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Brace Yourself

Why we want — and how we get — straight teeth

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In the fall of 2012, Stacey Mahnken decided to get braces. She was 24, and had just broken up with her boyfriend. While there wasn't a singular moment that made her walk into the dentist's office, she recalls going to bars, newly single, and feeling too skittish to talk to anyone.

"If I saw a cute guy at a bar, I was too nervous to talk to him," she tells me. "I was like, ‘Oh, my teeth are screwed up.' I need to get married some day, and I don't want my teeth to be crowded and weird-looking."

So the following September, she went in for a consultation, something she'd been avoiding after developing a fear of dentists as a kid. By July, after finding an orthodontist she really liked, her mouth was filled with spacers and a dreaded palatal expander, a torture device-like contraption that forces the roof of your mouth to spread out wider. A couple of months later, she got braces glued in place, and there they remained for two years.

Stacey is a friend of mine from high school, and for the record, her smile has always been nice. But she says that the decision to get braces was a pretty easy one. Though she had to wrangle the finances and find the right orthodontist, the underlying motivation was simple: "I wanted to have a nice smile and not be ashamed of my teeth."

She's not the only one, but no, this isn't a trend piece. According to the American Association of Orthodontists' most recent patient census survey, the majority of orthodontia patients are still young, between the ages of 9 and 14. Still, 1.2 million adults were treated by orthodontists in 2012. In 2014, that number was 1.4 million.

There's a statistic in that AAO survey that gets cited a lot — that between 1989 and 2012, the number of adult patients seen by orthodontists went up 40 percent. That's a lot, and at the same time a little misleading, because it doesn't account for the fact that the total number of patients seen by orthodontists also went up, as did the population.

When you compare the percent of adults that have made up the total number of orthodontia patients over the past 25 years, it's relatively stable. In 1989, 25 percent of the people who received orthodontic treatment from AAO members were adults. In 2012, it was 21 percent. In 2014, there was a slight uptick to 27 percent. And when you compare these numbers to the rise in United States population, the numbers seem to track quite nicely with the rise in the number of people with teeth. In other words, the "trend" of adults getting braces might not be anything more than a product of there being more adults out there to get braces.

The "trend" of adults getting braces might not be anything more than a product of there being more adults out there to get braces.

Despite this, there's certainly the perception of a trend. In fact, there has been for a long time. In 1987, two years before the AAO started keeping statistics on age and gender of patients, the New York Times ran a story under the headline "ORTHODONTICS FOR ADULTS: A HELP AT ANY AGE" which included the assertion that "adults with braces, a rarity 10 years ago, are almost commonplace nowadays."

In 2012, 25 years later, the Times ran a story under the headline "Orthodontists Market to Adults Seeking Prettier Smiles" which leaned on the AAO statistics and looked into a rise in advertisements aimed directly at adults. In the story, reporter Andrew Adam Newman talks to the then-head of the AAO Michael B. Rogers, who claimed that when he began his practice in the 1970s, adults only accounted for about five percent of his patients. He said that now, decades later, they made up a full quarter. But remember that, according to the AAO's own numbers, by 1989 adults were already 25 percent of orthodontia patients.

So adult braces might not be the trend that people seem to think they are. That's okay! There have still been a number of changes to both the patient population and the braces they use. As more and more orthodontists have started seeing adult patients, it's become clear that adult braces are a little more complicated than just slapping on the same metal wires you use on kids.

Braces have come a long way since 1989, but let's start before that. Let's start in 1728, when a man named Pierre Fauchard published a book called The Surgeon Dentist: A Treatise on the Teeth. (You can, of course, start even before that, all the way back in the 8th century, when wealthy Etruscans strung gold bands around their teeth to close up gaps. And if you want to start at the beginning of dentistry, not just orthodontia, you'll have to go back even further to something like 7000 B.C. For our purposes, let's skip ahead.)

Up until the 1700s, dentists tended not to focus on trying to make teeth straight. They had more pressing issues, like rampant tooth decay and shoddily constructed dentures. If you had all your teeth, and they weren't falling out, who cared if they were straight? But as dentistry became more and more successful at keeping people's teeth in their mouths, the desire for a straight smile started to take hold, and not just among the highest classes.

In his treatise, Fauchard described something called a "bandeau," a strip of metal meant to expand a patient's "dental arch" or the arch along which the teeth attach. He also wrote that straight teeth "give a healthy juvenile air to the countenance, improve the tone of the voice, render pronunciation more agreeable and distinct, help mastication, and preserve the opposite teeth from growing prominent." In this passage, Fauchard was talking about false teeth, not real ones, but one can assume he felt the same way about naturally straight teeth.

A crooked smile became associated with a crooked character.

Soon, a crooked smile became associated with a crooked character. Artists used a lopsided smile as visual shorthand for a criminal or cheat. Eugene Talbot, one of the first dentists to advocate for the use of X-rays, believed that crooked teeth were possessed by "neurotics, idiots, degenerates, or lunatics." Straight teeth were a sign of a good person, a wealthy person, a person of high moral standing. As such, devices to straighten teeth became more and more important.

In 1899, a man named Edward Hartley Angle (known today as the "Father of Modern Orthodontics") patented something called the E-Arch, a device that helps expand a person's dental arch. He then went on to patent several other devices that ultimately led to braces as we now know them. In 1910, he devised something called a "pin and tube" system (or, as Angle liked to call it, the "bone growing system"), and in 1915 he revealed a "ribbon arch" system that didn't require the same amount of time-intensive soldering that the pin and tube one did. From there, orthodontist Percy Begg built on Angle's system to create the "Begg light wire technique," which closely resembles the braces seen today — small metal brackets affixed to teeth with a wire running through them.

With updates and upgrades, that's how braces were, and that's how they largely remain: metal anchors affixed to teeth, pulled about by wires and rubber bands. As orthodontia became more popular and the field professionalized, more and more people sought orthodontists' services, and the stigma surrounding "bad teeth" persisted.

Sara Smarsh's 2014 essay in Aeon magazine chronicles the continued mockery of people with "poor teeth," the kind of teeth mostly possessed by folks who cannot afford a dentist. Crooked teeth are still used to signal poverty, backwardness, and stupidity on television and online — from Orange is the New Black to the popular People of Walmart blog. People like Smarsh who grew up places where dentists were few and far between notice those signals. "Poor teeth, I knew, beget not just shame but more poorness: people with bad teeth have a harder time getting jobs and other opportunities. People without jobs are poor. Poor people can't access dentistry — and so goes the cycle," she writes.

Because they're considered cosmetic and elective, adult braces are very rarely covered by health insurance. Which means that people who want them have to pay out of pocket for them, and some braces cost more than others. According to the AAO's most recent survey, conducted in 2011, adult braces cost on average anywhere from $4,725 to $6,940. But that's just for the actual braces part; many adults also need other work done before and after, to get their mouths ready for braces and to keep them in line after they're off. Stacey says her braces cost her between $6,000 and $7,000, all told.

"That was the only thing that really sucked was how much it costs," she says, adding that she opted for the cheapest design she could. According to CostHelper, ceramic braces and Invisalign systems (more on those in a bit) can cost more. Morris N. Poole, the president of the AAO, suggests that people put off by the cost consider a medical savings account, where they can put away money and pay off their braces using a payment plan. He also points out that braces are a lot cheaper than they used to be.

"The cost of those braces was almost the same as the cost of a new car, but now the cost of those braces is probably one-tenth of the cost of a new car."

"Back in high school, I could probably remember on one hand the people I knew who had braces, and they probably traveled 60 to 80 miles to see their orthodontist," he says. "The cost of those braces was almost the same as the cost of a new car, but now the cost of those braces is probably one-tenth of the cost of a new car." Still, one-tenth of a new car isn't something everyone can afford.

The AAO's website has a whole site called the Adult Hall of Fame that chronicles adults who've had their smiles corrected: a trial lawyer, a BMX racer, an optometrist. "Orthodontic treatment gave Kory the smile he felt he needed, especially now that his profession has him in the media," reads one blurb. "Greeting passengers with a warm and friendly smile makes the first impression critical when Amielle welcomes her passengers on board. But her smile bothered her, as her teeth weren't perfectly straight," says another.

Why orthodontics? the site asks. "A great smile helps you feel better and more confident. It can literally change how people see you — at work and in your personal life." There is even a section dedicated to "Positive Aging Through Orthodontics": "Orthodontics can help patients of any age look better throughout their entire lives. If you're ready to witness the life-changing effects of orthodontic treatment, simply click the link below."

It's no surprise that orthodontists want people to see orthodontists, of course. And when I ask Poole what tends to bring adults into the office, he lists a whole plethora of reasons that all come down to one basic desire. "Most of the time someone is driven by cosmetic concerns," he says. College students first encountering the job market who "know it's important to have a good impression." Adults who may be recently single, entering the dating scene again. "Most of the time it is, ‘I want to look nice and feel confident when I smile,'" he says. "Vanity is big, that's all we see on television. All the ads are about how we look, how we feel, and sexual performance."

Often, Poole says, parents will take their kids in to get braces, and get swept up by the process themselves: "So I'll be treating a child, and turn and say, ‘You know your mom and dad could come in here next,' and they'll jump on it." Many orthodontists have caught on to this, offering this strategy as a marketing technique.

According to Poole, for many adults, braces weren't financially viable when they were growing up. Or, for some, they had braces but didn't keep up with their retainers or maintenance and the teeth have shifted back out of alignment. Of course, there are functional reasons to have teeth moved about, too: bite alignment issues can cause wearing of the teeth, gum disease, and tooth decay. But in most cases, fixing those things are nice side effects, and not why people find themselves in the orthodontist's chair.

To put numbers on these anecdotes, one study from 2011 found that 68 percent of adults with braces got them to "improve my smile," and 35 percent got them to "improve the appearance of my face." The study also found that just under half of the subjects had a history of being teased about their teeth. Only 2.2 percent of patients said they came in for braces "because I heard about braces that you cannot see."

In 1999, clear alignment trays hit the market; you might remember commercials for Invisalign or ClearCorrect. For adults, these trays were especially attractive, as they promised to be invisible. The premise behind them is that rather than having metal brackets cemented to your teeth to slowly pull them into place, you wear a set of increasingly corrective plastic trays molded specifically from a 3D scan of your mouth.

When these trays hit the market, orthodontists were skeptical, and many of them still are. Poole warned me that the results from trays are often slower and less reliable than results from braces. They rely on the user putting the trays in regularly, which in his experience not everybody does. In 2000, Invisalign launched a $31 million ad campaign to both push the trays to the public and win over orthodontists. The New York Times reported that it was "the first effort by an orthodontics products company to appeal directly to consumers through television."

Today, orthodontists all over the United States offer clear trays like Invisalign, but they don't tend to recommend them for most patients. And in 2013, a comprehensive review of the literature available about these trays couldn't come to a conclusion about whether they were more or less effective than regular braces: "Currently there is no evidence to support using one form of treatment for managing relapse over another."

Nine years ago, after decades of shoddy dental work, a continually breaking crown, and constant dental pain, Janet Davis opted for braces. They were the best way to fix the existing problems she had with her teeth, putting Janet in the relatively small camp of adults with braces who opt for orthodontia to make other dental work easier. While Janet says she doesn't regret getting them at all, she didn't exactly enjoy having them on.

"They made me feel very unattractive, this icky glinting darkness in my mouth at all times."

"I felt like I had a mouth full of thistles," she says. "I hated the fact that food got caught in them all the time. It was so hard to keep them clean and from getting stained. It made me spit when I talked; I talk for a living a lot of the time and that part really stunk. They made me feel very unattractive, this icky glinting darkness in my mouth at all times."

Janet was 43 at the time, had just gotten tenure at the University of Texas at Austin, and was chair of the American Studies department. "It was actually kind of awful," she continues. "I was a relatively young chair, so having braces magnified that sense of out-of-placeness." Still, she doesn't regret getting them. It was two years of discomfort, but the dental woes that had plagued her have been kept at bay thanks in part to the braces.

Although the AAO is clear that there's no one too old to get braces, orthodontists do try to correct misaligned teeth early if possible. The older a patient gets, the harder it is to cajole the mouth into rearranging itself, says Poole. While a child is still growing, still full of the cells that create and reabsorb bone, adults might need to be a touch more patient with their mouths. But aside from the process taking longer, there are other considerations that orthodontists have to think about when working with adults.

Adults, for example, tend to have higher expectations from orthodontists than kids do. They see commercials and have had a whole lot of time to think about what they want their smile to look like. Poole says that setting expectations and talking about the reality of what braces can do is key.

In one study, researchers estimated that 7.5 percent of the adults who seek out orthodontic treatment have body dysmorphic disorder, a condition in which someone feels persistent negative feelings about slight imperfections in their body. This is especially striking when compared with the rate of BDD in the general population, which experts estimate to be between 0.7 and 3 percent.

"It is therefore likely that clinicians will come across such patients from time-to-time but recognition of such patients is important as not only is it much more likely that they will never be satisfied with an outcome but can even become suicidal," writes one team of researchers. Poole says that he has only encountered someone with BDD symptoms once or twice, but that those patients can be very difficult to handle.

There are other complications to adult braces too. Adults are more likely to develop or already have something called temporomandibular joint disorders, or TMDs, a group of troubles characterized by pain of the jaw joints. TMDs can be caused by all sorts of things, everything from teeth grinding to arthritis, and some research suggests that braces can exacerbate an adult's TMD. People taking certain drugs for osteoporosis, for example, have to stop taking those drugs while they remodel their mouths because the drugs kill cells that remodel bone, the same cells that orthodontists want to be active. Pregnant women have to be careful with braces since gum swelling during pregnancy can creep down onto the tooth and cut into the bracket.

"I think I take better care of my teeth now."

The flip side of these issues is that adults tend to take better care of their braces than kids do, avoiding the foods they're told to and wearing their retainers after the fact more regularly. Janet says her entire dental hygiene regimen improved once she got braces: "I think I take better care of my teeth now, in terms of being vigilant about how many times a day I'm brushing."

There's very little sociological research that examines the cultural impulses behind adult orthodontics. The desire for straight teeth, not to mention the underlying drive for commercial perfection, is something baked into a lot of industries. The rich and famous, from Faith Hill to Tom Cruise to Brett Favre, have all sported metal to make their smiles that much more appealing as adults, and orthodontists have pushed the idea that people with better teeth lead better lives. But unlike other procedures like tummy tucks or breast implants, braces are low-risk investments. Most people who get braces are glad they did.

Janet even says she's actually happy she got them as an adult rather than as a kid. "It gave me a profoundly new appreciation for people who have to have this done in adolescence, how awful that must be, at such a tough time in life anyway. At least I was relatively comfortable with who I was," she says. Stacey says that when people did ask about the braces, it was never in a teasing way: "Most of the time they were good, they'd ask, ‘Who's your dentist, do you like him?' With other adults with braces, we'd compare experiences and how far along we were."

These reactions are echoed in the studies that orthodontists have done on outcomes for adults. One study found that adults who got braces not only reported satisfaction with their appearance afterwards, but also more generally a higher quality of life and higher self-reported social success. Or, in Stacey's words, "Even when I had them on, I was so excited about not having my crooked and crowded teeth anymore I was already starting to smile."

Rose Eveleth is a producer, designer, writer, and animator based in Brooklyn. She’s the host of the podcast Flash Forward, a columnist for BBC Future, and the editor of Smithsonian’s Smart News blog.

Editor: Julia Rubin


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