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Gum disease may start with milder forms like gingivitis but progress to periodontitis which can have serious concequences. Misaligned or crowded teeth and orthodontics may increase the risk of or exacerbate existing gum disease so extra care is required.

Periodontal (gum) disease (also known as periodontitis) is an infection of the tissues that hold your teeth in place. If you have poor brushing and flossing habits you allow plaque to develop. This sticky film of bacteria adheres to the tooth surface and in the pockets surrounding the tooth and multiplies. As the immune system responds and releases toxins inflammation (known as gingivitis) occurs. If plaque remains, it can calcify to form tartar or calculus.

Periodontitis (gum disease) is typically preceded by milder forms of the disease known as gingivitis. However, this progression is not necessarily inevitable as most cases of periodontitis are preventable through good dental hygiene. In the early stage of gum disease, bacteria in the mouth multiply, leading to plaque build-up, which causes gum inflammation and teeth that bleed easily during tooth brushing. Untreated gingivitis can progress to periodontitis, and if this remains un-checked, then eventually tooth loss may result. It can also affect systemic health by increasing the risk of stroke, heart attack, and other health problems. 

What connects misaligned or crowded teeth to periodontitis?

Anything that makes brushing or flossing your teeth more challenging is likely to exacerbate plaque and tartar formation, which in turn increases your risk of developing gum disease.

For patients with crowded or uneven teeth, it can be particularly difficult to remove plaque: crowded teeth are difficult to clean as they may be twisted, overlap, or just be so closely placed together that it is difficult to get in between them. They, therefore, provide the perfect environment for bacteria to breed, which then becomes plaque. The issue is then further exacerbated by poor gum fit as it leaves more room for bacteria to grow. Patients with misaligned teeth must, therefore, be extra vigilant in order to prevent and treat gum disease.

Plaque build-up can be minimized in the following ways:

  • Flossing every day—flossing is an excellent way to remove plaque from between the teeth

  • Antibacterial mouthwashes used after brushing help kill bacteria that might otherwise be missed, with an added benefit of freshening breath.

  • Every time you eat, plaque is created for about 30 minutes after you finish eating as part of the digestion process. Therefore rinsing your mouth with water after each meal can be extremely beneficial as it flushes out not only existing plaque but more importantly, leftover food which will generate further plaque. 

  • Consider tooth-straightening: good dental hygiene is much easier to achieve with straight teeth because there are fewer tight spaces where bacteria can collect. Using Invisalign or braces, crooked teeth are easy to correct and, once straight, teeth are easier to keep free of plaque.

  • Ensure you visit your dentist 6-monthly so they can monitor your oral hygiene and check for signs and symptoms of gum disease.

How are braces associated with periodontitis?

There is a cyclical relationship between periodontal disease, orthodontics (the area of dentistry dealing with tooth and jaw misalignment) and adults in that while orthodontics can lead to periodontal disease, orthodontics also can help reduce its symptoms.

As many as 50% of adults in the US have periodontitis, and similar figures are reported for teeth misalignment. Given these statistics, the likelihood therefore of an adult orthodontic patient having periodontitis is very high, as are the chances of developing it during treatment. Even where there is no periodontitis, an adult aged 30 years or older undergoing orthodontic treatment, has a greater likelihood of developing the disease or its progression being more rapid. 

The reason for this is that when braces are fixed to teeth, it can compromise the periodontium, which are the specific tissues surrounding and supporting the teeth and maintaining them in the supporting bony structures. As braces are designed to change teeth positioning if gums are in poor health this be problematic to oral health.

However, there are also reports of patients whose periodontal pockets (spaces around the teeth where the gum has pulled away owing to gum disease) resolved following braces. In these cases, scaling and root planing was carried out and periodontal surgery postponed; some patients responded so well to interventions that surgery was no longer required. 

Those with orthodontics (braces) need to be especially vigilant about oral hygiene. Flossing should be carried out daily if not more frequently. An orthodontic floss threader is a valuable tool for flossing teeth with braces because it facilitates pulling of the floss through the teeth above the wires in order to get to the gum line, which is the important bit!  Antimicrobial rinses are also recommended and are to be used at each brushing and after each meal.

It is important for both dental professional and patient to be aware that periodontal disease is always a possibility. Orthodontists (or another dental practitioner) should evaluate the periodontal tissues before commencing orthodontic treatment, and this should be repeated every 6 months to ensure this evaluation is always up to date. 

Bridges and periodontitis — what's the connection?

Like misaligned or crowded teeth or where braces are fitted, bridges also affect the buildup and treatment of plaque because it can easily become lodged in the spaces around the bridge which are very difficult to clean. These spaces (especially below bridges) are extremely difficult to clean and so bacteria accumulates and forms into plaque. This is accentuated by poorly-fitting gums (a common problem), which affords more space for the bacteria to grow.

Studies purport that the parts of the surface of a tooth not surrounded by gum, known as supragingival locations, are the most likely locations for periodontitis to develop, and most specifically, in the crevices between the gum margin and the neck or root of a tooth.

As with braces, patients with bridges need to take extra-special care to ensure their dental hygiene is excellent. For example, special tools and techniques for threading floss can be employed to effectively clean around bridgework, in spite of the challenges that such prosthetics may pose. Water flossers are a useful aid in cleaning around all types of dental work including braces and bridges because they spray streams of water which flushes out areas that brushing and flossing cannot reach.

  • Photo courtesy of SteadyHealth.com
  • http://www.scielo.br/scielo.php?pid=S2176-94512011000400015&script=sci_arttext&tlng=en
  • https://www.ncbi.nlm.nih.gov/pubmed/10052767
  • https://www.ncbi.nlm.nih.gov/pubmed/20858782
  • https://evolve.elsevier.com/cs/product/9780323043526?role=student
  • www.orthopracticeus.com/orthouploads/Web/Martin_opus_april10.pdf
  • https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1600-0765.1970.tb00721.x
  • https://www.mouthhealthy.org/en/az-topics/w/water-flossers

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