In college when I asked my friend Charlie his type, he said, "straight teeth." His type once got braces for two years—sometimes twice, top and bottom. When she got them off one day and stared, horrified, at the yellow moss between her teeth, her orthodontist told her about Crest Whitening Strips. Charlie's type will sail to college, meet him at a tailgate, and smile.
The problem with Charlie's type is, once he's found her and locked her in like a retainer, her gums begin to disintegrate. This is the real cost of straight teeth: Some 400,000 Americans develop gum recession and gum disease from braces every year.
Still, if you ask dentists and orthodontists if there's a connection between braces and poor gum health, "you'll get different answers depending on who you talk to," says Kelly Blodgett, a dentist in Portland, Oregon.
Some take the risk very seriously. Joseph Nemeth, a periodontist in Southfield, Michigan, says many orthodontists now have patients sign waivers on associated gum risks. Others "don't appreciate the longterm ramifications of orthodontic treatment," Blodgett explains. "They're not seeing 40- to 90-year-olds like I am."
Indeed, I first learned of the correlation while reclined in my periodontist's chair in suburban Denver, more than a decade after getting my braces off. Last month, I had a gum graft, where my periodontist sliced tissue from the roof of my mouth and relocated it to the frail gums beneath my lower front teeth. The procedure left me $2500 poorer and drinking milkshakes for breakfast, wondering how I got to this point.
Poor hygiene is the main reason nearly half of adults under 30 have gum disease. In short, plaque and tartar increase bad mouth bacteria, inflame the gums and predispose them to infection. Braces make good oral hygiene harder to accomplish, and they make bad hygiene worse. These effects long outlast the short duration of orthodontic treatment.
Gums also recede from teeth moving. Specific movements, like tilting the teeth or moving the canines, can be particularly damaging. Braces are a little bit like Chinese foot binding, Blodgett says, with teeth forced to follow the direction of a pre-formed wire. "Throughout that whole process [of braces], you're putting stress on the bone—and by extension the gums—in a way that's not genetically intended." The constant pressure on teeth can cause inflammation and bone loss, which can lead to gum recession.
Of course, as my periodontist Franc Vanderven points out, braces can fix teeth crowding and ultimately result in better oral hygiene. But practitioners disagree on this point, too. Nemeth, for example, isn't convinced that straightening teeth significantly improves oral health. Unless crowding is really bad and will significantly impair one's ability to clean their teeth, "the primary reason for orthodontia is really cosmetic," he says. Empirical research to resolve the debate is surprisingly sparse.
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The metal from braces may also contribute to gum recession. Several studies have highlighted that the metal wire adversely affects bacteria accumulation and gum health. Similarly, researchers at Ohio State University found that patients with lip piercings were 41 percent more likely to develop receding gums than the control group, and their recessions were twice as deep. The metal factor may help explain why gum health tends to be worse after traditional metal braces than after Invisalign.
Finally, gum disease and recession depends on a patient's genetics and anatomy. "Some people are lucky to inherit thick gum tissue," Nemeth tells me. Others inherit thin gum tissue and have a much higher risk of recession. Braces may trigger or expedite these genetic predispositions.
Nemeth compares the genetics of gum tissue to immune system health. If someone enters a room with a very bad cold, other people in the room have a varying likelihood of getting it. Some won't get it at all, some will get a milder version, and some will get the full-blown flu. Likewise, some people are "resistant to organisms that cause periodontal disease." Others, unfortunately, aren't.
So if you're considering braces for yourself or your kids, work with a prudent orthodontist to assess existing gum health before starting treatment. "A good orthodontist will look not just at aesthetic but also function," Vanderven says. They'll also work in conjunction with dentists and periodontists to protect your gums. Sometimes patients will even get gum surgery preemptively.
But Blodgett encourages patients to delay braces until their teeth, gums and mouths have fully developed—sometimes not until the mid-twenties. There's "no advantage in intervening early." Or, rather than make braces the default right of passage through puberty, "maybe we should leave well enough alone."
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