Brace yourself

James Hill, a cyclotron engineer in Spokane, was driving his car and “chomping on nuts” when his tooth fell apart in his mouth.

He pulled over. A fast call to his dentist’s office secured an emergency appointment, where he learned a wisdom tooth that emerged when Hill was 37 had put so much pressure on another tooth that the tooth died and decayed. A hard nut was the last straw, and the tooth shattered.

OK, Hill said, long frustrated with overcrowding. It’s time to get the teeth fixed.

Now 41, he sports a full set of metal brackets that are uncrowding his teeth and moving them into alignment, including his protruding canines – as a kid, he said, people called him the “dude with the fangs.”

Hill is not alone as an adult with braces. Formerly the realm of adolescents whose parents could foot the bill, the orthodontist’s chair has seated a growing number of adults in recent years who can finally afford braces themselves – and who’ve found the hardware is more comfortable and less visible than it used to be.

In 2010, the number of adults in braces was up 23 percent from 1989, when the American Association of Orthodontists started tracking patients by age. Nearly 1.1 million adults were in treatment in 2010.

While the quest for a pretty smile still leads plenty of adults to braces, orthodontists say more patients are citing health concerns. Research is stacking up that links poor oral health – exacerbated by crowded teeth and bad bites – to poor overall health, including cardiovascular disease and kidney disease.

There’s an emotional aspect to getting braces as an adult, Hill said. It’s important to him that his straight teeth look better; his family couldn’t afford them when he was a kid in rural Georgia. But his major motivation was his belief that “good health starts in the mouth” – and that rotting, difficult-to-clean teeth are not healthy.

“I thought I was going to be the only adult (at the orthodontist’s office), or one of few and far between,” Hill said. “But it’s not the case. I’ve seen people in the chair two decades older than I am.”

‘Toward a healthy state’

Patients are more aware of the links between dental problems and other health problems, including gum disease and heart problems, said Pramod Sinha, a North Side orthodontist.

Crowded teeth can be difficult to clean and contribute to inflamed or infected gums, which can worsen over time if the problem isn’t fixed. Gum disease also has been linked to diabetes, preterm labor, osteoporosis, Alzheimer’s disease and some types of cancer.

As people work to improve their health in other ways – working out, eating better – they seek help improving their oral health, too, Sinha said. “When a person moves toward a healthy state, they want to have a healthy mouth, too.”

Another health-related factor leading adults to orthodontists: More of them have teeth left to fix.

People used to lose their teeth by their 40s or 50s, noted Bob Varner, secretary-treasurer of the American Association of Orthodontists, who practices in Roseburg, Ore., and is past president of the Pacific Coast Society of Orthodontists.

The advent of fluoridated water, in some places, and better preventive care allow more people to keep their teeth their entire lives – and they want to get them fixed, even if they’re grandparents by the time they can afford it.

Patients who are missing just one or a few teeth are making greater use of dental implants – permanent replacements for individual teeth as opposed to dentures or “flippers.” Implants often require other teeth to be moved into alignment to make room.

“We’re in an environment now where people want to keep their teeth for life,” said Stephanie Combs, Hill’s orthodontist in Spokane. “Years ago, that wasn’t the case, but now we have the technology to do that.”

Other adults are back for Round 2 of braces.

Joshua Johnson, another Spokane orthodontist, categorized up to a half of his adult patients as “relapse” cases. Some had braces as kids but stopped wearing their retainers after the braces came off, and their teeth “slowly and surely” moved forward every time they chewed, leading to crowded front teeth and bumping back ones.

In other cases, late-arriving wisdom teeth or jaw growth caused problems after the braces came off.

High-tech options

Those patients on their second round of braces may be surprised at how the technology has changed. Years ago, braces required the installation of a full metal band around each tooth.

“A lot of adults think, ‘Oh, God, I don’t want to go through that,’ when really it’s a lot more comfortable,” said Combs, who said about 30 percent of her patients are adults, higher than the national rate of 22 percent.

“Of course, braces are always going to generate a little discomfort, because you’re moving teeth through bone. But it’s a lot more comfortable than it used to be.”

Orthodontists are now much more likely to glue smaller brackets to individual teeth. A wire run from bracket to bracket puts constant pressure on the teeth, moving them slowly into a better position.

The brackets are growing smaller and less intrusive. They come in clear or tooth-colored materials, or they can be glued to the backs of your teeth.

In relatively easy cases, patients can use clear aligners to straighten their teeth – a series of specially made trays you trade out every couple of weeks.

The improvements are thanks in large part to advances in materials science – “clear” braces are made of material developed in conjunction with NASA. They’re also thanks to technology that improves efficiency and precision of tooth movement.

Johnson uses a digital form of orthodontics, making a scan of patients’ mouths that lets him look at each tooth from all angles, helping him decide the best way to move each one. Then the wires that run between brackets are robotically bent to precise specifications, shortening treatment by as much as a third, he said.

These days, orthodontists also are using tiny titanium-alloy “anchors” they can screw into bone between the roots of your teeth or into the bony part of the roof of your mouth, giving them a fixed point against which to brace a misaligned tooth when another tooth won’t work. The idea is that the anchors give orthodontists more precise control.

“We just throw these in and we can tie a couple of teeth to them,” said orthodontist Gerald Smith, whose office is on the North Side. “When you’re done moving the teeth, out they go.”

Whole-patient approach

Orthodontists say adults are often better at cleaning and other “patient responsibilities” related to braces.

But with maturity come worn teeth, fillings, crowns, gum inflammation, osteoporosis and other problems orthodontists have to work around with adults.

“Adults cases are almost always multidisciplinary,” Combs said, requiring orthodontists to work closely with a team of other providers: dentists, oral surgeons, periodontists, sometimes prosthodontists.

In general, adult teeth move at the same rate and to the same degree as adolescents’, said Varner, of the American Association of Orthodontists. The major difference between treating adults and kids is that multidisciplinary approach: “We want to make sure we’re looking at the whole health of the patient.”

And while health concerns are key for many, Varner doesn’t discount appearance as a motivator. “I suspect, though, deep down, that everybody cares about how they look,” he said.

Some adults are finally able to cover the cost, after lives spent frowning at their reflections and saving their money – or waiting until their kids are out of braces.

For others, orthodontia follows divorce or other forms of newfound freedom.

Before putting braces on an 83-year-old woman, Varner asked her what had taken her so long.

“ ‘Well, I’ve always wanted to do it, but my husband didn’t want me to,’ ” she told him, Varner said. “I said, ‘Well, what changed?’ She looked me straight in the eye and said, ‘He died.’ ”