Orthodontic treatment is becoming an adjunct for a variety of other dental procedures, such as creating space for a bridge or implant. Dr. Stacey Simmons interviews Orthodontist Priscilla K. Larson, DMD, who offers a fascinating insight into orthodontics, dental treatment ages, and why braces aren't just for teens anymore.
Editor's note: This article first appeared in DE's Breakthrough Clinical with Stacey Simmons, DDS. Find out more about it and subscribe here.
There is a misconception that once you are out of your teen years, you are too old for braces. In reality, however, the saying, “Age is just a number” couldn’t ring truer. There really is no age limit for getting one's "perfect smile." Furthermore, orthodontic treatment is increasingly becoming an adjunct for a variety of other dental procedures, such as creating space for a bridge or dental implant. My interview with orthodontist Priscilla K. Larson, DMD, offers a fascinating insight into some of the questions patients and dental providers commonly ask with regard to orthodontics, treatment ages, and why getting “wired up" isn’t just for teens anymore.
Background: When did your interest in orthodontics start?
Dr. Larson: I would love to say that I enjoyed my own orthodontic treatment (which was great) so much that I wanted to become an orthodontist after I got my braces, but for whatever reason, I never thought about it much during my treatment. I actually did not even consider a career in orthodontics until my senior year of college. I majored in chemistry and got a certificate in secondary education because I love kids and science, and I was planning to teach high school students. Sadly, I started doing the calculations right before graduation (in December). I realized that I went to a way-too-expensive college for teaching and that I'd be paying college loans into retirement if I continued on as planned.
At about the same time, my chemistry lab partner started telling me about how she had missed some of our classes because she had been interviewing at dental schools. She wanted to be an orthodontist, and listed all the reasons why she thought it would be a great career. Apparently, her arguments were pretty convincing, because I applied to dental school right after I graduated (hoping to get into an ortho residency afterwards) and haven't looked back! It is such a rewarding mix of art and science, which I enjoy. I do get to work with a lot of teenagers still, although not in the same way I did when I was student teaching.
How long have you been practicing?
Dr. Larson: I finished my orthodontic residency in 2010 and have been practicing ever since—for seven years now. Time flies!
You mentioned that you wanted to teach kids when first considering careers. Did you have any interest in treating older patients?
Dr. Larson: No. When I applied for residency, I still thought of orthodontic treatment as mostly involving kids and teens, which was one of the things that drew me to the specialty. I do enjoy adults and older patients, but I have always had a special place in my heart for kids and teens, and this influenced my choice of specialty early on. I really enjoy my older patient population though.
There is a common stereotypical thought that orthodontics is only for younger people. Why is that?
Dr. Larson: I think it is a very common thought. As I mentioned, it is one that I myself shared even after finishing dental school. I think many of us had braces as children or teens, so that is just how we always think about orthodontic treatment. We orthodontists would often much rather treat children and teens, and even the American Association of Orthodontists recommends that kids see an orthodontist by the age of seven for a screening. But this is largely because there are a lot of things we can do interceptively if we catch problems early, and also because there are certain malocclusions that can be treated more completely or more efficiently if we still have growth to work with. But these things certainly do not mean that adults—even older adults—cannot be treated.
One other reason people often think that orthodontics is only for younger people is that parents will, almost without fail, sacrifice their own health to give their children the best start in life that they possibly can. I think this is incredibly admirable, and it speaks volumes about our culture. We truly value the next generation and know that they are our future. But I see so many families come in for consultations in which the parents and children have identical malocclusions, but there is only so much wiggle room in the budget. The parents will say, "I always wanted braces to fix my teeth (or my bite), but my parents couldn't afford it. So now I want to do for my kids what I wish my parents had been able to do for me. I'll get my own treatment done when the kids are done with theirs." So, I think that there are more children and teens being treated orthodontically because of the sacrifices parents are making for their children.
What is the genesis for older people to suddenly take an interest in having straight teeth?
Dr. Larson: I think there are a number of factors. As I mentioned above, a lot of parents have always wanted orthodontic treatment, but they had to make sure their kids were taken care of first. As the kids leave home and parents (and grandparents) progress in their careers, there is more discretionary income to spend on what was always seen as a "want," not a "need." This is when I see a lot of older patients coming in for treatment.
I think that the increasing success of implants, and dentistry in general, has also had a lot to do with older patients seeking orthodontic treatment. People are expecting to (and being successful with) keeping their teeth much longer now than ever before. Years ago, orthodontic treatment for adults may have been seen as a waste of money, since people often didn't think it was realistic to try to keep natural teeth for life. Why straighten teeth and correct bites if you're going to be in dentures by age 60 anyway? But now, with restorative dentistry and periodontal treatments being so successful, a lot more patients understand that with good preventive care, teeth can and should last a lifetime. They understand that orthodontic treatment with the goal of healthy, functional occlusion may contribute to healthier teeth for a lifetime—as well as teeth that are esthetically pleasing!
Patients who would never have considered orthodontic treatment are also being referred for consultations prior to placement of permanent bridges and implants. They now understand that if we set up teeth properly prior to these restorations, it can positively impact the success of the other procedures or even make previously impossible procedures possible. Imagine trying to place and restore an implant for a missing maxillary first molar when the second molar has tipped forward substantially, leaving only 3 mm for the crown of the pontic or implant! Older adults are understanding about this and willing to undergo orthodontic treatment to obtain the best possible esthetic and occlusal results.
Do you treatment plan differently for your younger and older patients?
Dr. Larson: In many cases, yes. Treatment plans are often affected by whether or not we have growth left to work with. If a patient is Class II or Class III or has vertical problems (bite is too deep or too open) or transverse problems (posterior crossbites or buccal crossbites), we have to keep the potential for growth (or lack thereof) in mind when formulating a realistic treatment plan. With the advent of temporary anchorage devices (TADs), some of these limitations have been reduced, but still need to be considered.
Additionally, we have to keep in mind how long the patient is willing to be in treatment and what the patient's goals are. Of course, as an orthodontist with perfectionistic tendencies, I would love it if everyone went into orthodontic treatment with the goal of perfect occlusion. Many children and parents accept this goal (“Let's get as close to perfect as possible!”) and are willing to put in two to three years of treatment to achieve it. Many older adults are willing to tolerate orthodontic treatment for a limited period of time, so I have to adjust my goals accordingly to meet their needs.
And then there are the smaller adjustments to various plans that we must make. If we align crowding in a young patient who is still growing, we almost never end up with the dreaded "black triangles," because the growing surrounding tissues just fill in the gaps as previously crowded teeth are aligned. I almost always prepare my older adult patients with crowding to plan on some interproximal reduction (IPR) to reduce the black triangles that are sure to appear after their teeth are aligned.
Finally, there are some biomechanical considerations that are different for older adults if previous periodontal disease, medical history, or medications have impacted their dental health (or the way that the teeth will respond to orthodontic pressure).
Why should older individuals get orthodontic treatment? What are the benefits? Are there increased risks?
Dr. Larson: I think I may have partially addressed this in one of the earlier questions. Many older adults have always wanted orthodontic treatment simply for the esthetic benefits or to correct a bite issue that has always bothered them. It is so rewarding to treat older patients, and afterwards hear them say they no longer have to talk or laugh with their hand over their mouth because they are embarrassed, or that they can now have their picture taken from either side; they no longer have a "good side" and a "bad side" for dental reasons. Confidence is invaluable at any age!
Also, orthodontic treatment can make other necessary dental treatments possible or give them better prognoses. I cannot think of a branch of dentistry that does not benefit from well-aligned teeth and good occlusion. Subgingival fillings on partially impacted teeth can be a nightmare, but made simple with the help of orthodontics. Vertical defects due to partially impacted teeth and other periodontal problems caused by traumatic occlusion can be improved or completely corrected with proper orthodontic treatment. I outlined the benefits in setting up for implants and bridges earlier. Even endodontic outcomes, in some cases, can be improved if the occlusion is correct.
Increased risks can come into play for a variety of reasons. For example, if a patient with a history of periodontal disease has lost any significant amount of attachment, there will be a poorer prognosis for any teeth that suffer root resorption over the course of treatment—although the risk of root resorption does not increase with age, to my knowledge and in my experience. Patients with dry mouth due to medical conditions or medications (again, much more likely in older adults than in children or teens) will be at greater risk for developing white spots and caries during orthodontic treatment. All of these risks can be managed or modified with proper planning and cooperation with other specialists and the patient's general dentist.
Is treatment typically longer or shorter in an older individual?
Dr. Larson: In my particular population of older adult patients, treatment is typically shorter than for younger patients for a variety of reasons. This is certainly not true for all patients or all practices. Some of this is patient-driven. Some patients just give me a limited time frame to work with, and some only want limited treatment—for example, uprighting a molar or intruding a supra-erupted tooth to prepare for an opposing bridge.
But some of this is simply due to better compliance. Older adults tend to come to all of their appointments, take good care of their appliances, wear elastics when required, and never break a bracket or lose an aligner over the whole course of treatment. These are all things that will make any patient's treatment shorter, but more likely to be achieved by a motivated older adult than a child or teenager without the same drive to get things done efficiently.
What are some of the compliance challenges or issues between older and younger patients? Are there differences between the two groups?
Dr. Larson: As briefly outlined above, older adults almost always demonstrate excellent compliance. I suspect this is due to several factors. First, older patients who are seeking orthodontics are generally making the decision to pursue treatment themselves, so they are motivated to get good results and will follow the instructions that will get them there. Younger patients are often in treatment because their parents have made the decision for them; thus, they are not always similarly motivated.
Older patients have their own finances on the line and, for this reason, are much less likely to be careless with appliances or aligners. They also tend to have a better handle on delayed gratification and the concept of cause and effect than younger patients. Wearing a removable appliance that causes soreness will usually motivate an older adult to quip that "beauty hurts," take some Tylenol, and remain complaint. That same soreness often motivates a younger patient to just stop wearing the appliance (or elastic or aligner) altogether.
Older adults understand that if they don't maintain excellent oral hygiene, their periodontium and enamel will suffer—often irreversibly. They are willing to put in the required time and effort to maintain it. Young patients often don't understand the cause-and-effect issues or are unwilling, or occasionally unable, to modify their brushing and flossing techniques to obtain optimal long-term results.
Is retention better in younger or older patient generations? Are they still as important?
Dr. Larson: Retention is now understood to be a lifetime commitment, no matter what age the patient is when treatment is rendered. Gone are the days that we would tell patients to "wear retainers for two years, then get your wisdom teeth out, and you'll be fine!"
Some would argue that if you fix an occlusion in a growing patient, it will be more likely to be stable, but I am unaware of any research that supports this opinion. It is true that some malocclusions are naturally "self-retaining," and some give orthodontists retention nightmares. For example, an anterior crossbite corrected at any age tends to be self-retaining, since the tooth would have to "jump the bite" to get back into crossbite. Anterior open bites and spacing, on the other hand, seem to pop back open at any and every opportunity.
There are some auxiliary procedures that can help retain certain corrections (frenectomies for maxillary midline diastemata, for example, or circumferential supracrestal fiberotomies for severe rotations), but these have nothing to do with patient age.
I think most orthodontists would agree that the most important factor in long-term stability is patient compliance with retainers. If the patient is compliant (again, much more likely in older adults, since they don't want to have to go through treatment or pay for it again), generally corrections will be stable. This is not taking into account younger patients who "outgrow" their treatment, particularly problematic in Class III patients since mandibles grow so late into the teenage and early adult years.
What is the average age and range of patients you treat?
Dr. Larson: I still treat many more children and teenagers than I do older adults. However, I have a very large population of 20- and 30-year-olds. The number of patients in their 40s and 50s take a dip in my practice, and I suspect that's because this population is likely to have children and teens in orthodontic treatment and college, and the discretionary income isn't there. But then I have a lot more patients in their 60s and even 70s. I would have to say that the average age of my patients is about 20.
Editor's note: This article first appeared in DE's Breakthrough Clinical with Stacey Simmons, DDS. Find out more about it and subscribe here.
