Braces are now a ststus symbol Dr. BERTRAND R. STUART DDS.

MANY years ago, children tried hard to avoid having to use braces. So did their parents once they knew the high cost of orthodontic treatment. Now it is virtually a status symbol for middle and upper class children to have metal smiles. Television advertisements show pert teenagers speaking to each other with closed mouths, only to break into broad grins as each recognizes the other had braces. There are jokes about kids calling out the emergency squads to separate braces entangled during a kiss. Even adults who have long suffered unsightly crooked teeth now undergo years of orthodontic treatment. I had a seventy-five year old patient requesting braces a few weeks ago.
Given the popular concern over crooked teeth, one cannot overemphasize that malocclusion is not a disease. There is no convincing evidence linking crooked teeth to decay and periodontal disease. Dental caries and periodontal disease are bacterial plaque diseases. Even though the uneven surface presented by crooked teeth requires a little more diligence in brushing and flossing, people with malocclusion do not necessarily experience more decay or gum problems.
But there are exceptions to most generalizations. The lower front teeth may hit the palate rather than coming to rest on the inside of the upper front teeth. The palate and gum may then be periodically, sometimes continuously, traumatized. Correction of this type of malocclusion is the best way to eliminate discomfort and prevent further injury.
Dentists also recommend correction of malocclusion to improve mastication, the chewing of food. But unless the condition is so severe as to prevent the opposing teeth from coming together, virtually any bite – “good” or “bad” from the dentist’s viewpoint – functions adequately. In fact, teeth barely meet in chewing. The mouth senses contact of opposing teeth as they shear and grind food, immediately reversing the movement of the lower jaw so that the teeth are not gnashed together. It is sort of like tough football. You do not have to tackle the ball carrier to stop the action. A slight tough of tooth contact is all that is necessary to have the play whistled dead. If it were not this protective proprioceptive mechanism, the teeth would be ground down to the gum line in the first two or three decades of life.
Nonetheless, many people develop pernicious habits such as clenching and grinding – bruxism – of teeth, which wears the enamel flat and may even penetrate into dentin, causing hypersensitivity and pain. Night grinding is also quite common even among children and can be damaging to the teeth and supporting bone. But these habits have nothing to do with normal chewing. Correction of malocclusion does not cure bruxism. In fact, bruxism may not be curable, particularly when it is done during sleep. In that even, the patient needs a protective plastic occlusal night guard, much like a football or basketball player’s mouthpiece to prevent tooth-on-tooth contact during sleep or during the daytime.
Other conditions frequently attributed to malocclusion are myofacial pain dysfunction (MPD) and temporomandibular joint disorder (TMJ/TMD), in which the individuals suffer mild to extreme pain in the facial muscles and joints of the jaws. For unknown reasons, MPD and TMD problems occur much more frequently among women in their late twenties and early thirties, after which pain frequently disappears when or not treated.
Despite the lack of controlled studies to link MPD and TMD pain with malocclusion, orthodontic treatment is often recommended for present or anticipated problems. Rather than malocclusion, the common causes of MPD or TMJ discomfort are tension, clenching, and muscle spasms or injury to the attachment ligaments of the joints, which makes opening and closing painful. The injury may follow a large yawn or third molar surgery or occasionally, orthodontic treatment. Quite often the condition is alleviated by physiotherapy, including dry or moist heat packs and ultrasonic treatment, muscle relaxants, antidepressant drugs for chronic pain, special muscle stretching and relaxation therapy, the avoidance of extreme jaw movements such as yawning and biting whole apples, and simply outliving the symptoms. In a small number of TMJ osteoarthritic degeneration of the bony ball and socket comprise the joint. In such extreme cases surgery may be necessary to replace the disc with a plastic insert or to reconstruct the jaw joint. This procedure is far from reliable and is notorious for its failures. It should be considered only when there is no other recourse. Too often premature and unnecessary surgery is performed, at times leaving the patient much worse off that if nothing had been done.
TMJ/MPD diagnosis and treatment should be viewed with caution and skepticism. Most X-rays taken for TMJ diagnosis are not worth the price of film. X-ray films of the joints purportedly demonstrating displaced discs or osteoarthritis often are of such poor quality as to require a great deal of imagination in diagnosis. Even with good films, X-ray diagnosis of the jaw joints is notably inaccurate. Before subjecting yourself to head X-rays, which radiate the brain as well as the joints, rely on symptomatic diagnosis to identify the location of pain and restriction of movement. Initial treatment should be limited to alleviation of the symptoms. Only when significant pain persists for a long time and is not relieved by symptomatic treatment should one consider TMJ X-rays, and then only by an experienced TMJ X-ray technician.