The Dreaded White Spots

 

Many parents fear the dreaded white spots.  They ask regularly during their child’s orthodontic treatment if their child is getting white spot lesions. What they often forget is that the white spot lesions are not from the braces. They are from not keeping the teeth clean enough, and they can happen with or without braces.

White spots on teeth are actually white scars, and once they appear, they may become permanent.  The white spots are the first step in the caries process; white spots become cavities. Poor oral hygiene allows plaque to build up on the tooth surface.  Maintaining adequate hygiene is even more difficult when braces are present because the brackets create hiding places for this bacterial accumulation.  The bacteria in the plaque eat the food which is left on the tooth surfaces; they especially like to eat sweet and sugary foods. The bacteria then “poop” on the teeth. This acidic bacterial excrement can erode or “decalcify” the enamel surface of the teeth.  Demineralization (a decrease in the mineral content of the enamel) can happen on the surfaces you can see, but it can also happen between the teeth if dental floss or waterpik irrigation is not used daily. (The decalcifications between the teeth are seen on x-rays as “incipient lesions”, i.e. early cavities.)  As fluoride and the natural minerals of your saliva fight to keep the enamel strong, the decalcified areas are recalcified.  This process of decalcification and remineralization creates unsightly color changes (both white spots and dark areas) of the tooth surface.

White spot lesions are also common in people who have dry mouth issues.  Reduced saliva flow lower’s the mouth’s natural ability to neutralize the acids. Many people with dry mouth “self -medicate” with lemon drops. Although the lemon drops increase salivation, they also feed the bacteria on the tooth surface as well as increase the mouth’s acidity directly (lemons are acidic). Both acid from the bacteria, and acid from the food increase demineralization of the tooth surfaces. Remember, this demineralization is the first step in tooth decay. A better option to increase salivary flow would be using xylitol candies and sprays, such as Xylimelt dry mouth lozenges or Carifree spray, because xylitol inhibits bacterial growth.

Another factor in white spot lesions, in addition to accumulation of bacteria, is the application of dietary acid straight on tooth surfaces. Many foods and beverages are acidic.  When people sip a lot of acidic beverages, like carbonated beverages (seltzer and soda), lemonade, sports drinks, tea with lemon, or coffee, they bathe the tooth surfaces in acid. The longer the period of time during which the acidic beverage is applied, the more damage it does.  This is why Dr. Okun recommends drinking the acidic beverages with a meal so that there is increased salivary flow as well as other foods to decrease the acidity of the mouth. She also recommends limiting the time that sugary foods are in the mouth. (Eat a cookie and then rinse out rather than suck on a candy or lick a lollipop for more than 10 minutes.) Dr. Okun recommends rinsing with water after eating or drinking, to wash the food particles and acid off of the teeth. It is also beneficial to rinse with fluoride daily to strengthen the tooth surfaces and to help the teeth re-calcify following acid attacks.

For help with proper cleaning of the teeth, see our hygiene videos on our website https://www.okunortho.com/brushing-and-flossing.  Be sure to brush thoroughly at least two times a day, and either floss or use the “Waterpik” dental irrigator daily to clean between the teeth.

How Long Does Orthodontic Treatment Take?

 

Orthodontic treatment is a carefully planned process that focuses on both function and appearance. Patients often ask how long orthodontic treatment with braces or aligners like Invisalign will take, and the answer depends on several individual factors. While the average orthodontic treatment timeline is about two years, each case follows a unique path based on the patient’s needs.

In many cases, traditional braces are worn for 18 to 30 months. This timeframe allows for gradual, controlled tooth movement that protects the health of the gums and bone. Some patients may complete treatment sooner, especially if alignment issues are mild, while more complex cases (such as those with impacted teeth) can take longer.

Aligner treatment timelines (for example, Invisalign or Spark clear aligner systems) are often similar, though they can vary depending on how consistently the aligners are worn. Most Aligner (Invisalign or Spark) patients receive a series of custom trays designed to shift teeth step by step. Each set is typically worn for one to two weeks before moving to the next, creating steady progress over time.

Age plays a role in how long orthodontic treatment takes. Younger patients often respond more quickly because their jaws are still developing, making tooth movement more efficient. Adults can achieve excellent results as well, though treatment may take slightly longer due to denser bone structure.

Consistency is one of the most important factors influencing treatment duration. Following instructions, such as wearing elastics with braces, or wearing aligners for the recommended hours each day or maintaining proper care with braces, helps prevent delays. Missed appointments or inconsistent habits can extend the overall timeline.

Orthodontic treatment moves at a pace that protects long-term oral health, not just the speed of results. This approach ensures that teeth are correctly positioned and remain stable after treatment. Rushing the process can lead to complications or relapse, which may require additional correction later.

Patients in Westchester County (including White Plains, Rye, Rye Brook, and Port Chester) often ask how their local orthodontic treatment timeline compares to national averages. In most cases, the duration is similar, as orthodontic principles remain consistent regardless of location. What matters most is the individualized treatment plan created after a thorough evaluation.

Regular check-ins allow orthodontists to monitor progress and make necessary adjustments. These visits are essential for keeping treatment on track and addressing any concerns early. Whether using braces or Aligners (such as Invisalign or Spark clear aligner systems), small changes over time lead to meaningful, lasting improvements.

Ultimately, orthodontic care is an investment in both health and confidence. While two years may seem like a long commitment, the gradual process is designed to deliver stable, functional results that last well beyond the treatment period.

Keywords Used: orthodontic treatment timeline, how long do braces take, Invisalign treatment timeline, braces duration, orthodontic treatment White Plains, NY, average braces time, Invisalign aligners

What to Eat and What to Avoid when Wearing Braces

Changing your eating habits is one of the most difficult adjustments when wearing braces. Some foods are more likely to damage your braces and your teeth than others. I advise patients to avoid:

1. Candy and other high sugar content foods, especially if they will spend a long time in your mouth.  Eating a cookie and then rinsing with water will do much less damage than sucking a sugar candy for 10 minutes.  The bacteria in your mouth will eat the sugar and give off acid which will decalcify the tooth surfaces.

2. Soda (all carbonated beverages i.e. carbonic acid) and other acidic beverages (like lemonade, fruit smoothies, and energy drinks.) Acid will decalcify (eat away) the part of your teeth that are not covered by the brackets, leaving a change of color which will later finish turning into a cavity. If you drink the acidic beverage be sure to rinse it off your teeth with water instead of leaving the residue in your mouth.

3. Sticky things like chewing gum, taffy, Ike and Mikes, gummy bears, and caramels will bend the metal.  This will cause the glue to crack underneath the brackets and bands. As the cracked glue washes out the metal pieces will come loose.  The sticky things will also deform the wires, causing the bent wires to push the teeth to incorrect positions. 

4. Foods with a hard back (ribs and corn on the cob) should be separated from the hard back (the bone and the cob) in order to not break off the front brackets.

5. Hard and Doughy Foods that have resistance to bite into should be cut thin. Don't bite straight into an apple, carrot, bagel, pizza crust, or fat sandwich.  Cut them into thin pieces before eating. Also, eat one piece at a time. One potato chip will not break your braces, but a handful all-at-once may.

6. Energy and Power bars are too hard and chewy. Cereal bars and thin snack bars are better choices, especially if you break them into small pieces before putting them into your mouth.

7. Seeds and popcorn (with a husk) should be avoided when wearing a palatal expander because the small hard pieces get stuck between the plastic and the palate causing a wound.

The link for the article which I wrote for HelloNation (and which they edited, i.e. changed) is below, followed by a screenshot of the first page.

https://orthodontistexpertinwhiteplainsny.org/navigating-braces-what-to-eat-and-avoid-in-white-plains-ny/

Age to Start Braces

It's never too late to wear braces.  We can improve alignment and function at any age, but there are some ages that are more ideal than others.  For example, I cannot change the bone structure in an adult, but I can change it in a growing patient.  Palatal expansion (changing the width of the upper arch) is most effective below age 12 for a girl, and below age 14 for a boy.  Headgears can restrain growth of the upper jaw, but only if there is more growth available, therefor starting by age 8 is more efficacious. If treatment is started after facial growth is finished we are more likely to need to remove adult teeth or reshape the existing teeth in order to achieve alignment. Treating adults limits the facial and jaw balance that can be achieved.

HelloNation published my first article on the best age to start braces.  Unfortunately, working with them also means accepting their edits to match their writing style. The photos in the hello nation articles are theirs too. Here is the link and a screenshot to the first page of the article. 

 https://orthodontistexpertinwhiteplainsny.org/when-kids-should-get-braces-guidance-for-families-in-white-plains-ny/

Healthy Gums do not Bleed

 

When I was a teenager, my father arranged for me to observe dentists in several dental offices, in order to convince me that dentistry was not what I wanted to do for my livelihood.  My parents’ plan backfired.  I loved what I saw, and knew in my heart that I would be a good dentist. Some of what I heard, however, did not sit well with me.  One dentist, in response to his patient’s concern about her bleeding gums, stated “everybody’s gums bleed.” NO! Everybody’s gums do not bleed, and they should not bleed.

If your hands bled when you washed them, you would be concerned.  You should also be concerned if you clean your teeth and your gums bleed.  Bleeding gums are sick gums. 

Healthy gums are light pink in color, are flat to the tooth surface, come to a neat point between the teeth, and are stippled like an orange peel.  Sick gums are more red in color, especially around the necks of the teeth, they are rolled like a bagel near the tooth surface, the triangular areas between the teeth are bulbous (they puff out) and the surface is shiny. The first stage of gum disease is gingivitis, the inflammation in the gums that creates the red appearance, that allows the gum tissue to flop in the breeze, and which bleeds when you brush, floss, or touch it. The more you avoid touching it, the more the bacteria build up, the more the tissue reacts to the toxins from the bacteria, the worse the inflammation gets.  You can only break the cycle by brushing and flossing (or brushing and irrigating with a water-pik.)  If your gums are bleeding they are saying, “Help, I’m sick. Please clean me.” If you continue to neglect your gums, the disease process will progress to periodontitis.  Now the whole attachment around the teeth is inflamed, and the bone that holds the teeth in your mouth starts to go away so that the necks of the teeth start to stick out of the gums. Over time the teeth also get loose, and some will fall out.  Gum disease is the leading cause of tooth loss in adults.

If you move teeth orthodontically, or with mouth habits like leaning your tongue on your teeth or sucking your thumb, and your teeth are not clean, you are at risk of accelerating the damage caused by gum disease.  For information on how to clean your teeth, watch our hygiene videos on-line at https://www.okunortho.com/brushing-and-flossing

Spring is in the air, Let's keep our teeth for a lifetime

 

Spring is in the air (the snow is starting to melt). Soon all the seedlings will sprout and new plants will crop up everywhere.  If only it were so easy with teeth.  We only get two sets.  Most of the time, if everything is normal, we grow a total of 20 primary teeth.  These baby teeth are replaced between the ages of five and twelve (on average) with adult teeth.  New adult teeth also erupt distal to (further towards the back of the mouth than) the full set of primary teeth. The total number of permanent teeth, including wisdom teeth which erupt in adulthood, is 32.  We do not get replacements for the “second set.”  Despite the fact that we call adult teeth “the permanent dentition”, if we don’t take care of these adult teeth they do not last for a lifetime. Neglect can lead to a lifetime of restoring the damage with fillings, gum grafts, and replacement teeth (bridges, implant crowns, and dentures.)

In my recent agricultural volunteer experiences, I have learned that growing plants is not effort-free. It is not simply waiting for new plants to crop up everywhere. In addition to planting seeds in containers, clearing and fertilizing the fields and planting the seedlings in the ground, keeping the plants well-watered, and weeding out the unwanted vegetation, the plants need pruning (removing extra leaves that are sapping nutrients and removing extra fruits that are too heavy for the plant), pests have to be kept away from the plants, the plants need to be protected from the weather, and the fruits need to be harvested, boxed, and sent to market. (Did you know that cauliflower gets sunburned [i.e. it turns brown] if it gets too much sun?  The farmers need to bent the leaves over the head of the cauliflower daily to keep the cauliflower white.) Farmers don’t just plant the seeds and harvest the fruit.

People have to take care of their oral health with just as much effort.  We need to properly brush and floss to remove bacteria from our teeth daily in order to prevent cavities and gum disease.  We can also use other aids for cleaning our teeth like the Waterpik Dental Irrigator and ultrasonic electric toothbrushes like the Philips Sonicare toothbrush. Many of us need to use fluoride rinse daily to strengthen the enamel to resist decay and discoloration. We can use special rinses to keep the gums healthy (examples are The Natural Dentist Healthy Gums rinse, StellaLife VEGA rinse, warm salt water, or a combination of hydrogen peroxide and water.) We need to visit our dentist every 6 months to make sure that we are keeping the disease processes at bay.  If we are having issues, like cleaning the crooked teeth, or having enough space for the adult teeth to erupt properly, we need to visit the orthodontist to make the teeth easier to clean.  The orthodontist also puts the teeth into their best positions to withstand the functional forces of chewing and talking.  If we have parafunctional habits that put excessive forces on our teeth, we need to have the orthodontist make acrylic devices to wear on our teeth at night to protect our teeth from habits like grinding our teeth, leaning our tongue on our teeth. We also need to break habits like chewing our shirtsleeves, sucking our fingers, or biting our pens. Keeping teeth for a life-time is a lot of work!

 

Valentine’s Day is coming and millions of Americans are planning to take their loved ones out to eat, buy them flowers, and buy them jewelry.  Relationships take effort and time to maintain, even relationships with family members, friends and co-workers.

Teeth also take effort and time to maintain. We need to clean them effectively (brushing and flossing daily (https://www.okunortho.com/brushing-and-flossing) is the number one priority, because all diseases of the mouth are caused by the bad bacteria which build up when you don’t clean effectively. Eating fewer sugary things, keeping the time that the sugar is bathing your teeth to a minimum, and rinsing the sugar off your teeth after eating, will all help to minimize dental decay.  Eating fewer acidic things, and rinsing after having acidic beverages (like carbonated beverages, fruit smoothies and sports drinks) will help to keep decay and erosion to a minimum. 

Teeth that are well aligned are easier to clean than teeth that are crowded. Dr. Okun will happily show you how to clean difficult areas, but she will also recommend orthodontic treatment (braces) when it is indicated for the longevity of your teeth. Properly aligned teeth are in positions and angulations that help them to function at their best, and to hold up to the functional forces of chewing and speaking. But even well aligned teeth have trouble holding up to excessive forces that are generated by clenching and grinding your teeth (bruxism) and generated by leaning your tongue on your teeth at rest or when swallowing (tongue thrust).  Obviously, it’s best to eliminate these damaging habits, but it’s impossible to monitor habits when you are sleeping.  Therefore, if Dr. Okun diagnoses you with one of these habits, she will recommend that you wear acrylic appliances (such as a hard full occlusal coverage maxillary guard, or a Hawley retainer) at night (indefinitely) to protect your teeth and their supporting structures from these damaging habits.

(NOTE: This blog was written in January, and  did not post on it's scheduled post date. Sorry it's late.)

Help your teeth celebrate the New Year

 

New Years 2026 blog

How did you celebrate New Year’s? Did you curl up with a book, watch a movie on TV with your family, or go out with friends?

Human beings are social creatures.  We often share our special occasions with other people.  Too much “alone time” often leads to depression. Teeth are not too different.  One tooth that stands alone does not do very well; it has too many forces applied to it from chewing, speech, and swallowing.  But if that tooth has “friends” nearby, they can share the functional forces, and each one “suffers” less. When orthodontists rearrange teeth to a more ideal alignment, each tooth gets less abuse. The front teeth, with narrow edges, incise or cut the food. The corner more pointy teeth guide the chewing forces. The back teeth, with a wide biting surface, support the vertical forces of chewing.  The back teeth also support the vertical height of the face, while the front teeth help the tongue and lips to enunciate (speak more clearly).

The teeth are only one component of the chewing process.  The chewing muscles, tongue, and saliva also play a role.  The muscles help the jaws open, close, and move sideways in order to cut and crush food.  The tongue helps push food onto the chewing surfaces so the teeth can crush the food. The saliva helps by moisturizing the chewed food and filling it with digestive enzymes before swallowing.

There are also some “bad players” that live in the mouth's neighborhood.  Anaerobic bacteria (the ones that live without oxygen) cause cavities and gum disease.  It is our job to help our teeth by effectively removing the bacterial build-up daily with proper home care. If we don’t remove the bacteria effectively, within 24 hours the plaque layer gets thick enough to provide a place for the bad bacteria to live.

If you are not sure how to clean your teeth properly, please view our hygiene videos at https://www.okunortho.com/brushing-and-flossing.

Pain management with the Electro-Accuscope (e-stim energy medicine)- letter from a patient

 

 

 Dear Dr. Okun,

I am writing to thank you for suggesting that I bring my children to you for “electric medicine” treatments following their wisdom tooth extractions.  It clearly worked like a charm to alleviate a great deal of the swelling, pain and discomfort that they had to endure.  Although my oldest two children had all four teeth extracted at the same time, they came directly to your office for treatment and experienced minimal swelling and discomfort for a few days.

 

I was still a little skeptical that the treatments actually worked until my youngest daughter had her teeth pulled recently.  The first tooth was pulled in August and I was unable to bring her to your office from the surgeon’s.  The swelling and pain from this one tooth was extreme and lasted more than a week.  After the other three teeth were pulled this past December we took no chances and came directly to your office.  She used the “electric medicine” for the prescribed time and had no swelling on one side and minimal swelling on the other.  Within a few days she was completely comfortable with no signs of the surgery.    

 

We are all now firm believers in this method that noticeably speeds the healing process.  My children used it whenever you adjusted their braces over the years and I can confirm that this “medicine” really worked.  They never complained about pressure from their braces and the treatments definitely healed cuts in their mouths right before our eyes. 

 

I am no longer skeptical in the least because this last success was not one that could be explained away by the power of suggestion.  We saw and felt the results.  I cannot thank you enough for all your wonderful work and sage advice.

 

Sincerely, J.T.                                                                                    

Why did my teeth shift after the braces came off: part 4- The Finish

Reasons for Relapse Part 4: Reasons for relapse: Finishing a case properly to minimize relapse

 

Why did my teeth shift after the braces came off?

I often hear from patients that their teeth moved after their braces came off and they want to know why.  There are basically 3 reasons for a failed case (that was treated well.)

1. The patient did not wear their retainers properly. This is patient error.

2. The patient did not eliminate mouth habits, and did not wear appliances to protect them from their mouth habits. This is a combination of patient and dentist error (if the dentist did not make the patient aware of their habits, and/or did not make appliances that could protect the patient from these habits.)

3. The patient grew unfavorably. No one had control over this one. 

(4. If the teeth were not aligned in the middle of the bone ridge, they will relapse to be centered in the ridge again. The treating dentist had control over this reason.)

The next few blogs will address these errors. Today we will address #4. How ideally the case was finished.

 

In an ideal world, teeth have certain angulations (tips) in order to function properly.  Upper front teeth and lower front teeth should tip slightly forward toward the lips.  Upper back teeth should be vertical, or have very slight tip toward the cheeks.  Lower back teeth should be vertical or have very slight tip towards the tongue. All of these angulations are dependent on the position of the underlying bone.

 

In a front to back direction, the top jaw should be very slightly in front of the lower jaw (Class I skeletal relationship) in order to achieve the proper anterior tooth tips.  If, however, the jaws are not aligned ideally the angulation of the front teeth can be adjusted to achieve the scissor like relationship of the top to bottom front teeth. These adjustments are called dental compensations.  Now suppose the upper jaw is too far forward for the lower jaw (Class II).  If the teeth are angled properly to their supporting bone, the top front teeth will stick out too far for the lower front teeth.  The angulation of the teeth can be changed so that the roots can remain in the bone, but the crowns (the visible part of the teeth) can still meet like a scissor in the front.  The top front teeth can be tipped more toward the tongue, and the lower front teeth can be tipped more toward the lip. These dental compensations often occur naturally, but can also be applied by the treating orthodontist in order to achieve proper function. Now suppose the lower jaw is too far forward for the upper jaw (Class III). If the teeth are angled properly to their supporting bone, the top front teeth will be behind the lower front teeth.   In order to get the top teeth in front of the lower teeth, the top teeth can be tipped more toward the lip, and the lower front teeth can be angled more toward the tongue. Although small amounts of dental compensation are very acceptable, large amounts of dental compensation create an unstable bite. The teeth may try to find more favorable inclinations, and teeth that were tipped towards the lip (creating a larger arch form) will move towards the tongue (creating a smaller arch form) and become crowded.

 

Now let’s discuss the side-to-side direction.  If the upper jaw is too narrow for the lower jaw, in order to get the top teeth outside the bottom teeth (if the skeletal base is not corrected) the upper back teeth have to be tipped towards the cheeks, and the lower back teeth have to be tipped towards the tongue. If the teeth are tipped excessively, the teeth will try to find a more ideal inclination, bringing back the posterior crossbite (the top teeth bite inside the bottom teeth.)

 

Some orthodontists, like Dr. Okun, like to treat orthodontic cases early (age 7 to age 10) in order to influence the jaw bone size and position, so that the inclinations of the teeth can be more favorable.  Changing the bone structure might mean moving the bones of the palate apart (palatal expansion), restraining the growth of the upper jaw (traditional headgear), or advancing the growth of the upper jaw (palatal expansion combined with a protraction headgear.) Once the supporting structures are idealized, the permanent teeth can erupt into straight positions. With Dr. Okun’s technique, it is rare for early treatment cases to need a second phase of treatment.

Some orthodontists like to treat orthodontic cases later (age 11 to 18) in order to have all of the permanent teeth present when the case is finished. The advantage of teen treatment is that you are likely to need only one phase of orthodontic treatment.  The disadvantage is that you need to tip teeth less ideally in order to compensate for growth that has already taken place. You also are more likely to need extraction of permanent teeth in order to align the remainder of the teeth in a crowded case. Relapse potential is much higher in cases that are treated later, i.e. the teeth don’t stay in place after the braces are removed.  The later the case is treated, the more likely it is that the patient will need retainers at night forever in order to maintain their result.

Halloween- reposted from October 31, 2010, and still relevant!

 

Halloween is nearing the end, and all our children will be enjoying their candy tonight. Here are some hints to preserve their teeth:

- Sticky candy will break braces and aggravate TMJ problems. If you are wearing braces or have TMJ/facial pain DO NOT EAT chewing gum, gummy bears, taffy, jelly beans, and other sticky candies. If the candy is hard to bite through, break it into very small pieces before eating it.

- Avoid eating candy that sits on your teeth a long time. A Kit Kat Bar or a Hershey's Kiss will do less damage than a lolly pop or sucking candy.

- Rinsing your mouth with water after eating candy will decrease the risk of white spots and cavities. In addition, spraying your mouth with Carifree spray or sucking a xylitol "candy" will inhibit the bad bacteria (in  your mouth) that have feasted on the sugar you just ate.

- Rinsing with fluoride rinse before bed daily (especially important if candy was eaten that day) will help reverse the damage that candy does to your teeth.

- If there are already white spots (the beginnings of cavities) present, your dentist can use Curodont to help the lesions remineralize (fading the white spots.)

Why did my teeth shift after the braces came off? Part 3: unfavorable growth.

 

Why did my teeth shift after the braces came off?

I often hear from patients that their teeth moved after their braces came off and they want to know why.  There are basically 3 reasons for a failed case (that was treated well.)

1. The patient did not wear their retainers properly. This is patient error.

2. The patient did not eliminate mouth habits, and did not wear appliances to protect them from their mouth habits. This is a combination of patient and dentist error (if the dentist did not make the patient aware of their habits, and/or did not make appliances that could protect the patient from these habits.)

3. The patient grew unfavorably. No one had control over this one. 

(4. If the teeth were not aligned in the middle of the bone ridge, they will relapse to be centered in the ridge again. The treating dentist had control over this reason.)

The next few blogs will address these errors. Today we will address #3: unfavorable growth.

Unfavorable growth is the growth that takes place after the braces are removed which destroys the final bite. One jaw grows more than the other. The teeth in each jaw may stay perfectly aligned, but the bones that support the teeth may not stay in balance with each other. 

We can all see that children look like their parents.  Facial balance is also genetically determined. Parents with “buck teeth” have children with “buck teeth”; Parents with “underbites” have children with “underbites.” Although we can change the skeletal balance and esthetics with orthodontic orthopedics in young patients, the patients continue to grow after their active orthodontic treatment is complete.    A patient who started with their front teeth sticking out “way too far” will relapse in that direction- their top jaw will continue growing and after several years they may have front teeth that stick out farther than when they completed treatment. This relapse growth issue is seen most vividly in “underbite” cases. The bottom jaw will continue growing for many years after the top jaw stops growing, so a patient who started with a prominent lower jaw will continue growing that prominent lower jaw and the lower jaw may “outgrow” the balance that had been achieved with the orthodontic orthopedic treatment. In addition, lower jaw bones rotate internally, although the outside remodels and looks the same.  The lower front teeth  tip forward with this rotation and in order to stay behind the upper teeth, the lower teeth develop "middle age crowding."

The skull, like the rest of the body, shows early growth “high up” and later growth “low down.”  We see this in babies who have large skulls with respect to the rest of the body versus adults who have small skulls with respect to the rest of the body.  The skull stops growing earlier than the legs stop growing.  Within the skull, the top of the face stops growing earlier than the bottom of the face. The midface stops growing earlier than the lower face.  With orthodontic orthopedics (palatal expansion with headgear treatment) we can modify the growth of the maxilla (upper jaw), which is in the mid-face. Palatal expansion is successful in girls until about age 12, and in boys until about age 14, when the midface stops growing.  While creating width of the upper jaw (palatal expansion) forces can be exerted on the jaw to restrain the growth (traditional straight pull headgear to the top of the head and the back of the neck) or to increase the amount of growth in the forward direction (with front pull headgear against the forehead and chin.) These treatments are no longer effective after the midface has finished growing because the sutures (the zippers between the bones) close with physical maturity. The mandible (the lower jaw which is in the lower third of the face) continues to grow for many more years than the maxilla (upper jaw bone), until about age 17 in girls, and until about age 23 in boys.  If the mandible was genetically programmed to be small, we do not notice the forward growth of the mandible after the maxilla stops growing.  If the mandible was genetically programmed to be large, the forward growth of the mandible is obvious and often results in a return of the “underbite.” 

When I treat “underbite” cases I overcorrect the forward correction of the maxilla, leaving the young patients with the opposite problem from which they presented.  They start with the upper teeth and jaw behind the lower teeth and jaw, and I finish them with the upper teeth and jaw too far forward for the lower teeth and jaw. An ideal bite has the upper front teeth one to two millimeters in front of the lower front teeth.  A Class III underbite may have the upper front teeth behind or tip to tip to the lower front teeth.  I overcorrect the jaw position leaving the upper teeth three to four millimeters in front of the lower teeth in order to allow for up to 2mm more lower jaw growth in the future.  I do not aim for a correction of over-jet to 5mm because I do not want to take the risk that the lower jaw does not have a late growth spurt, and the final result (as an adult) remains with excessive over-jet (seen as “buck teeth.”) Anticipating how much relapse growth will take place is an educated guess based on family history and the appearance of the parents.

Another phenomenon, related to unfavorable growth is the relapse of tooth rotations and teeth that grew in to the outside or inside of the arch form.  The longer the teeth “live” in the poor position, the more they have ingrained that “memory” of that position.  If the size of the arch form is corrected early and the teeth grow into a straight position, the teeth are more likely to stay in a straight position.  If the jaw size is corrected and the teeth aligned within a year after the teeth erupt, the teeth are more likely to stay in a straight position.  If the jaw size is corrected as an early teenager, the teeth already have a memory of the crooked position, and are more likely to return to that crooked position after orthodontic treatment has been completed.  If the teeth are aligned in adults, after facial growth is complete, the teeth are much more likely to return to the crooked position.  This is why night time retainer wear is so important in patients whose teeth were aligned later in life.

Why did my teeth shift after the braces came off? Part 2: mouth habits

 

Why did my teeth shift after the braces came off?

I often hear from patients that their teeth moved after their braces came off and they want to know why.  There are basically 3 reasons for a failed case (that was treated well.)

1. The patient did not wear their retainers properly. This is patient error.

2. The patient did not eliminate mouth habits, and did not wear appliances to protect them from their mouth habits. This is a combination of patient and dentist error (if the dentist did not make the patient aware of their habits, and/or did not make appliances that could protect the patient from these habits.)

3. The patient grew unfavorably. No one had control over this one.

4. If the teeth were not aligned in the middle of the bone ridge, they will relapse to be centered in the ridge again. The treating dentist had control over this reason.

The next few blogs will address these errors. Today we will address #2: mouth habits.

A mouth habit is something you do with your mouth other than talking and eating.  Some examples include biting your fingernails, biting your pen/pencil, chewing on your lips or inside of your cheeks, leaning your tongue on your teeth, and grinding/clenching your teeth. Any force that you exert on your teeth, if it is applied for enough time, will move your teeth.  Patients who bite their pencil consistently in the same area of their mouth will either push the bottom tooth toward the tongue, push the top tooth out towards the lip, or a will form a gap vertically between the top and bottom tooth where the pencil sits. Patients who chew on their bottom lip create crowding of the lower front teeth, or spacing between the upper front teeth. 

Tongue habits can occur in different areas of the mouth. If the tongue sits over the tops of the side teeth it can create an open bite which is an area where the top teeth do not touch the bottom teeth when the patient is biting their teeth together. If the tongue is leaning against the front teeth down low, it will create spacing between the lower front teeth, just as if it is leaning against the front teeth up high, it will create spacing between the upper front teeth.  If it is leaning between the top and bottom teeth in the front it will create an anterior open bite, i.e. the top teeth will not overlap the bottom teeth in the front. Sometimes the patient leans their tongue on specific teeth with less force or duration, and instead of moving the teeth, the excessive force generated on the teeth accelerates loss of bone and gum around the teeth. (Periodontal disease is an inflammatory disease of the supporting structures of the teeth- the gums and bones. It is cause by bacteria which live in the mouth.  When the bacteria are removed frequently (by daily brushing and flossing) the inflammation levels are low, and there is no disease.  When the bacteria are not efficiently removed, the “bad” bacteria set up housekeeping and flourish causing inflammation which is seen as red, puffy, bleeding gums.  Over time the bone around the teeth is lost leaving the roots of the teeth visible in the mouth.  When there is excessive force applied to the teeth, from leaning the tongue on the teeth or from clenching/grinding the teeth, the rate of bone loss is accelerated. Then the roots start showing even in cases where the gums are not visibly red, puffy, and bleeding.)

Bruxism is the clenching and grinding of the teeth.  Clenching is when the teeth are tightly closed when there is no reason, like chewing, to be closed.  Grinding is when the patient moves the teeth “side to side” or “front to back” as if they are chewing, but there is no food present to chew. The most common reason for bruxism is stress, but it also occurs from boredom, concentration on a difficult task, or when a young child has pressure in their ears which they are trying to relieve. Bruxism does a lot of damage to the teeth and their supporting structures (which was discussed in the post October 21, 2020.)  Bruxism can also move the teeth.  When clenching, the back teeth which meet vertically, are pushed deeper into the bone, much like a nail can be hammered into a piece of wood.  As the posterior bite support is lost, the front teeth start to overlap more vertically (i.e. the bite deepens), and the front teeth bypass each other (like a scissor.)  In order for the lower teeth to stay behind the wedge shaped upper front teeth, the lower front teeth start to crowd, and the upper front teeth start to develop spaces between them.

Habits can be controlled in the daytime through awareness, but it is impossible to control habits like improper tongue posture and bruxism while one is sleeping.

Retainers and occlusal guards are used in order to prevent the shifting of teeth from mouth habits. Although retainers should be worn full time immediately after braces are removed, they can be continued at night indefinitely to protect teeth from habits.  Mouth habit appliances should be rigid so that they can’t be deformed by the habit-forces. The design of retainers was discussed in the August 2025 blog. Other appliance designs will be discussed in future blogs. 

Why did my teeth shift after the braces came off? Part 1: retainers

I often hear from patients that their teeth moved after their braces came off and they want to know why.  There are basically 3 reasons for a failed case (that was treated well.)

1. The patient did not wear their retainers properly. This is patient error.

2. The patient did not eliminate mouth habits, and did not wear appliances to protect them from their mouth habits. This is a combination of patient and dentist error (if the dentist did not make the patient aware of their habits, and/or did not make appliances that could protect the patient from these habits.)

3. The patient grew unfavorably. No one had control over this one.

4. If the teeth were not aligned in the middle of the bone ridge, they will relapse to be centered in the ridge again. The treating dentist had control over this reason.

The next few blogs will address these errors. Today we will address #1: the patient did not wear his retainers properly.

In order for teeth to move with orthodontic treatment, the bone around the teeth has to remodel.  The bone on the pressure side (the side to which we are moving the teeth) resorbs, and bone on the tension side (the side from which we are moving the teeth) rebuilds.  Over time, the teeth are surrounded by new bone.  This new bone is immature and weaker than mature bone. 

Imagine that you broke a bone and went to the orthopedist to reset the bone.  After aligning the bones to the best position, the orthopedist would put on a cast to hold the bones still, in that new position, until the bone fills into the break, and matures in that position.  The retainer is like the cast.  The teeth are slightly mobile when the orthodontic treatment is completed and the teeth need to be held in their final positions while the bone holding them matures.

A good retainer is rigid, like the cast for a broken bone is rigid.  It should hold the teeth still even if the patient leans his tongue on the retainer, or if the patient clenches or grinds his teeth.  Rigid retainers are made of hard acrylic, and have wires that hold them and the teeth in place.  

It has become common for orthodontists to use other forms of retention. Essex and aligner retainers are non- rigid vacuum formed retainers which are less expensive to make, and are less effective because they flex when forces are applied to them.  These plastic retainers also stretch out over time and need to be replaced frequently. If the treating orthodontist does not intend to provide long term retention care he may choose to use this style retainer.

It is also common for the orthodontist to "glue" the front teeth together, often with a wire or fiberglass thread that is bonded to the tongue surface of the teeth.  Bonded retainers will hold the front teeth straight with respect to each other, but the bonded  can move as a unit with respect to the back teeth.  The bonded retainers offer no retention to the back teeth, and if the patient has mouth habits (like grinding the teeth) the retainer will break as the back teeth move vertically. Bonded retainers are difficult to keep clean, and often have issues with developing cavities and gum disease.

A removable retainer has to be worn "fully seated."  If the patient lifts the retainers with his tongue, or floats it above his teeth, it cannot do it's job.  If the patient repeatedly moves it in and out with his tongue he may actually make the teeth looser, rather than letting the teeth "tighten up." If the retainer is "floating" it is not contacting the teeth, and therefore cannot hold them in place. If the patient is holding the retainer in his hand, instead of wearing it in his mouth, the retainer can also not do it's job.

Retainers should be worn full time until the teeth "tighten up".  This takes between two and six months.  Then the wear-time should be decreased, and the mobility of the teeth should be evaluated by the orthodontist.  If the retainer always feels the same when it is replaced after a period of time, as when it is replaced immediately after removing it, it means that the teeth have not moved when the retainer was out of the mouth.  If the retainer feels different after it has been left out for a period of time, it means that the teeth had a chance to move somewhere, and the retainer had to push the teeth straight again.  The goal is to eliminate the habits that are causing the teeth to move, in order that the teeth stay in place when the retainer is removed.  Over the course of the first year the patient should be able to decrease wear-time to be only when sleeping.  The orthodontist needs to evaluate whether it is necessary to continue retainers at night indefinitely, or whether the patient can discontinue night time wear of the retainers when his face finishes growing.

Uncertainty is Stressful

None of us know what will happen next with the Corona Virus pandemic, and this uncertainty has created high levels of stress and anxiety in the world.  How we handle the stress varies, but many of us are taking out our stress on our teeth.

Bruxism, the clenching (biting down hard when there is no food to bite through) and grinding (rubbing the bottom teeth against the top teeth) of teeth damages the teeth, the periodontium (supporting structures of the teeth), and the jaw joints (aka TMJ, temperomandibular joints), and stresses the muscles of the face that help you chew. 

Some signs that you are clenching your teeth are:

-Wearing down of the biting surfaces of the teeth

-Chipping, cracking, and fracturing of the teeth

-Abfraction, the denting of the root surface at the necks of the teeth

-Loss of the bone that supports the teeth, so that the roots show, despite good dental hygiene

-Tooth pain, or dead teeth (from suffocating the teeth when cutting off their blood supply)

-Shifting of the teeth with increasing vertical overlap of front teeth, increasing spaces between the upper front teeth, and increasing crowding of the lower front teeth over time

-Facial pain and headaches

-Cracking noises from the joint in front of your ears when you open and close your mouth

There is no cure for bruxism, but you can mitigate some of the deleterious effects by:

-Making an effort to not close your teeth when you are awake, but not eating

-Wearing a custom hard, acrylic (plastic) dental appliance on all of your top teeth (which bites evenly on  all of the bottom teeth)  when you are sleeping so that you do the damage to the guard instead of to your teeth. (Dr. Okun can make this “occlusal guard” for you.)

-Limiting chewing (i.e. eat a softer diet that does not contain foods that have resistance to bite through) when you are experiencing periods of facial pain and headaches

-Using ice paks or hot compresses on the tender muscles on the sides of your face and head

-Puffing out your cheeks, as if you are blowing bubbles, to stretch and release tension in your chewing muscles

-Taking anti-anxiety herbs (such as Valerian, Lemon Balm, or Chamomile) in tea or pill form before bed

Uncertainty Stress and "TMJ" Facial Pain

 

No one knows what’s going to happen next.  Will schools open for “ in person learning” this month?  Will gatherings of students start a second wave of the COVID19 pandemic?  Will restaurants open for indoor dining?  Will gyms be able to meet their overhead expenses with only half the number of clients in order to meet social distancing guidelines? Will small businesses survive the long shut-downs? Will parents be able to go back to work when their children are staying home for remote learning?

One thing that is certain is that uncertainty is a stress that takes a toll on our health. 

One way many of us deal with stress is by clenching and grinding our teeth.  Unfortunately bruxism, the clenching and grinding of one’s teeth, is not benign.  It wears down the surface of the teeth, cracks and chips the teeth, accelerates the bone loss from gum disease, causes root resorption (shortening of the tooth roots), kills the nerves in the teeth, causes undesirable shifting of the positions of the teeth, and causes spasm of the chewing muscles and changes in the jaw joints. (Symptomatic temperomandibular joints and associated facial pain are often referred to as “TMJ”.) There is no cure for bruxism, but there is something you can do to minimize the damage it causes. 

The best treatment for “TMJ” and bruxism is to wear a hard plastic guard on all of the top teeth at night.  This “occlusal guard’ should cover all of the top teeth and touch all of the bottom teeth evenly when the teeth are closed, so that the teeth are all splinted together and share forces evenly. That way the damage from the excessive forces is done to the plastic instead of to the teeth and their supporting structures. The guard should never be soft; a soft guard will allow the teeth to rock back and forth as the plastic flexes.  Although Soft guards protect the teeth from chipping, they can accelerate the loss of the bone that keeps the teeth in the mouth.  The guard should cover every tooth on the top, and touch as many bottom teeth as possible; that way the teeth don’t shift, altering the bite.  A properly made custom occlusal guard is not something you can buy over-the-counter in the drug store.  Dr. Judith Okun has years of experience treating TMJ and facial pain with properly made occlusal guards.  Call her office at (914) 253-0722 to set up an appointment to evaluate if you are taking out your stress on your teeth, and if you could benefit from the night time use of a custom occlusal guard.

Okun Orthodontics is Now Open

Dear patient,

In a surprise announcement by Governor Cuomo on May 31, all dental office in New York State are permitted to open June 1, 2020. We are so excited to be able to get back on track with all of your treatments.  In order to provide a safe environment for you when you are in our office, we are following the guidelines of New York State, the Centers for Disease Control, the Department of Health, the New York State Dental Association, and the American Dental Association for infection control and social distancing. Please read this letter so you know what to expect when you come to our office.

Everyone in the building must wear a mask over their mouth and nose at all times except when it is necessary to remove it for dental (or medical) treatment.

Call from the parking area to see if we have a room open for you.  Reception area seating has been limited to maintain social distancing. We have also eliminated high touch items from the reception area; there will be no blocks, books, magazines, patient information pamphlets or game cube controllers available until the Corona Virus is no longer a threat, so there is no entertainment waiting for you in our office. We are making an effort to schedule more lightly to minimize wait times and maintain social distancing; this might mean that you will be offered fewer options when scheduling your appointment.

Only one person may accompany a patient into the office.  Please leave additional “visitors” (siblings, friends, parents) at home.  If a second parent would like to participate in a treatment discussion, we will include them over a video-conference medium like face time or Skype.

Take the stairs; avoid the elevators if you don’t need them. The doors to the stairways are propped open so that you don’t need to touch them. The elevators are limited to 2 passengers at a time.

Use the bathroom before you leave your house. We can’t control the number of people in the building’s restrooms.

Please wait at the door to the office until there is someone at the front desk to greet you, take your temperature, and ask you screening questions.  If you or someone with whom you have spent time has had a fever, cough, shortness of breath, inexplicable loss of taste or smell, or has tested positive for COVID19 in the last two weeks, please call to reschedule your appointment. If you come with these symptoms we will not be able to treat you and we will be rescheduling your appointment anyway.  Also, if you develop these symptoms within 2 weeks of the time you were here, please call us so that we can notify anyone with whom you may have had contact in our office.

Once you have passed pre-screening, you will be directed to a sink in the treatment room for all parties to wash their hands with soap and water.  Patients will rinse with ioRinse to minimize the number of viable microbes that may be aerosolized during treatment procedures.  IF YOU ARE ALLERGIC TO IODINE PLEASE LET US KNOW SO THAT WE MAY GIVE YOU AN ALTERNATIVE RINSE. Please throw paper towels in the green pail near the entrance to the room, not under the sink.  Please save your cup in case you need it to rinse during your appointment.

After your appointment, please wait in the treatment room until there are no other patients waiting at the front desk.  Then walk to the reception room and speak to the front desk staff through the glass window to schedule appointments or make payments.

We look forward to seeing you again and are happy to answer any questions you may have about the steps we take to keep you, and every patient, safe in our practice. To make an appointment, please call our office at (914) 253-0722. 

Thank you for being our patient. We value your trust and loyalty and look forward to welcoming back our patients, neighbors and friends.

Sincerely,

Dr. Judith Okun, Tracey, Corinne, and Deborah

The Power of Prayer

Years ago I read a Reader’s Digest Summary of a scientific study on the Power of Prayer which had been published in a medical journal. The patient records of cardiac patients from several hospitals were compiled and then divided into two groups, to make each group (the test and the control) equal by severity of illness and types of treatment.  The names of the patients (with some personal information about each of them) in the test group were given to strangers with the instructions for each person to pray for his/her assigned patient “in any way you see fit.”  None of the patients or hospital personnel were told who was in the study group.  At the end of the study there was a statistical difference between the groups, as if the test group was given a “miracle drug.”(Note that this study would have been illegal in today’s world because of HIPAA privacy laws.) 

We are living in a unique time.  Every continent in the world, except Antartica, has been affected by this COVID-19 pandemic.  Our hospitals are overwhelmed with the sheer numbers of infected patients who need care. There are not enough respirators and personal protective equipment to meet the needs. Businesses and schools have been closed to limit the spread of the illness. Routine medical care has been put on hold. Dentists cannot deliver needed care to our patients because the illness is spread by both breath and saliva; Dental procedures aerosolize the virus, and the virus stays airborne for up to three hours. Dentists do not have hospital air filtration, hospital gowns, and N95 masks which would be necessary to deliver care in our offices. 

We need to slow down the rate that this virus is infecting people, and we need to limit the number of people who are infected- both those that are ill and those that are asymptomatic carriers. Social distancing is one tool we are using to limit the spread of the virus, but it is not enough.  We all need to pray, in whatever way is comfortable for us. Pray for a speedy end to this pandemic, for a speedy and complete recovery for the people who have been infected, for the mental health of all of us living in social isolation, for the return of a healthy economy, and for the return of our normal lifestyles, before the virus took over.- A personal note from Dr. Judith Okun

One Day, A Corona Virus Update

Dear Patients,

Once again, I need to stress to you that the New York State "stay at home" law has deemed all of dentistry “non-essential business”. This law only permits dentists to see emergencies of pain, infection, and trauma that might cause you to go to the emergency room. New York on Pause was put in place to enforce social distancing to slow the spread, and hopefully decrease the total number of Coronavirus cases. All of us should be doing our part in this social distancing effort.

The Governor's original “'stay at home” mandate extended through April 19, 2020 and was soon extended to April 22. As of today the American Dental Association is recommending that we extend the policy to only see emergency procedures through April 30. The end date seems to change every few days as they learn more about the spread of the virus and its impact. Since we do not know when we will be returning to work, we are delaying rescheduling patients for at least another week, in hopes of not having to call you every week to reschedule your appointments.

It causes me much distress to tell any of you that I cannot see you to adjust your braces, take care of your loose brackets or poking wires, or keep your treatment on course for a timely debond (removal of braces at the end of treatment.) Some of you have been worrying about what impact this delay will have on your treatment. To set your mind at ease, I want you to know that if the NY Stay at Home law continues only until the end of April it should not have a dramatic impact on most of your treatments. 

If it extends longer it will mirror the experience of our patients who attend sleep-away camp, and the impact will be related to how well you took care of your orthodontic appliances. This means, those who followed the rules about avoiding sticky/chewy foods, cut food thin, took smaller bites and kept up with oral hygiene will usually not prolong the time it takes to successfully complete their case. Those who don’t keep their mouth and orthodontic appliances clean, don’t wear their appliances as recommended, eat food they shouldn’t or in ways unsafe for their braces will need to be “put back together” after this unforeseen delay and may very well extend their treatment time. 

The social distancing law does not, prevent us from having virtual treatment visits. Some of you have already taken advantage of tele-dentistry by emailing to me a photo and brief description of your orthodontic problem (along with your phone number) so that I can call you back to discuss your issue. If we are not back at work by the beginning of May and you wish to have a virtual visit, you can email me at drj@okunortho.com and provide me with your cell phone number for a “What's App” or “Facetime” call. For some patients this will only give them the assurance that their treatment is on track. For others I may change the direction of elastics or the force of the headgear. If you are running out of elastics, please let me know so that I can mail more to you.

In the meantime let's use our stay at home time productively. I am forever hearing people say “one day” I will have time to do this or that. As this Coronavirus Pandemic has shown, we don't know what tomorrow will bring. Instead of waiting for “one day” to have less time at work and more time with our families (the two most common end-of-life regrets), let's take advantage of this unexpected opportunity to bond with our families and make special memories. If your family is still working in an essential business, thank you for all you are doing to keep all of us safe at home.

“One day” we will all be back at school and work. Hopefully it will be soon, and we at Okun Orthodontics can get back to giving you the orthodontic and TMJ treatment which you deserve. I look forward to hearing from you,

Dr. Judith A. Okun 

Stay-At-Home But Keep Your Treatment Moving Forward

Okun Orthodontics remains closed, except for emergencies, until at least April 20, because of Governor Cuomo's executive order for New York State to close non-essential businesses in order to limit the spread of corona virus. We are permitted to see emergencies of pain, trauma and infection. If you are having an emergency, please take a picture of the problem, and email it with a description to Dr. Okun directly at drj@okunortho.com.  We are still returning phone messages, so please feel free to leave messages on our phone answering machine (914) 253-0722.
No one knows how long this state of emergency will last, and how long non-essential businesses need to remain closed.  Please confirm with us that your appointment is still valid before heading out to see us. Please also TAKE THIS STAY-AT- HOME EDICT SERIOUSLY. Even though there are no cases of COVID-19 in children, your children can still bring the virus home to you on their hands and clothes.  The longer that people disregard the social distancing guidelines, the longer our lifestyles and the economy will be held hostage by the spread of the virus.  Today I was speaking with a 90 year old woman who was reminiscing about the polio epidemic of her childhood (causing infantile paralysis.) She remembers the closure of swimming pools, movies, and ball games.  That epidemic came to an end, and so will this one.
Remember that we still have a portal available through our website www.okunortho.com for you to view your appointments, images, and financial information.  You can print out any information you need to submit your healthcare finances for flex plans and tax documents.
Many of you are home schooling your children.  We will be posting home schooling ideas in future posts.  As always, remember to keep your teeth and braces clean, use fluoride rinse, wear your elastics, retainers, guards, and headgears as prescribed.  This current situation may slow down the progress of your treatment because I can't see you monthly, but you can certainly keep your treatment moving forward.
Dr. Okun