find you an alternative treatment plan that suits your needs.

I’ve treated several thousand cases and I know that I’ve pulled fewer than 10 teeth in all that time! This is my soapbox. This is my passion. And I hope that I can convince you of the importance of getting orthodontic treatment without resorting to pulling teeth. If you feel like orthodontics may benefit you, give our dental team in South East Boise a call and we’ll set you up with a consultation to see how we may be able to help.

~Dr. Wagner

Conducting rigorous policy research is a painstaking process. I’ve even heard it compared to pulling teeth—and there’s some truth to that. After all, designing and executing a high quality study can be arduous, but if all goes according to plan, you’ll have a result that helps improve well-being.


I hadn’t thought about any other connections between good dental care and quality policy research until several months ago, when a report from the Associated Press called into question the benefits of flossing. The story went viral because it challenged the conventional wisdom that flossing and brushing are better than brushing alone. And, from my perspective at Mathematica, it made me think about a critical issue that researchers always grapple with—what are the best ways to generate reliable, high quality evidence?


Although there are many ways to answer that question, there are two critical steps that researchers must get right:

  1. Define the question you are trying to answer
  2. Apply the right tools and approach to find the answer


Beyond the Gold Standard

In the case of the Associated Press report, the focus was primarily on the approach. The report cited 25 studies that showed weak or unreliable evidence of flossing’s benefits. As Jamie Holmes, a fellow at New America, wrote in The New York Times, this conclusion was driven by “the absence of support in the form of definitive randomized controlled trials, the so-called gold standard for scientific research.” 


Randomized controlled trials (RCTs) are indeed a bedrock of rigorous research. Mathematica’s nearly 50-year body of work features numerous large-scale RCTs that have generated important insights and influenced decision making across the public policy spectrum. But such studies are not the only option for producing high quality, impactful findings.


In the case of flossing, why is there no “gold standard” evidence about its benefits? Holmes notes that long-term RCTs are difficult to implement, and in this case such an approach would face ethical challenges as well. Instead (as Holmes points out), based on “a range of evidence, including clinical experience,” dentists have concluded “that flossing, properly done, works.”  


Now, I’m not here to argue for either side of the Great Flossing Debate—perhaps clinicians’ experiences are enough to justify the use of floss, and perhaps more rigorous evaluation is necessary to determine its utility. But I believe that expert opinion and scientific research might not be in conflict on this point—they just address different questions.   


Yes, we want to know whether flossing is better than not flossing. But the phrase “properly done” above is critical, as it reflects how the question of interest can vary in subtle ways and can align with different research methods. When dentists assess the benefits of flossing for oral health, they might frame the question in terms of whether a given patient flossing according to their guidelines can generate improved oral outcomes. But researchers might frame the question differently, to look at the effects of how people actually floss, and this question might be addressed most effectively through RCTs or similar rigorous analytical methods applied to data. Hence, one can imagine that one patient might improve his or her oral health by flossing properly, but the broad use of flossing, which might not always be properly done, could have limited effectiveness.           


Addressing Key Policy Questions

The need to ask the right question from the outset is also critical in the policy world. Take education policy, for example. When I led the first national evaluation of the impact of Teach For America (TFA) teachers on student learning, we sought to answer the question of whether TFA had a positive impact on the students it served. We conducted a random assignment study comparing the performance of TFA corps members with that of other teachers in the same elementary schools. We found that students of TFA teachers outscored their schoolmates on math achievement tests and matched their average performance in reading. Hence, we concluded that TFA had a positive effect on the students in the schools that it served at the time.


Many teaching experts saw TFA as harmful because the teachers had not gone through the training that most experts agreed generated good teachers.  Similar to the case with the dentists and flossing, some critics of the TFA findings were upset that our study did not align with their own framing and address the question of whether the program creates good teachers. That is certainly a good question and it might actually sound the same as the question we investigated—but it’s not. To isolate the impact of the program on students, we simply wanted to measure the relative effect of TFA teachers compared with what would have happened in their absence, as represented by the non-TFA teachers.    


These examples do not minimize the validity of the perspectives of experts in the field. But more often than not, answers to tough policy questions are affected by a myriad of contextual factors that can only be sorted out through objective analysis of relevant data. Thus, policy researchers can’t determine which approach to use—be it Bayesian methods, adaptive randomization, rapid-cycle evaluation, or predictive analytics—until we clearly define the research question we are trying to answer. It’s important that we explore all the tools at our disposal to match the right methods with the right questions—even if it sometimes feels like pulling teeth.


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