Oral Hygiene: Possible Problems and Complications
“First, do no harm” is a fundamental guiding principle in medicine and dentistry. All too often orthodontists are confronted with having to consider this principle with a patient who develops poor oral hygiene partway through the orthodontic treatment. Clearly the placement of orthodontic brackets, wires, etc. creates a challenging environment for maintaining good oral hygiene. While there are measures that can be used to maintain or improve a patient’s hygiene, these may not always be effective for reasons most often related to patient compliance. If unaddressed, the accumulation of bacterial plaque associated with poor hygiene may lead to demineralization of enamel and the appearance of white spot lesions, an early sign of caries formation. In addition, the bacteria growing on the teeth and orthodontic appliance will cause inflammation of the gingival tissues, a process demonstrated by enlargement or overgrowth of interdental papillae and gingival margins. Although gingivitis is reversible in most individuals, there are situations in which patients are particularly prone to gingival overgrowth (e.g., caused by genetic variations in the response of gingival tissue or side effects of medications needed for systemic health). For these patients, resumption of good oral hygiene may be inadequate, making other procedures necessary to restore normal gingival architecture. Lastly, with increasing numbers of adults seeking orthodontic treatment, more patients will have had or will need periodontal treatment prior to orthodontics, and the orthodontist will be confronted with coordinating the timing of orthodontic treatment following periodontal therapy. The questions that follow relate to the areas briefly described above and should be useful for the appreciation of some aspects of the relationship between orthodontics and periodontology.
1 What are evidence-based recommendations regarding the most effective means of preventing white spot lesions in orthodontic patients?
Systematic reviews have concluded that toothpastes with fluoride concentrations of 1500 to 5000 ppm demonstrate greater preventive effects for white spot lesion formation than those with a concentration of 1000 ppm.< ?xml:namespace prefix = "mbp" />1,2 In addition, supplemental use of a brush-on gel with 5000 ppm fluoride once a day has more of a preventive effect than conventional fluoride toothpaste alone.3 The use of a polymeric tooth coating4 or sealant5 on the tooth surface around the brackets has been shown to have little impact on demineralization.
2 Do mouth rinses impact gingivitis?
A number of oral rinses and dentifrices have been tested in clinical trials.6 One standard for proving the efficacy of these products for the treatment of gingivitis was implemented by the American Dental Association (ADA). The ADA Seal of Acceptance is given to a product that reduces plaque and demonstrates effective reduction of gingival inflammation over a period of at least 6 months. The agent must also be safe and not induce adverse side effects. Several products have been given the ADA Seal of Acceptance for the control of gingivitis. In one of the products the active ingredients are thymol, menthol, eucalyptol, and methyl salicylate.7 Active ingredients in other products are chlorhexidine digluconate and triclosan.7
Side effects of chlorhexidine digluconate include tooth and tongue staining, increased calculus deposits, bitter taste, mouth and throat irritation, mouth sores (ulcers), coated tongue, and changes in taste of food and beverages.
If properly used, the addition of a topical antiplaque agent to a gingivitis treatment regimen for patients with deficient plaque control will likely result in the reduction of gingivitis.8 However, experimental evidence indicates that penetration of topically applied agents into the gingival crevice is minimal.9 Therefore, these agents are useful for the control of supragingival, but not subgingival, plaque. Among individuals who do not demonstrate excellent oral hygiene, supragingival irrigation with or without medicaments may reduce gingival inflammation beyond that normally achieved by toothbrushing alone. This effect is likely due in part to the flushing out of subgingival bacteria.10
3 Is oral hygiene better using a power toothbrush compared with a manual toothbrush?
Powered brushes have been defined as toothbrushes with a mechanical movement of the brush head. Powered brushes have been divided into six groups depending on their mode of action11:
1. Side-to-side action:
brush head moves laterally with a side-to-side motion.
brush head rotates in one direction only.
3. Rotation oscillation:
brush head rotates in one direction and then the other.
4. Counter oscillation:
adjacent tufts of bristles (usually 6–10) rotate in one direction and then the other, independently. Each tuft rotates in the opposite direction to that adjacent to it.
brush bristles vibrate at ultrasonic frequencies (i.e., above 20 kHz).
6. Unknown action:
indicates a brush action that the reviewers were unable to establish from either the trial report or the manufacturers.
Numerous clinical trials have compared manual and powered toothbrushes for their effectiveness in improving oral health, and the results are often conflicting.11 Recent systematic reviews by the Cochrane Oral Health Group have summarized this information and provided unbiased conclusions.12 Powered brushes reduced plaque and gingivitis at least as effectively as manual brushing. Rotation oscillation powered brushes showed statistically significant reductions of plaque and gingivitis in both the short13 and long term.12,13 No solid evidence was found for a higher efficacy of sonic brushes.
The systematic reviews just described used studies of general populations and were not orthodontic specific.12,13 There is a clear need for long-term trials on the efficacy of powered brushes in the orthodontic patient population. From existing studies it can be concluded that compared with a manual toothbrush, orthodontic patients using a powered toothbrush will show a slight, but significant, reduction of bleeding on probing.14 No conclusions can be made concerning which type of powered brush works best.14
4 Which oral prophylaxis technique is better for orthodontic patients: air-powder polishing system or rubber cup and pumice technique?
The conventional rubber cup prophylaxis (RCP) and the air powder polishing (APP) system (Prophy Jet) are both effective professional techniques for plaque and stain removal without detrimental effects on tooth structure and gingival tissues when used correctly.15–17 The APP system uses a jet formed by a mixture of air, powder, and water to remove dental plaque, soft deposits and surface stains from pits, grooves, interproximal spaces, and smooth surfaces of the teeth. Barnes and associates18 showed that the use of the APP system in orthodontic patients neither affected the composite resin or zinc-phosphate cement used to secure brackets and bands, nor caused any damage to arch wires or other appliances. Ramaglia and colleagues19 used a split-mouth experimental design to compare the efficacy and efficiency of the APP system with the RCP technique. Significant reductions in the plaque index were found after either APP or RCP. APP was somewhat more efficient, requiring significantly less time to remove dental plaque and staining.
5 Are there ways to prevent periodontal complications during orthodontic treatment?
The use of steel rather than elastic ligatures has been recommended on brackets, including tooth-colored (“esthetic”) brackets, because elastomeric rings have been shown to attract significantly more plaque than steel ligatures.20 Use of self-ligating brackets may have a similar effect as steel ligation, but this has yet to be documented. In addition, bonded brackets are preferable to bands as demonstrated during orthodontic treatment of adults where molars with bonded brackets showed less plaque accumulation, gingivitis, and loss of attachment interproximally than did those with bands.20–22
It is evident in adults with a reduced but healthy periodontium that orthodontic tooth movement can be performed without further periodontal deterioration.23–25 After a 4- to 6-month observation period following periodontal treatment, a careful clinical examination and recording of the periodontal status is necessary before orthodontic treatment is initiated. Professional scaling may be especially indicated during active intrusion of elongated maxillary incisors when new attachment is desired26,27 since orthodontic intrusion may shift supragingival plaque to a subgingival location.28,29 Should efforts aimed at maintaining excellent-to-good oral hygiene prove unsuccessful, termination of orthodontic treatment (appliance removal) has been recommended.30
6 When can orthodontic treatment be started on a patient who has been treated for periodontitis?
Following active periodontal treatment, patients in the maintenance phase of periodontal therapy should be observed for 4 to 6 months before initiating orthodontic treatment. This provides time for full expression of the benefits of the periodontal therapy and for monitoring of the patient’s oral hygiene and motivation.31 Once orthodontic treatment is started, periodontal maintenance should be scheduled at shorter intervals, in many instances with the patient being seen as frequently for periodontal maintenance as for orthodontic appliance adjustments (i.e., every 4–6 weeks).32
7 Are patients who have been previously treated for periodontal disease more likely to lose periodontal attachment if they receive orthodontic treatment?
Tooth movement in adults with reduced but healthy periodontium does not result in further significant loss of attachment.33 However, adults with teeth that do not have healthy per/>
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