Are Your Teeth Crowding You?

What if your dentist says you have "dental malocclusion" and recommends that you get it fixed as soon as possible? Would you know what to do?

Dental malocclusion means teeth crowding and it can be an orthodontic problem for older adults, often due to a decrease in jawbone density.

"Nobody dies from crooked teeth, but rotated and overlapping teeth can be very challenging to keep clean," says Laurie McNamara McClatchey, adjunct clinical associate professor at the University of Michigan School of Dentistry. An orthodontist, she also has a part-time private practice.

Sally Cram, consumer adviser spokesperson for the American Dental Association, agrees that crooked and crowded teeth can make daily oral hygiene difficult. Cram specializes in periodontics at her practice based in Washington, D.C.

Over time, crowding may lead to caries or cavities (tooth decay), gingival (gum) disease and, possibly, tooth loss, Cram says. "An improper bite can interfere with chewing and speaking, cause abnormal wear to tooth enamel and lead to problems with the jaws."

McNamara McClatchey says patients are motivated to improve their dental health because of their concerns about the potential for tooth loss, fear of increased recession and the need to create space for future crowns, implants or veneers.

"I often hear about a parent or grandparent who wore dentures because they had not taken care of their teeth" she says, adding that many of these patients come to her with a referral from their general dentist who has a specific concern.

Treating older adult patients is not like treating younger patients, according to McNamara McClatchey. "We are dealing with a non-growing population of patients. We cannot do the traditional growth modification" that takes advantage of a younger person's natural growth to guide the lower jaw to a more favorable, forward position."

Age does not keep teeth from moving, she continues. Regardless of the patient's age, "it's the same physiological process that moves teeth through bone."

Past dental experiences may complicate treatment. Older individuals often have a history of periodontal disease with bone loss, implants, bridges, fillings, missing teeth, misshapen or worn teeth, sleep apnea appliances and bite splints.

Braces and clear aligners are the main tools used to move teeth into place, while retainers are meant to stabilize and preserve the results of treatment. Procedures such as crowns and veneers may be other potential options for those looking to address crowded teeth, Cram says.

"Braces realign the teeth by applying pressure with small brackets cemented to each tooth. They are connected by a wire which your dentist or orthodontist gradually tightens to shift teeth and your jaw over time," Cram explains. Braces can sometimes be placed behind teeth as well.

Braces can be tricky for older patients, who are much more likely to have restorations such as crowns, fillings, implants or bridges, McNamara McClatchey says, and this can make the use of brackets challenging. Metal bands (rings around the tooth) may need to be used in these cases. And it can be challenging to glue braces to a non-enamel surface such as gold, porcelain or composite.

Additionally, she says, the edges of brackets can be sharp and irritating for those who suffer from dry mouth, a problem that tends to increase with age. 

Braces come with dietary restrictions along with increasing the amount of time needed to perform oral hygiene procedures. Patients are seen in the office every one to two months and the braces adjustments can make the teeth quite sore.

Like traditional braces, clear aligners are designed to move teeth gradually. They put gentle pressure on teeth to slightly reposition them, straightening them slowly over time.

Clear aligners have many advantages for older adults, according to McNamara McClatchey, First, and perhaps foremost, is comfort: "There's less tooth soreness because of the weekly aligner changes and they are smooth against the soft tissues, helpful in cases of dry mouth."

Hygiene is easier because aligners are removed from brushing and flossing and there are fewer dietary restrictions.

The plastic aligners are nickel free, which is important if a patient has metal allergies.

And there are fewer in-person appointments, with the option of virtual appointments. "This is important for those that travel frequently, such as snowbirds," she says.

The major disadvantage to clear aligners, McNamara McClatchey explains, is that they are completely compliance based.

"They are ideally worn 20-22 hours per day. It is recommended that they are removed for eating and drinking anything other than water. If they are not worn as recommended, they do not work."

The price varies by city and insurance coverage is unlikely in older adults. Because they are paying out of pocket, this does tend to be a highly motivated patient population, she says.

Ninety percent of her adult patients opt for clear aligners "and I am supportive of this in the majority of cases. I charge the same for clear aligners and braces but some orthodontists charge more for clear aligners."

Not everyone is a good candidate for braces or aligners. McNamara McClatchey warns that bisphosphonates, a class of drugs used to treat bone metabolism disorders, bone diseases and bone pain from cancer, are powerful inhibitors of bone resorption and inhibit tooth movement.

If a patient has a history of taking a bisphosphonate, "the orthodontist cannot guarantee successful tooth movement" and may advise against treatment, she says. If the patient proceeds with treatment "they must understand this risk of increased duration of treatment, slower tooth movement and incomplete treatment."

Many of her older patients come to her for esthetic reasons, McNamara McClatchey adds. "The increase in the use of Zoom and FaceTime has heightened their awareness [of imperfections]. They consider it a form of self-care, doing something nice for themselves. I often hear them say 'It is finally my turn.' "

Stephenie Overman writes about workplace and health issues. She is the author of Next-Generation Wellness at Work. Read More