ORTHODONTIC PERSPECTIVE
Correcting the least emphasized feature of orthodontic therapy Dr. Larry White relates the quality of oral hygiene and tooth-brushing regimens to orthodontic outcomes Abstract Dental plaque often gains unusual vigor throughout orthodontic therapy and has the ability to damage the teeth and gingiva irreversibly, which often cancels the esthetics of optimal alignment. Orthodontists have applied several strategies to minimize the destructive effects of caries, decalcification and gingivitis — i.e., oral hygiene instruction, dietary counseling, fluoride varnish and rinses, sealants, and chlorhexidine rinses, etc. — but the results remain equivocal and imprecise. Most of the damage from decalcification, aka, white spot lesions, occurs at the gingival margin of the teeth, and this clearly is the area that needs emphasis in the oral hygiene regimen. Unfortunately, this feature has not received the profession’s attention until now with the development of a specially designed tooth brush that addresses this oral hygiene deficit. This article will display this brush and its unique ability to apply cleansing to this area, while simultaneously showing a dramatic way of bringing this to the patient’s attention.
Introduction All of the elements of orthodontic therapy gather plaque — e.g., brackets, bands, elastics, elastomerics, springs, wires, plastic sleeves, etc.,1,2 (Figure 1) — and despite orthodontists’ best attempts to limit the destructive results of plaque such as caries, gingivitis, decalcification with products such as oral hygiene instruction, fluoride varnish and rinses, chlorhexidine, sealants, and dietary restrictions, researchers have discovered that oral bacteria increase significantly during orthodontic therapy.3 Other researchers4-7 discovered how the escalation of Streptococcus mutans during orthodontic treatment jeopardizes dental enamel for caries and/or decalcification. Grant8 has further shown how typical mouth bacteria
Larry White, DDS, MSD, FACD, is in Private Practice of Orthodontics in Dallas, Texas.
66 Orthodontic practice
can mutate into pathogenic types during orthodontic therapy, while Matassa9 demonstrated how oral bacteria use as nourishment dental composites with which orthodontists attach brackets to enamel. Orthodontic clinicians have known for several decades about the relationship between the quality of orthodontic outcomes and the patients’ quality of oral hygiene.10 Also, much research has revealed the relationship of plaque to gingival inflammation,11 which lowers patients’ pain tolerances.12 This lowering of tolerances leads to further neglect of oral hygiene, which ultimately results in a cycling from neglect to plaque accumulation, to gingival inflammation, to lowered pain tolerances, and back again to more neglect. This cycle of neglect contributes greatly to orthodontists’ inability to achieve consistently quality treatment outcomes with patients.13 Ample evidence exists that defines sensitivity among other temperaments as genetic traits14 and may well discourage dental clinicians from trying to seriously alter patients’ tooth brushing behaviors.
Commonly used strategies for limiting plaque Some currently used preventatives against plaque include intensive oral hygiene instructions,15,16 fluoridated rinses,17-20 and/ or fluoridated gels/pastes.16,20-23 Others have advocated fluoride varnishes,24-27 fluoride-containing adhesives/primers,19,20 and fluoride releasing/filled sealants,28 and/ or antimicrobial varnishes (e.g., chlorhexidine or cetylpyridinim chloride).18,29 Recently, light-cured filled sealants have shown some effectiveness in preventing enamel decalcification.30,31 Although these various techniques have shown effectiveness, they remain somewhat inefficient because some require reapplication by clinicians or recharging of fluoride ions through patient compliance.16,23,27 These features of compliance by both clinicians and patients have limited their clinical adoption. Even more disturbing, Derks, et al.,32 discovered that although orthodontists know about the
Figure 1: A typical example of chronically poor tooth brushing
various demineralization therapies available, few routinely use any of the strategies other than oral hygiene instruction.
A personal observation Regarding Derks’ study of routinely used anticaries/decalcification protocols by orthodontists, I have worked in 26 orthodontic offices over the past 25 to 30 years for colleagues who have died, had extended illnesses, or absences from their practices for various reasons. This has given me an unusual opportunity to experience firsthand what clinicians do as preventive measures. Outside of brief explanations at the beginning of treatment, little else occurs throughout the patients’ treatments that the clinicians might consider preventive measures. If patients have a lot of plaque or food on the teeth, they may return to the sink to brush — uninstructed. During this time, I have never encountered an office that used plaque stain to reveal to the patients where their brushing deficit existed. Nor have I witnessed any special technique of brushing or a particular toothbrush given to the patient. Poor tooth-brushing patients are almost without exception highly sensitive patients who display several dental behaviors that limit successful treatment:33 • Resisting wearing removable appliances • Salivating copiously • Frequently breaking appliances • Habitually failing to wear permissibleappliances, e.g., elastics, headgears, etc. • Hurting easily and frequently complaining of discomfort Volume 9 Number 2