Tuesday, April 3, 2018

Crowded teeth can lead to early tooth loss.

Does Crowding of teeth lead to early tooth loss?

I always try to temper initial exams when it comes to advising perspective patients of my services; sometimes I even may preface what I recommend by telling borderline cases that we want to avoid picking at everything slightly out of alignment just because I am an orthodontist.  Similar to a neck doctor that may always see neck/back issues or a foot doctor that can always seem to find a foot problem, I do not want to recommend treatment on every single case with just the mildest of rotations or crowding and certainly if they are more concerned about function and health and less so about esthetics.

That being said, there is an issue that has been debated in multiple disciplines of dentistry that is a significant consideration when making a decision to correct crowded teeth or leave them.  Before we entertain this though Americans in particular should realize that recent generations are keeping their teeth well into their older years and this is a good thing.  Our General Dentists have done a great job at restoring damaged teeth, protecting developing teeth (fluoride and regular cleanings) and keeping teeth that in the past may have been lost due to fracture, infection or simple neglect.

With keeping the teeth longer, we now have to focus on the supporting bone around the teeth; the gum tissue and alveolar bone.  Today, loss of teeth is mostly from Periodontal disease (disease of the supporting tissue around teeth) which is a bacterial infection of the gums that destroys bone and eventually causes the loss of supporting tissue for teeth; forces from chewing then eventually loosen the teeth to the point that the bone no longer can support the tooth or teeth and they are lost.  Of course there is a more complex mechanism leading to the bone loss which is dependent on types of bacteria and toxins released, but the idea can be summarized as an infection of the gums.  Clearly, as a dental professional, one of our main goals is to prevent prevalence and progression of Periodontal disease at every stage of patients’ lives in order to maintain the teeth as long as possible.

One significant factor to Periodontal disease can be crowding or spacing of teeth.   

So do crowded teeth cause Periodontal disease?

The answer is no; bacteria is the primary cause of the disease.  But the real question is how does the bacteria become detrimental in specific areas and mouths?


What are the ways crowded teeth can affect Periodontal Disease?


The most recent study in the AJO-DO explains this best by concluding that certain positions of teeth or “traits” such as incisor crowding provides “a poor environment for maintaining periodontal health …. due to food retention and subsequent plaque accumulation. (1)”

Consider the crowding in the patient below:

Crowding here has completely blocked the surfaces of several teeth from being cleaned; even with floss, cleaning these overlapped teeth is nearly impossible.  Over time, it is highly likely these teeth will be lost if not corrected. 


After correction you can see how the teeth can easily be cleaned and maintained.
Additionally, as teeth cross over and crowd, the roots are drawn closer together leaving less bone and supporting tissue between teeth.  This also can lead to more rapid progression of periodontal disease between adjacent teeth.  Soft tissue becomes obliterated from a lack of space to develop and there is less protection against bacteria between these teeth.

Finally, teeth that are crowded can push other teeth out of the arch and out of the bone.  This can lead very thin tissue on the outside of the teeth leaving these teeth more susceptible to periodontal disease (see the picture below).

Note in this patient how the severe crowding has caused the canines to be pushed essentially out of the bone which has led to recession of the gum tissue and loss of bone at the neck of these teeth.
How can spacing between teeth affect Periodontal disease?

Spacing specifically between upper incisors was also shown to contribute to Periodontal disease (2) by allowing food to pack between teeth and leading to chronic inflammation and eventual progression into periodontal disease and loss of bone.


This type of spacing has been shown to lead to more rapid progression of periodontal disease by allowing food to pack in between teeth.

Following correction, you can see how the area between front teeth is now protected from impaction of food and can be easily cleaned.


What can you do to make sure your teeth are not at risk of Periodontal disease from crowding?

Clearly the only way to reduce or eliminate this risk is to align teeth that are moderately crowded.  Research has shown that the areas of the dentition most at risk from crowding are the upper and lower incisors (2). When these incisors are crowded or overlapped, pockets are created that are not easily cleaned and although daily and meticulous flossing should theoretically prevent plaque formation in these areas, all too often we are not effective enough in our oral hygiene to fully clean these areas.
Prior to Correction with braces.


Following Correction with braces.

So in summary, alignment of crowded teeth is not only for esthetics; there is a real reason to align crowded teeth if we want to be able to keep our teeth for a lifetime of function and health.  this article only touches on the aspect of periodontal health and maintaining teeth however overall health is also affected by oral health; maintaining disease-fee dentition also prevents dissemination of bacteria into our bloodstreams; bacteria that can cause more severe problems such as systemic infections and even possible heart tissue infections.  The public should always keep in mind oral health can be a reflection of general health; it is all connected and very important over the course of our lives.

(1)  Hellgren, A. The association between crowding of the teeth and gingivitis. Trans Eur Orthod Soc. 1956; 32: 134–140

(2)  Alsulaiman, a. Incisor Malalignment and the risk of periodontal disease progression. AJO-DO. 2018; 153: 512-522  

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.


Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 22 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com. 


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