About Phase 1 Orthodontic Treatment

A while back I wrote an article titled, “Why do I see so many eight year-olds in braces these days?” I believe it is imperative that a parent knows why early treatment has been recommended by an orthodontist, as there should be a clearly defined reason that treatment cannot wait for one comprehensive phase when the majority of the permanent teeth have erupted.

The questions I ask myself when evaluating a younger child’s facial and dental development before all of their permanent teeth have erupted are:

  • If I do not treat this patient now, will a window of opportunity be missed that will negatively affect their facial structure, bite, or esthetics in the future?
  • If we do two phases of braces, will I achieve a better or more stable result than if we treated with one phase?
  • Will the patient look or function differently as an adult if we treated in one phase versus two?

If the answer to any of these questions is “yes”, then early, or phase 1 treatment may be indicated. Whenever possible, I prefer to treat patients in a single phase of treatment (this is not always the case with all orthodontists), because a second phase is usually needed to fully align the teeth when the child is older. When early treatment is recommended, I like parents to know exactly why. Here are the most common reasons (it important to note that I see many of these cases, but they are not the most common types of jaw/dental orthodontic problems- more about that later!)

  • Posterior-Crossbite3Posterior crossbites with a functional shift.  Posterior crossbites are when the back teeth are biting on the wrong side of one another, usually due to an upper jaw that is too narrow compared to the lower jaw. Why is early treatment recommended?  Early treatment is recommended if the lower jaw is shifting to one side for the child to find a comfortable bite. If left untreated, this can result in permanent asymmetric lower jaw growth to one side. If your child has a posterior crossbite without a shift, I will discuss the magnitude of the problem with your family- not all posterior crossbites require early treatment!
  • underbite-beforeAnterior crossbites due to skeletal growth issues.  Anterior crossbites are when the lower front teeth are located in front of, or edge to edge with the lower teeth. If this is caused by the lower jaw growing too much or the upper jaw not enough, early treatment is almost always recommended for these cases (unless it is so severe that facial surgery is the only option). Teeth will often tip to try to compensate for this growth, and it is possible to not have full crossbites, but have the skeletal pattern detected early (my youngest daughter has this  skeletal pattern).This type of bite is one of the most complicated and difficult types of treatment, and is distinctly different than teeth that have merely erupted in the wrong place. Why is early treatment recommended?  Underbites that are skeletal in nature usually become more severe as children enter their adolescent growth spurt. We try to reduce or eliminate the need for a surgical correction, or identify surgical cases as early as possible.(Please ask about previous articles that I have written about the complications with this type of skeletal pattern).
  • crowding 4Severe crowding that leads to impacted teeth, severe misplacement, or compromises the periodontal (gum) structures hold the teeth stable.  Crowding and misaligned teeth are the most common reasons that patients seek orthodontic treatment, but only a minority need early or phase 1 treatment. This is where it is up to the ethics and integrity of the orthodontist to properly guide the family, and not to treat early because it is good for the practice’s bottom line. But at times, teeth cannot even enter the mouth due to crowding, and treatment is indicated. Why is early treatment recommended? If teeth cannot enter the mouth, or are in extreme positions, Phase 1 treatment may be needed. Examples include canines that are becoming impacted (an would need a future surgery to correct without intervention), incisors and premolars that cannot enter the mouth properly, loss attachment (gums and bone) on the lower front teeth, or severely protruding upper teeth (often from thumb sucking) that is a clear trauma risk. Other reasons can include severe deep bites where the lower teeth are biting against the top of the mouth, severe open bites or permanent teeth that are becoming excessively worn at an early age. I will show parents the specific problems present, and relate them to the three Phase 1 criteria listed above if I believe that phase 1 treatment is needed for these reasons.

Now, just as importantly, things that should not require early, or Phase 1 treatment:

  • crowding 3 Most crowding, spacing and misalignment of teeth at an early age. As stated above, these are the most common reasons children are brought in for an exam, and the vast majority do not need early treatment for this reason. Why not?  Simply put, most crowding, spacing and misalignment is most efficiently, and just as effectively treated when the majority of permanent teeth have erupted (usually ages 10-13 for girls, and slightly later for boys). If possible, less time in braces is healthier for the teeth and gums, reduces family stress (retainers are needed to hold phase 1 corrections until kids are ready for full braces), and reduces “burnout” from being in treatment too long. Also, space can be gained from skeletal maxillary expansion anytime before the maxillary suture fuses, near the end of the adolescent growth spurt (early teens for girls, mid-teens for boys). Again, proper, well informed guidance is needed to not treat too early, or at times too late– once the maxillary suture fuses expansion is no longer possible.
  • overjet 2Excessive overbites (Orthodontists and dentists refer to this as “Overjet”).  Overjet is actually the term for how far the upper teeth stick out forward from the lower teeth, and this is the second most common concern I see for young kids in my practice. The vast majority of kids with this issue do not need phase 1 treatment. Why not? Vast amounts of research have shown that correction of this issue is most efficiently treated in one phase of treatment, usually during the adolescent growth spurt, and when most of the permanent teeth have erupted. Now, I do see a number of kids each year where the overjet is severe and they are having social problems, and there is a clear risk of trauma to the upper teeth and lips. In these relatively few cases, early treatment is certainly indicated.
  • opgggUpper canines (and other teeth) that are erupting at an angle when seen on a radiograph.  I often hear parents say this was the reason their kids received early treatment, but this is usually not an indication for phase 1 treatment. Why not?  Early treatment should only be started for this reason when the canines have started to actually cross over the roots of the neighboring incisor teeth, or are otherwise severely off course. Canines that are erupting at an angle is usually age appropriate.

My next article will explain what to expect from Phase 1 treatment if it is needed, what to expect immediately after the treatment (retainers), and how early treatment is related to full braces when your child is older.

Dr. Dan Rejman is the owner of Meadows Orthodontics, a private specialty practice in Castle Rock, Colorado. He has treated over 6,000 patients with braces and Invisalign, and has been Board Certified since 2007.

Starting with a Rapid Palatal Expander (RPE)

Kuhlberg - RPE 1A rapid palatal expander (RPE), is very commonly used in orthodontics as a means to gain space for crowded teeth, and to correct crossbites. This device may look a bit intimidating, but treatment with an RPE is actually very gentle and is usually quite comfortable for the patient. Here is what to expect if Dr. Dan recommends an expander for your child.

  • Placing separators: Dr. Dan will check if there is enough space between the upper molars to comfortably and accurately fit bands around these teeth. If the teeth are really tight together, we will place “separators” in between the back teeth to create a small space. Patients often describe separators as feeling like there is food caught between their teeth for several days. If the separators fall out with several days off being placed, let us know-you may need new ones placed. If it is only several days until the next appointment, you don’t need to call us!
  • Band fitting appointment:  Bands are like “rings” around the upper molars, and act as an anchor to keep things in place and stable. We will find the exact band that is the right size for your teeth. We will then take an impression of your teeth with the bands on them, remove the bands, and send everything to a lab where your expander is created. Your expander is custom for your mouth only, and it takes about two weeks make.
  • Appointment for placing the expander: At this visit, your expander will be delivered by cementing or bonding it to your upper teeth. We will teach parents how to turn the expander at home, and let them know how many turns are needed. We will also discuss hygiene and diet tips for keeping the expander secure and clean.
  • First expansion check appointment: After a week or two (depending on the amount of expansion Dr. Dan determines is needed) you will return, and Dr. Dan will check to make sure the amount of expansion is just right. Sometimes he will ask for several more turns to be made.
  • Your RPE will stay in place (without turning) for 6-9 months: This gives the maxilla, or upper jaw, time to remodel and make the changes remain after the expander is removed. We often slightly over-expand to account for relapse that usually occurs after the expander is removed.

Common questions and concerns

Kids are usually surprised that there is relatively little discomfort associated with the above appointments. Separators usually cause soreness for several days after they are placed, and there is a pushing sensation when we fit the bands. Patients most commonly report a “tight” sensation for several minutes after their parents turn the expander, but pain is relatively rare. Also, expect a small space to form between the front teeth (a sign that the upper jaw is expanding!).  If your “S” sounds are a bit slurred when speaking, read out loud as often as you can, and in several days your original speech will be very close! If you have any concerns at all, give us a call- we are always happy to answer any questions you may have!

Dr. Dan Rejman is the owner of Meadows Orthodontics, and is a board certified specialist in orthodontics and dentofacial orthopedics. Meadows Orthodontics serves patients from Castle Rock, Castle Pines, Franktown, Elizabeth, Larkspur, Parker, Highlands Ranch and Lonetree.

How to finish your braces faster!

Kids are generally really excited to get started with their braces, but about half way through their treatments, they get just as excited to finish and have the braces removed. I get asked, “Is there anything that you can do to get the braces off sooner?”  Here are some tips to help get you finished up as quick as possible.

  • Wear your rubber bands (elastics) exactly as directed by your orthodontist! This is by far the elasticslargest contributor to moving along as planned, and getting your braces off as quick as possible. If I ask you to wear elastics 22-23 hours a day, and they are only worn an average of 12 hours, treatment will likely take over twice as long as it normally would. That means what would have taken 18 months may take over 2-3 years! Start off immediately with great rubber band wear, and often you will finish faster than what I estimated at the start.
  • Related to this…doubling up your rubber bands will not make things move faster. In fact, just the opposite occurs, as too heavy a force placed on teeth can make them move slower! I usually see this after rubber bands were not worn for several weeks, and kids are attempting to “catch up” before their next appointment. Your orthodontist wants things to move as efficiently as possible, and will direct you to wear the elastic that is most ideal for you.
  • Keep your teeth and mouth really clean! A really clean mouth has less images4inflammation, and this can help your teeth move faster. Cleanliness leads to gums that do not bleed, which helps the braces stay on the teeth better, resulting in less broken brackets and less emergency appointments (along with better breath and less permanent staining on teeth).
  • Come to your appointments as scheduled! If you miss appointments, you are delaying the next step in your treatment. Sometimes life happens and you have to miss an appointment. We understand this – but try to re-schedule as soon as possible.
  • Be careful what you eat, and how you eat with your braces on. Eating foods on the “no-no list” can cause the brackets to come loose and temporarily stop tooth movement until it can be repaired. Avoid really sticky, crunchy foods, and slow down while you are eating meals to ensure less breakage!

Do your best to follow the above tips, and you will be out of your braces with an amazing smile in no time!

Dr. Dan Rejman practices and lives in Castle Rock, Colorado. He is the owner of Meadows Orthodontics, and has been Board Certified by the ABO since 2007.

“Why does my child grind their teeth at night?”

images (2)During the course of an initial orthodontic consult, we discuss whether parents notice if their children grind their teeth at night. Surprisingly, a large percentage of parents report that they can actually hear their kids grinding, which can often be alarmingly loud. I remember being able to hear my daughter grinding her teeth from outside her room when she was 8-9 years old! It is normal to wonder if this is something to be concerned with, and if it will do any short or long term damage.

Bruxism, or bruxing, is the medical term for grinding teeth, and sleep bruxism is grinding teeth at night. Ginding at night is considered a sleep-related movement disorder, and although a large percentage of the population grinds their teeth at night, the frequency and severity varies from mild to severe. Signs and symptoms of bruxing include teeth with enamel wear or chipped edges, sore jaw muscles, headaches or what may feel like an earache, and tooth sensitivity. Sometimes their are no symptoms, and other household members just hear the grinding! There is not a well established link between bruxing and long term TMJ disorders, but it certainly can be a contributing factor.

images (1)The causes of bruxing are not completely understood, but the following may be causes or triggers: Emotionalcauses such as stress, anxiety and anger; A response to pain such as headaches or teeth erupting; Abnormal alignment of the teeth such as severe crossbites; genetic causes and related sleep disorders such as sleep apnea and snoring; sometimes there is no apparent cause at all. Bruxing is most common in young children, and most kids will outgrow it as they age. However,if you feel that the grinding is excessive and is becoming a concern, options include:

  • Informing your dental professional at your next visit. I check for signs of tooth wear, sore “chewing” muscles, and a history of headaches in the early morning upon waking.
  • Identifying causes of stress and anxiety. Addressing these issues can often reduce the frequency and intensity of grinding.
  • For adults, try reducing caffeine, smoking and alcohol intake.
  • In severe cases, we can make a splint, or night guard, to protect your teeth. Wearing a night guard before all the permanent teeth have erupted is often difficult, as kids go through stages of loosing and gaining new teeth. This makes fitting a night guard that will fit securely in their mouth difficult to impossible depending on their dental development.
  • If a bruxer is currently in braces or orthodontic treatment, teeth are actively moving and they often have to wait until the braces are removed to get a night guard that will stay secure long-term. Once the braces are removed, I will review special retainer options for my patients who are bruxers. Night guards can be incorporated into retainers quite nicely!
  • Orthodontic treatment itself may not always reduce the amount of grinding, but it certainly can help reduce wear on teeth that are wearing or chipping. I will determine if any teeth are wearing excessively or disproportionately (patients can often see uneven wear on their front teeth before starting treatment), and I will make a plan to move teeth to minimize wear. You may hear me checking for “canine guidance” and “interferences”… I will let you know that that means if you are interested!

Dr. Dan Rejman is an orthodontic specialist in Castle Rock, Colorado. He is the owner of Meadows Orthodontics, and has been Board Certified by the American Board of Orthodontics since 2007.



The Genetic Influence of Facial Structure and Tooth Development

I just returned from the College of Diplomates of the American Board of Orthodontics annual summer meeting. I attended four days of speakers presenting research related to how genetics influences the treatment of our orthodontic patients.  Topics included the genetic influence on temporomandibular disorder (TMD), obstructive sleep apnea (OSA), missing and malformed teeth, external apical root resorption (roots of DNA - Molecule of Lifeteeth becoming shorter during braces), and the latest research on a possible connection between missing upper lateral incisor teeth and an increased risk of ovarian and colorectal cancer. I will write a separate blog about several of these topics individually, but below are some interesting points about genetics.

  • The human genome contains 3.2 billion (!!) base pairs, or chemical nucleotides.
  • There are approximately 25,000-30,000 human genes, which are the smallest units of “instructions”.
  • 99.9% of the human genome sequence is the same!
  • Genetic variation can often arises from what is called a SNP (“snip”), a single nucleotide polymorphism. One nucleotide change within a gene can result in no discernible change, or can result in a change in phenotype (an observable trait, characteristic, shape, etc…)
  • Tooth development, or odontogenesis, involves over 300 genes.
  • Sporadic changes, or snips, in the genome can cause dental agenisis (failure to develop, or missing teeth), or a change in the size or number of teeth.
  • About 2-9% of the U.S. population has hypodontia, or teeth that are developmentally missing.
  • Genes such as AXIN2 and PAX9 have been identified as genes that can contribute to a family history of teeth that are missing.

I will follow up with an article on the genetic influence on obstructive sleep apnea, and its ramifications on orthodontic treatment.

Dr, Dan Rejman is a Board Certified Orthodontic Specialist. He practices in Castle Rock, Colorado, and treats children and adults with braces, clear braces, and Invislaign.

Early Orthodontic Correction of Posterior Crossbites

I see many young patients who have what is called a posterior crossbite, and it is important for parents to understand why certain crossbites should be corrected at an early age. Basically, a posterior crossbite means that the back teeth are located on the wrong side of one another. As an orthodontist, I determine what the cause of this problem is, if the crossbite is causing the lower jaw to shift to one side, and if this issue needs early correction before they are ready for a full set of braces. Usually a crossbite that is causing a shift should be corrected as early as it is detected (when the permanent teeth start to erupt), and I like parents to know why.

Constriction-palatine-glissement-fonctionnel-KaVe-iof-en-RC-orthodontiste-Chamberland-QuebeccrossbiteA common cause of crossbite is an upper jaw (maxilla) that is narrow in contrast to the lower jaw (mandible). As the lower jaw and it’s teeth close in a straight path, it contacts the upper teeth and they do not “fit” correctly. This is an uncomfortable feeling, and the child shifts their jaw to one side to find a comfortable place to bite. We call this a “unilateral posterior crossbite with a functional mandibular shift.” Several issues to note about this shifting:

  • The shift to one side becomes habitual, and the child’s neuromusculature becomes adapted to the new position.
  • This new shifted position causes the condyle (the uppermost portion that is apart of the TMJ) of the lower jaw to push upward and backwards on the side of the crossbite, whereas the condyle on the other side is pushed forward and downwards.
  • This change of position causes compression (pressure) on the crosbite side, and tension (pulling) on the non-crossbite side.
  • If left long enough in this position, remodeling of the condyle (upper portion of the lower jaw) and glenoid fossa (the “socket” portion of the skull and TMJ) can occur. Specifically, less bone grows on the crossbite side, and more bone grows on the other side.
  • This asymmetric mandibular growth can cause facial disharmony and functional changes in the masticatory (chewing) muscles. Other than the obvious aesthetic and facial symmetry issues, the effects on TMJ disorder are still being researched.

It is interesting to note that the correction of the lower jaw’s asymmetric response to the narrow upper jaw is to symmetrically widen the upper jaw. If treated young enough (before the upper jaw’s mid-palatal suture fuses), the lower jaw will go back to biting in line with the middle of the upper. Unfortunately, I see older patients in their mid to late teens and adults who no longer can be corrected with orthodontics alone, and jaw surgery is the only way to correct the skeletal imbalance that has occurred. If there is any question at all about your child’s bite, give me a call an I will be glad to take a look and discuss if early treatment is indicated.

Dr. Dan Rejman lives and practices as a Board Certified Orthodontic Specialist in Castle Rock, Colorado. He is a proponent of treating children with braces at the proper age (some younger, some later!), dependent on their unique facial and dental relationships.


How Much do Braces Cost?

“How much do braces cost?”, and “What does Invisalign cost?”, are questions that I am often asked at parties, my kid’s sporting events, and of course during new patient consultations. Here are a number of factors that go into deciding how much braces or Invisalign cost, along with a number of tips that you may find very helpful in budgeting and planning for braces for yourself or your family.

  • Every orthodontist is different, but I give estimates based on the complexity and difficulty of a case. This is why it we do not give quotes over the phone before a consultation and full exam. One child may need several months of treatment, while another may require over two years of treatment in braces.
  • Adult treatment in our practice is generally not more expensive than treatment for teens or children. Again, it is case by case, and many adult treatments are surprisingly short and relatively inexpensive.
  • img5Whether you have insurance or not, we offer in house, interest free financing that can spread the fee for braces or Invisalign into monthly payments over the course of your treatment. Most families are pleasantly surprised at how affordable braces are.
  • If your family has orthodontic insurance, the insurance contribution will be determined by your specific plan. The good news is that if your orthodontist participates with your insurance provider, your fee will be substantially reduced. It is important to ask your orthodontist if they participate (if they are a provider) with your insurance. We all accept insurances, but if we are a provider for your plan, we are contracted to charge a fee that is often lower than our standard fees. Then you get the insurance contribution on top of the reduced fee. If we do not participate with your plan, we set the fee independent of the insurance company’s influence, but there is often a contribution that the insurance company will pay (although this contribution may be less than if you are seeing a participating provider). Insurance and benefits can be very confusing-please feel free to call our office manager, Julie, to answer any questions that you may have!
  • Take full advantage of Health Savings Accounts  (HSA’s) or Flex Spending programs. In addition to Insurance benefits, utilizing these plans can save an additional 20-30%! Timing is often important in setting aside funds for these programs, and we will work with you to make sure you take full advantage of this often overlooked area for savings.
  • Whenever possible, Dr. Dan prefers to treat in one comprehensive phase of braces. If your child needs early treatment, and will need two phases of braces, we will set out a financial game plan for the entirety of treatment immediately (for everything)- we don’t like our families dealing with surprises.
  • Invisalign has advantages and disadvantages compared to braces. In general it tends cost more than braces, but each case is different, and we try to keep prices comparable.
  • Please do not feel shy about discussing any financial concerns with us. We are a private, locally owned practice, and we really want to make the experience of getting a new smile enjoyable and stress-free. Dr. Dan and Julie will make you feel comfortable, and will answer any questions you have!

Dr. Dan Rejman is a Board Certified Orthodontic Specialist and Castle Rock, CO. local. He has the best office manager in the world (his wife, Julie!), who will answer any of your financial questions regarding braces, clear braces, or Invisalign.

Why a Patient’s Age is Often Important in Orthodontics

Just this week I saw several patients for an initial consult, and because of their age and facial structure, each had an entirely different chance of achieving an ideal outcome with braces or Invisalign (a healthy, functioning bite with optimal aesthetic results). One woman was in her 50’s, and she was wondering if she was too old to 6a01156e42deab970c017ee4610272970dhave her crowded teeth aligned. Because she had a balanced skeletal structure, I informed her that her crowded teeth could be treated to very ideal and beautiful outcome, and her age would have little influence on this outcome.  Later that day, I was visited by a 20 year old young man who also desired to have his teeth aligned with braces. His lower jaw had grown disproportionately less compared to his upper jaw, resulting in an excess “overbite” (as orthodontists we call it “overjet”). Due to his skeletal structure, combined with the fact that at his age his jaw growth was relatively complete and in a stable position, I had to explain to him that the ideal age to treat his condition has passed. Yes, I could ogreatly improve his bite and appearance, but because of his age and jaw structure, the finished result would have to be a compromise if treated with orthodontics alone (he would require surgery to re-position his upper and lower jaws into an ideal position). The mother of this patient stated that she heard that he could have his teeth corrected after they had all come in, and unfortunately this led to him not having an exam at a younger age.

The two cases above illustrate the misinformation that patients sometimes hear and believe, whether that information comes from the web, family, friends, or just long held beliefs about teeth that still exist. It also demonstrates that older adults can often be treated to ideal, while if younger patients miss a window of opportunity with their growth (especially through adolescence), the chance of treating to an ideal result is greatly diminished.

The American Association of Orthodontics recommends that children have an orthodontic exam no later than age 7. Although I feel that the majority of children I see at this age do not need early treatment with braces, many issues that parents need to be aware can be seen by an orthodontist at this age. The most common examples include:

1) Excess crowding (only severe cases need early treatment). Most often mild to moderate crowding can be treated at a later age when all the teeth have erupted. As the first example above demonstrates, this can often be corrected ideally from adolescence through adulthood. As mentioned, severe cases do need early intervention.

2) A lower jaw that is not growing enough, or a upper jaw that is growing too much (what is referred to by the public as an “overbite”)  We usually like to wait until the adolescent growth spurt to treat this growth pattern, but if a patient waits too long (like the 20 year old above), the bite often cannot be treated ideally.

3) A lower jaw that is growing too much, or upper not enough (known as an “underbite”). It is extremely important to identify this pattern early, and treatment for this pattern often begins at a very young age. Very severe cases are often not treated at all until a patient is ready for a combination orthodontic/surgical correction. The important thing for these cases is early identification, and to try to avoid the need for surgery if possible.

4) An upper jaw that is too narrow. A narrow maxilla is often the cause of crossbites, and if it causes the lower jaw to shift to one side or contibutes to abnormal eruption of teeth, we will often treat this condition early. Expansion of the upper jaw can accomplished before the the two sides of the maxilla fuse together. This fusion usually occurs earlier for girls (early to mid teens) than in boys (mid teens).

The take home message here is the importance of early identification of issues that may exist, and informing parents of the ideal age to address these issues. Even though the majority of children do not need early treatment, some do and the window for achieving a correction is relatively small. For the others, it is important for parents to know the “game plan” for the future treatment of a child’s individual facial skeletal structure. Just as important is letting parents know when treatment is largely aesthetic in nature, and if there is little concern over an “ideal” age for elective treatment.  Always feel free to contact me if you have any questions regarding your child’s teeth or facial growth!

Dr. Dan Rejman is currently the only Board Certified Orthodontist in Castle Rock or Castle Pines, Colorado. He has been a Board Certified Diplomate of the American Board of Orthodontics since 2007.

How to Prevent White Spots and Staining on Your Teeth While in Braces

download (1)You may have noticed bright white staining on some peoples teeth after they have their braces removed. These white areas are often permanent, and as an orthodontist it is very disappointing to see after after all the work we have done to get the alignment of the teeth so ideal. It is extremely important for patients and their parents to understand how these stains form, and what can be done to prevent them.

biofilmdevWhite spots occur on teeth by a process called decalcification,  which will start on any tooth surface where plaque is allowed to sit for an extended period of time (often only several days). Dental plaque’s composition includes a large number of bacteria called Streptococcus Mutans, and Lactobacillus. When these bacteria reproduce and accumulate on the teeth, they appear as a white sticky film (like the bacteria in Petri dishes in school!). This plaque commonly forms and grows near the gum line and around braces if the bacteria are not removed. As living organisms, these bacteria feed on the sugars and carbohydrates that you place in your mouth. After feeding, these bacteria multiply and excrete acid as a waste product for up to 20 minutes. It is this acid excretion that dissolves enamel, and causes a loss of minerals in your teeth.

The white spot that forms is actually the first sign of tooth decay from the loss of minerals from your teeth. Often the outer layer of enamel is hardened from flouride, and the decalcification occurs below the surface of the tooth deeper into the enamel. This is why once damage occurs it is most often a permanent stain on the tooth. Left untreated, this stain can progress to a cavity and will need restoring (or “filling”) by a dentist.

download (2)Braces themselves do not cause staining or plaque to form, but they do present a physical barrier to brushing and increase the surface area for plaque to accumulate. This is why from your very first consult with us, we stress them importance of excellent hygiene and brushing technique. It sounds simple, but by just removing this plaque by proper brushing twice a day, these permanent white stains can totally be avoided. But as a father of two kids in braces, I know that most children are not “programmed” to think about medium to long term consequences of leaving plaque on teeth. Since myself and my staff often only see a patient every 6-7 weeks, monitoring the child’s plaque removal must involve the parents (this is probably the most important take home point in this article- I am an orthodontist and my own children need constant checking!) After teeth are perfectly clean, it only takes several days for plaque to build up, and in several weeks can start to permanently stain the teeth!

Several important things to remember:

When brushing, technique is just as important as time spent brushing! Parents often tell me that they see their kids brushing often, but at their orthodontic appointment there is heavy plaque. This is due to a pattern of brushing that consistently misses the same places over and over again. Even if some areas are spotless, the missed areas will form these permanent decalcification stains.

downloadThe most common areas that are missed when brushing teeth are near the gingival margin (where the teeth meet the gums), the sides of one or all of the braces on your teeth (which is why the white stains are often shaped in a halo- the braces have protected the enamel under the braces while the plaque surrounding the braces leaves a distinctive mark), and the upper lateral and canine on the side of a child’s dominant brushing hand.- this is usually where they “flip” the tooth brush. These are all points that we cover in depth after the braces are placed, when we review brushing and flossing. Please ask any of us at Meadows Orthodontics if you have any questions!

Once stains are present, they usually cannot be removed. There are several products on the market that claim to reduce white spot lesions, but the research on them have been largely non-conclusive to date. Prevention remains the best option! Other than plaque removal, reducing the amount of processed sugar ingested greatly reduces the chance of staining, as this removes plaque’s food source. The biggest offenders are sugar drinks, including soda, sports drinks, and even sipping on too much fruit juice. Fluoride rises (such as ACT) for at risk patients can often help. We also have a fluoride releasing protective sealant that can be applied for higher risk patients.

Remember, every patient is unique, and each child needs their own level of attention and motivation to ensure their teeth are protected as much as possible while they are wearing braces.

Dr. Dan Rejman is a Board Certified Diplomate of the ABO, and practices at Meadows Orthodontics in Castle Rock, CO.

How to handle emergencies with braces

Thankfully, there are very few medical emergencies that are associated with wearing braces. There are a number of issues of concern that can arise while you are in braces though, and I will discuss the most common “emergencies” and what to do should they occur.


A bracimages (1)ket (or “brace”) has come loose  A bracket that has released from a tooth is the most common concern we see. Brackets are the square metal or ceramic part of braces that are bonded to your teeth with adhesive. This adhesive is designed to release from the tooth if excess force is placed on the braces. This breakage can occur due to a large amount of light “taps” on the braces from chewing (even from foods that might not normally be suspected), or one or two sudden heavy collisions with crunchy, chewy, or tough foods. Patients most often report that they were not eating any chewy or crunchy foods when the braces came off, and we explain that it often takes a day or two before the brace moves and is noticeable. Weakening of the adhesive can accumulate over a period of time before the braces finally releases from an otherwise harmless bite into food (similar to the last “chop” that cuts a tree down). We also explain that the breakage is not necessarily a bad thing, as a stronger adhesive would rip enamel off the tooth with the braces- the release is actually a protective mechanism.

We understand that life happens, and will gladly repair the loose bracket. If we see a pattern of multiple braces coming loose, we will work together with the patient to identify eating habits that are contributing to the breakage. If the bracket is loose, but still attached to the wire, simply use your fingers, a q-tip, or a tooth pick to slide or rotate the brace until it is in a comfortable position. Call our office, and we will help you find the best time to re-attach the bracket.

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A wire is poking your cheek.  Occasionally a wire may deform, or move out of place and start to irritate a patients cheeks or lips. First, try using a q-tip (or the end of the plastic mirror handle that was included in your hygiene kit) to push the wire against your teeth or to a more comfortable location away from the cheek. A nail clipper can also trim many poking wires. If this does not work, use a small pea- sizdownload (1)ed piece of relief wax from your kit, and place it over the irritating piece of wire. If the irritation persists, call our office, and we will likely have to clip or re-position the wire.



download (3) A wire has broke, or a band is loose.  If an arch wire has broke into two pieces, try to remove the broken part if it is loose. A light wire can often easily be pulled out of the mouth with just a light pull. If this cannot be done, try to keep the pieces in a comfortable part of the mouth, and call our office for a repair as soon as possible. If a band around a back tooth, or an expander has come loose, try lightly pushing it back onto the teeth, and call our office as soon as possible.


images (3)A colored or clear tie has come off a bracket.  We call the small rubber rings on your braces ligatures, and occasionally one may come off. If everything else appears in place and you have an appointment soon, we will be able to place a new one at your upcoming appointment. If it will be more than a few weeks until your next appointment, call us and we will replace the tie.


images (4)Canker sores.  Canker sores, or aphthous ulcers, can be very painful. They are usually not caused by braces, but the braces can irritate them and exacerbate the discomfort. These sores last about two weeks, and there is no known way to make them go away sooner. The best option is to keep the area as comfortable as possible. Try using over the counter topical anesthetic such as Orabase or Ora-gel, and apply as needed with a q-tip.


General tooth and gum pain soon after braces are placed. Discomfort is to be expected the first 4-5 days after braces have been placed. I tell patients to hang in there, they are not alone- this is very common the first week of wearing new braces. For sore teeth, eat a softer diet (mac and cheese, pasta, soup, smoothies…) until things start to feel better. Take Ibuprofen if and as directed by your orthodontist to help with the discomfort. If your lips and cheeks are sore from rubbing on the braces, roll up a small pea sized ball of comfort wax, and press it onto the braces near the area of discomfort.


Dr. Dan Rejman is the owner of Meadows Orthodontics in Castle Rock, Colorado. He is a board certified orthodontic specialist, and provides treatment with clear braces, traditional braces, and Invisalign.