Download Soft-Tissue Maintenance During Ortho Treatment

Earn
4 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
Soft-Tissue Maintenance
During Orthodontic
Treatment
A Peer-Reviewed Publication
Written by Michael Florman, DDS
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Educational Objectives
Upon completion of this course, the clinician will be able to
do the following:
1. Understand oral-healthcare guidelines that need to be
stressed and explained to an orthodontic patient, as
well as practiced by the patient, to maintain oral health
during treatment
2. Understand the sequelae of poor oral hygiene during
orthodontic treatment, including plaque retention,
bleeding, and pain
3. Understand methods for plaque removal during orthodontic treatment that encompass types of toothbrushes,
interdental cleaning, oral irrigators, and mouthrinses
4. Understand the oral irritations that may be inflicted on
an orthodontic patient during treatment and list types
of products available that aid in combating, managing,
and healing these oral reactions to ensure continual oral
healthcare home maintenance by the patient
Abstract
Orthodontic treatment is widely recognized for its results. By
accepting orthodontic treatment, patients usually commit to
two to three years of active therapy. Increases in plaque retention in orthodontic patients lead to an increased incidence of
decalcifications. Almost all fixed applicance orthodontic patients experience moderate gingivitis and, to varying degrees,
oral irritations. Even with attention to oral hygiene procedures, patients are at risk. Consideration of the use of antibacterial mouthrinses may be warranted for these patients. Oral
irritations cause pain and impede oral hygiene — medications
in the form of pastes, gels, liquids, and rinses can help relieve
pain and, depending upon the medication used, may also promote healing. Patient selection, education, and adherence to
oral hygiene measures, together with adjunctive preventive,
palliative, and curative care, will not only help patients have a
more comfortable experience, but will also increase the likelihood of both functional and aesthetic success.
Introduction
Orthodontic treatment is widely recognized for its results.
Through the use of fixed and removable appliances, clinicians
have been able to offer patients great improvements in their
appearance and oral health. Depending upon the specific type
and severity, malocclusion is known to be associated with
inadequate oral hygiene, periodontal issues, TMJ disease,
speech problems, mouth breathing, and where appearance is
an issue, poor self-esteem.
There are between 4 million and 6 million orthodontic
cases at any given time. Orthodontic treatment may begin
at an early age while the patient still has his primary dentition. Twenty percent to 25 percent of the total number
of orthodontic cases are adults.1 Orthodontic treatment is
provided to adults, partly due to an increased awareness
by patients of the impact of malocclusion and crowding,
2
an increased emphasis on appearance, and an increase in
affluence in our society that has enabled adult patients
to seek orthodontic treatment that was unaffordable for
their parents when they were younger. Nonetheless, the
majority of cases are still carried out on otherwise healthy
adolescents,2 an age group renowned for noncompliance
with oral hygiene.
Removable appliances have traditionally involved the
use of an acrylic plate with combinations of clasps and wires
in place to move the teeth. The introduction of full mouth
resin coverage orthodontic aligners (Invisalign®, Align
Technology; Essix Aligners, Dentsply Raintree) has influenced and changed removable orthodontic therapy.
Fixed appliances are the most common form of orthodontic treatment in the United States. They offer excellent
and predictable results but require patient compliance and
cooperation during active treatment.
Oral Health During Orthodontic Treatment
Patients need to understand and be aware of the implications
for their oral health, whether they decline or accept recommended orthodontic treatment. By declining, patients may be
exposing themselves to increased risk of future oral disease.
On the other hand, accepting fixed appliance orthodontic
therapy has important implications for patients’ home care.
Acceptance of orthodontic treatment means patient commitment to a regimen of increased attention to oral hygiene and
oral health to help avoid potential iatrogenic problems from
arising during treatment.
Duration of Treatment
By choosing to accept orthodontic treatment, patients are
usually committing to two to three years of active therapy.3
One study found an average of 23.5 months, with a range of
between one and 37 months. Duration of treatment was found
to be associated with three factors related to patient behavior
and compliance, together with fixed characteristics of the particular case such as extraction or nonextraction treatments. A
direct statistically significant correlation was found between
poor oral hygiene and duration of treatment (Table 1).4
Following completion of active orthodontic treatment, the patient must use a retainer to prevent relapse,
potentially indefinitely.5
Microbial Environment
Typically, patients experience gingival inflammation after a
fixed appliance is placed. An increased number of microbes
is present and the composition of the microbial load changes.
One study of motivated patients undergoing fixed orthodontic
therapy who were clinically healthy after their first six months
of treatment revealed they had significant microbiological
changes including a substantial increase in supragingival motile rods and subgingival spirochetes. Control of the microbial
load would reduce the risk for future periodontal disease.6
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Table 1
Pretreatment
Orthodontic patient with
gingival hyperplasia
Cooperation Factors
• Poor Oral Hygiene
• Poor Elastic Wear
• B racket
Broken/Loose
Increased
Treatment
Time
Preexisting Factors
• Maxillary Crowding
• Male Gender
• Class II Molar
• Extractions
-Planned
-Delayed
Posttreatment
Upon removal of fixed orthodontic appliances, over
a 30-day period, improvements in gingival health are
found and reductions in the presence and mix of microbes occur. One study specifically found reductions in
Actinobacillus actinomycetemcomitans and Bacteroides
forsythus, two organisms that have been identified as
periodontal pathogenic bacteria, at the 30-day mark.7
With respect to Strep. mutans and caries risk, recolonization by Strep. mutans following antimicrobial therapy
is significantly higher in teeth with brackets and bands.8
It has also been found that fixed appliances promote the
intra-oral carriage and presence of Candida albicans and
coliform bacteria.9
The number of orthodontic cases in periodontally
compromised patients has also increased. Orthodontic
treatment may be indicated in these patients for a number
of reasons, including the reduction of periodontally induced drifting or splaying of teeth.10 Even more vigilance
by the patient and clinician is required with respect to
oral hygiene and home care in these patients.
Gingival Hyperplasia
Gingival hyperplasia during orthodontic treatment can lead
to pseudopocketing, where there is no attachment loss, but
the hyperplasia results in an artificially deep “pocket” that
resolves with resolution of the hyperplasia. No differences
in gingival or plaque indices or pocket depth were found
when comparing elastomeric rings and ligature wires in
fixed orthodontic appliances.11 It has been suggested that a
shift to more anaerobic flora occurs where pseudopockets are
present.12 Gingival hyperplasia necessitates care on the part
of the patient to ensure that plaque retention within these
pseudopockets does not result in a deterioration of soft and
hard tissues.
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Sequelae of Poor Oral Hygiene
During Orthodontic Treatment
Poor oral hygiene during orthodontic treatment leads to the
development of incipient and frank carious lesions, and gingivitis of increasing severity with the potential for subsequent
periodontal disease. Use of resin system aligners has been
shown to result in a lower plaque index when compared to
plaque indices of patients with fixed orthodontic appliances.13
Given that the aligner is removed prior to performing oral hygiene, this is not an unanticipated outcome since there are no
orthodontic appliances in place while brushing and flossing.
Recent advancements in self-ligating brackets, as an
alternative to elastic ligatures, show promise in their ability
to reduce plaque retention and improve oral hygiene. Selfligating brackets use a door mechanism or clip that slides over
the wires to hold the archwire into the bracket slots. Their use
reduces friction between the wire and the brackets, thereby
reducing overall treatment time. Reductions in plaque buildup have been noted in preliminary investigations.
Plaque Retention, Bleeding, and Pain
Plaque retention during fixed appliance therapy is concentrated around brackets and gingival margins. Around brackets, this leads to increased caries experience. Decalcification
around orthodontic banding has been shown to occur in as
little as one month,14 and in the absence of any preventive
program, up to 50 percent of orthodontic patients experience
white spots.15
Increased plaque retention around the gingival margin and
in the sulcus leads to gingivitis of increasing severity, gingival
bleeding, and pain. In some cases, it can also result in pocket
formation and loss of attachment. Bourdillat et al. found that
among 540 orthodontic patients surveyed concerning their
orthodontic-related quality of life, almost all experienced
some or considerable gingival bleeding while brushing under fixed orthodontic appliances. Patients regarded this and
associated pain to be the most negative aspect of their treatment.16 Niederman and Ho found bleeding upon probing at
78 percent of sites in orthodontic patients aged 11–17 with
gingival inflammation.17
3
Orthodontic
patient with
gingivitis
Discontinuation of Treatment
Discontinuation of treatment and the removal of orthodontic appliances can be a result of poor oral hygiene and may
be necessary if it helps prevent damage associated with the
patient’s unwillingness or inability to perform appropriate
oral care. This is warranted from an ethical perspective
if the treatment is more damaging than discontinuation.
Additionally, discontinuation of treatment in these circumstances can help to manage and reduce the risks of litigation on the part of the patient or his parents.18 Continued
orthodontic therapy requires a high level of commitment to
home care and the use of appropriate measures to counter
plaque retention.
Plaque Removal During
Orthodontic Treatment
Plaque removal and control during orthodontic treatment can
be achieved mechanically and chemically. Even motivated patients will find it more difficult to perform good oral hygiene
during fixed orthodontic treatment. The physical impositions
of banding, brackets, and archwires result in brushing and
flossing difficulties, and plaque and debris accumulation,19 all
of which may require patients to learn new techniques.
Manual and Electric Toothbrushes
Manual and electric toothbrushes have been extensively studied in orthodontic patients. Results from these studies are
mixed. While a study of 36 adolescent patients by Trimpeneer
et al. found that a manual multitufted toothbrush was more
effective than three different electric toothbrushes,20 other
studies indicate that electric toothbrushes are as effective as
manual toothbrushes in orthodontic patients with reasonable oral hygiene.21,22 One study concluded that the use of an
electric toothbrush by orthodontic patients with preexisting
gingival inflammation resulted in a 57 percent reduction in
supra-gingival plaque (versus a 10 percent reduction using a
manual toothbrush) and a 29 percent reduction in the gingival
index. Bleeding sites were reduced to fewer than 25 percent
from 78 percent.23
Manual toothbrushes are available that are specially designed for orthodontic patients. These have soft bristles that
are fashioned in a V-cut to enable the bristles to reach over the
top of the brackets and make contact with the tooth surface
and gingivae apical to the brackets.
4
For patients who do not spend enough time on oral hygiene, electric toothbrushes may be more effective due to
their speedier plaque removal.24 One assessment of an ionic
toothbrush found that there was no difference in plaque reduction or gingivitis between it and a nonionic toothbrush of
the otherwise same design.25
In my experience, the technique and time spent
brushing are the most important factors in proper oral
hygiene, especially when patients are wearing fixed
orthodontic appliances.
Interdental Cleaning
Interdental cleaning presents more of a challenge for orthodontic patients. With clear instructions and education by
dental professionals, and commitment on the part of the patient, effective flossing can be achieved using a floss threader
(Eez-Thru® Floss Threaders, Sunstar Butler) adjacent to
the area being flossed or using floss with a thickened end
(Superfloss®). Manual interdental brushes are effective interproximally and, depending upon the interdental space, some
patients may find this easier than using floss. Interdental
brushes can have coated or uncoated wire. The wire coating
on interdental brushes is intended to help prevent scratching
theorthodontic appliance. A further type of coating used on
some interdental brushes is an antibacterial coating intended
to help reduce the microbial load remaining on the brush.
Electric interdental cleaning is a further option, with devices
that remove plaque through either physical motion or irrigation. Electric interdental cleaning devices have varying
results, and one study found only a subjective improvement
on the part of patients, without any clinically objective improvement in plaque indices or bleeding upon probing.26
Comprehensive orthodontic kits offer convenience for
patients and add value. They offer an opportunity to provide
a better training experience to the patient. Providing a comprehensive kit ensures that the patient has all the oral hygiene
supplies they will need.
Oral Irrigators
Some studies have found oral irrigators to be effective oral
hygiene adjuncts. Significant reductions in plaque and
gingivitis have been demonstrated in patients using oral irrigation devices.27 However, another study concluded that
there is no difference in plaque and gingivitis levels between
patients using a manual or an electric toothbrush, with or
without irrigation.28 Use of a magnetized oral irrigation device in patients without orthodontic banding has been found
to have no significant effect in gingival indices and causes
only a 2.2 percent reduction in plaque (although there was
a significant reduction in calculus).29 A recent study found
oral irrigators to be effective for plaque reduction proximally, gingivally, and interproximally, and the study also
found that they result in fewer gingival abrasions than using
an electric toothbrush.30
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It can be concluded that results achieved will depend upon
patient education and preference. Results from the research
are not definitive regarding superiority of either manual or
electric toothbrushes. Flossing and interdental brushes have
both been shown to be effective, and use of an oral irrigator
may be a helpful adjunct.
Mouthrinses and Adjunctive Chemical
Plaque Control
Various pastes, gels, varnishes, and mouthrinses have been
researched on orthodontic patients and used as chemical
agents for plaque control.
The application of hydrophobic polymers every three
months to the enamel to control plaque, Strep. mutans, and
gingivitis was found to be ineffective by Fornell et al., and
no statistically significant difference was found between
coated and untreated teeth.31 Studies have found that the
use of sustained released chlorhexidine varnish reduces total
bacterial counts in orthodontic patients.32 Chlorhexidine varnishes have also been researched in combination with fluoride
varnishes for their ability to reduce bacterial counts and for
anti-caries efficacy.
A study by Boyd found 0.4 percent stannous fluoride to
be an effective adjunct during orthodontic therapy to help
reduce gingivitis, although its efficacy in this regard is controversial.33 A recent study found that the use of 0.4 percent
stannous gel did not result in a decrease in Strep. mutans
colonies in the biofilm,34 suggesting that any anti-caries efficacy is due to the fluoride in the gel (same fluoride level as
regular toothpastes).
Chlorhexidine Mouthrinses and
Orthodontic Treatment
Mouthrinses have been found to be effective in reducing
plaque and gingival indices, alone and adjunctive to brushing
and flossing, during fixed orthodontic treatment.
Chlorhexidine mouthwash effectively reduces plaque
and gingival indices. It has also been shown to have a
continued effect for up to five days on the gingival index
following cessation of use in orthodontic patients.35 While
some studies on orthodontic patients were carried out on 0.2
percent chlorhexidine (available in Europe) rather than the
0.12 percent chlorhexidine available in the United States,
these are clinically equivalent when the dosage and rinsing
time are taken into account.36 One 12-week study conducted
on children aged 11–17 using 0.12 percent chlorhexidine
(Peridex®, Zila Pharmaceuticals) for 30 seconds morning
and evening resulted in a reduction in plaque and gingival
indices of 64.9 percent and 60 percent, respectively, and in
gingival bleeding by 77 percent.37 A second study also demonstrated significant reductions in plaque and gingivitis.38
Gehlen et al. found that the use of 0.2 percent chlorhexidine
(Corsodyl®, SmithKline Beecham) is useful adjunctively
with mechanical plaque control and recommended its use
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particularly in severe cases in which patients experience
pain and bleeding upon brushing.39 The long-term use of
chlorhexidine is associated with increased staining and
temporary taste disturbances. One study recommended
trimonthly prophylaxis and found that this controlled stain
formation. Taste disturbances were not cited as an issue. A
further consideration was to use chlorhexidine short term
in patients during periods of exacerbated plaque levels and
gingival inflammation.
Alcohol content in mouthrinses is an issue for some patients. The use of alcohol-containing rinses should be avoided
in children and is also contraindicated in patients who have
a sensitivity to alcohol, are immunocompromised (in some
cases), or are undergoing head and neck radiation.40 Because
of alcohol’s drying effect, a relative contraindication would be
xerostomia. With respect to oral mucosal irritations, alcohol is
an irritant and may also cause stinging. The use of an alcoholcontaining medicament or rinse should therefore be carefully
assessed in these patients.
Typically, commercially available chlorhexidine contains
11.6 percent alcohol. In the United States, one alcohol-free
0.12 percent chlorhexidine rinse is available (Sunstar Butler).
In addition, a non-CHX mouthrinse that is alcohol free and
includes 0.07 percent CPC mouthwash (Crest® Pro-Health
Rinse), has been shown to reduce plaque over six months
by 15.8 percent compared to placebo and to reduce gingival
inflammation by 15.4 percent.43 In Europe, a comparative
study between 0.12 percent alcohol-free chlorhexidine with
0.05 percent CPC (PerioAid®) and 0.2 percent chlorhexidine
(Corsodyl®) found no difference in plaque reduction.44 One
double-blind clinical study specifically addressed the issue of
whether alcohol has an additive effect with chlorhexidine and
found that the absence of alcohol in otherwise identical formulations of chlorhexidine had no effect on clinical efficacy.
The chlorhexidine formulations with and without alcohol
were clinically equivalent and found to be equally effective in
reducing plaque and gingival inflammation.41 A further study
found alcohol-free mouthrinses to be effective and the alcohol-free chlorhexidine to reduce plaque index over a four-day
period by 40.4 percent.42
Oral Irritations
Oral Ulcerations and Irritations
Oral irritations and ulcerations are common around brackets,
clasps, and bands. These can be painful and further impede
oral hygiene measures as the patient avoids the area when
brushing and flossing. Oral ulcerations can be minimized
with careful appliance design and care by the patient. Gentle
brushing with a soft-bristled toothbrush is required, and care
is needed using interdental brushes and floss. If an electric
toothbrush is used, it should be used gently to help prevent
gingival abrasions in areas of already inflamed tissue and to
protect brackets.
5
Orthodontic patient
with an oral wound
from a bracket
risk was found with the use of stannous fluoride in combination with nickel-titanium wires and commonly used metallic
orthodontic brackets (titanium, iron-chromium-nickel, and
cobalt-chromium).48 In patients with sensitivity to these metals, an alternative anti-caries therapy may be indicated.
Latex sensitivity has been reported to occur in up to 6
percent of the general population. Sometimes this is associated with elastomeric ligatures,49 and in patients with latex
sensitivity, the use of these ligatures should be avoided.
Summary
The use of orthodontic wax as a physical barrier helps protect the mucosa around brackets, bands, and wire, and assists
in the prevention of irritation and friction. Orthodontic wax
helps relieve pain at an existing irritation or ulcer by acting as
a mechanical barrier.
Pain Relief and Healing
Considerations for pain relief and healing include the use of
locally applied oral medications and rinses. For isolated oral
ulcerations, there are a number of locally applied medications
proven to provide pain relief. Locally applied pastes, gels, and
liquids are available, which contain 20 percent benzocaine to
relieve intra-oral pain (Orajel® Ultra, Colgate® Orabase®,
Anbesol®). In a recent study, orthodontic wax combined with
slow-release benzocaine for pain relief was found to reduce
pain significantly more than wax alone, while still providing
a physical barrier.45
Oral irritation and discomfort can also be relieved by a
rinse application. This is particularly useful when there are
multiple irritations and may be easier for a patient to use. A
nonprescription rinse is available (Rincinol®, Sunstar Butler),
which creates a bio-adherent mucosal coating, is alcohol free,
relieves pain, and promotes healing. It contains no alcohol
(which can cause stinging) and does not cause numbness. A
second alcohol free bio-adherent rinse (Gelclair®, OSI Pharmaceuticals) has also been shown to be effective in relieving
pain and to promote healing. This requires mixing and is
available by prescription only.
Allergic Reactions
Allergic reactions to orthodontic materials can occur. It has
been found that 30 percent of the population has nickel hypersensitivity.46 Intra-orally, this may present as an area of
erythema or gingivitis. In a review of patients, Ramadan et
al. found that 15 percent had nickel-related allergic reactions
in the form of gingivitis. While this resolved within a month
of treatment, it was recommended that fluoride-free toothpaste be used together with mouthrinses for such patients.47
However, consideration needs to be given to the decalcification risk associated with banding. Recent research has found
an interaction between 250ppm fluoride mouthrinses and
orthodontic materials, resulting in corrosive products with
the potential for local allergic reactions. The highest corrosion
6
Patients derive both functional and aesthetic benefits from
orthodontic treatment. The majority of orthodontic cases are
conducted on adolescents, an age at which patients tend to be
less compliant with treatment and less attentive to home care.
Increases in plaque retention result in an increased incidence
of white spots or decalcifications, and almost all fixed orthodontic appliance patients experience moderate gingivitis
and, to varying degrees, oral irritation. By careful patient
selection, an emphasis on the need for patient commitment to
scrupulous oral hygiene, and recommendation of and provision for adjunctive care as needed, these risks and sequelae
can be managed and minimized.
Oral hygiene measures include brushing with a softbristled toothbrush or an electric toothbrush, both of which
have been shown to be effective. While orthodontic brackets and archwire are physical impediments, interdental
cleaning is essential for oral health, and adjunctive devices
such as floss threaders and fine interdental brushes provide
assistance. Even with attention to oral hygiene procedures,
patients are still at risk. Consideration of the use of antibacterial mouthrinses may be warranted for these patients
depending upon the level of oral hygiene and patient response, and has been shown to reduce the microbial load,
gingival indices, and bleeding in orthodontic patients. The
use of an alcohol-free mouthrinse should be considered.
Oral irritations cause pain and impede oral hygiene, but
medications in the form of pastes, gels, liquids, and rinses
can help relieve pain and, depending upon the medication
used, may also promote healing.
Patient selection, education, and adherence to oral hygiene
measures, together with adjunctive preventive, palliative, and
curative care, will not only help patients have a more comfortable experience, but also increase the certainty of both
functional and aesthetic success.
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28. Jackson CL. Comparison between electric toothbrushing and
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31. Fornell AC, Skold-Larsson K, Hallgren A, Bergstrand F,
Twetman S. Effect of a hydrophobic tooth coating on gingival
health, mutans streptococci, and enamel demineralization in
adolescents with fixed orthodontic appliances. Acta Odontol
Scand. 2002;0(1):37–41.
32. Beyth N, Redlich M, Harari D, Friedman M, Steinberg D. Effect
of sustained-release chlorhexidine varnish on Streptococcus
mutans and Actinomyces viscosus in orthodontic patients. Am
J Orthod Dentofacial Orthop. 2003 Mar;123(3):345–8.
33. Hastreiter RJ. Is 0.4% stannous fluoride gel an effective agent
for the prevention of oral diseases? Comment in: J Am Dent
Assoc. 1989 Jul;119(1):10, 12, 172–4.
34. Bretas SM, Macari S, Elias AM, Ito IY, Matsumoto MA.
Effect of 0.4% stannous fluoride gel on Streptococci
mutans in relation to elastomeric rings and steel ligatures
in orthodontic patients. Am J Orthod Dentofacial Orthop.
2005 Apr;127(4):428–33.
35. Gehlen I, Netuschil L, Berg R, Reich E, Katsaros C. The influence
of a 0.2% chlorhexidine mouthrinse on plaque re growth in
orthodontic patients. A randomized prospective study. Part I:
clinical parameters. J Orofac Orthop. 2000;61(1):54–62.
36. Van Strydonck DA, Timmerman MF, van der Velden U, van der
Weijden GA. Plaque inhibition of two commercially available
chlorhexidine mouthrinses. J Periodontol. 2003;74(2):214–218.
37. Brightman LJ, Terazhalmy GT, Greenwell H, Jacobs M, Enlow
DH. The effects of a 0.12% chlorhexidine gluconate mouthrinse
on orthodontic patients aged 11 through 17 with established
gingivitis. Am J Orthod Dentofac Orthop. 1991;100:324–329.
38. Anderson GB, Bowden J, Morrison EC, Caffesse R. Clinical
effects of chlorhexidine mouthwashes on patients undergoing
orthodontic treatment. Am J Orthod Dentofac Orthop.
1997;111:606–612.
39. Gehlen I, Netuschil L, Berg R, Reich E, Katsaros C. The
influence of a 0.2% chlorhexidine mouthrinse on plaque
re growth in orthodontic patients. J Orofac Orthop.
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2000;61:54–62.
40. Eldridge KR, Finnis SF, Stephens JA, Mauad AM, Munoz
CA, Kettering JD. Efficacy of an alcohol-free chlorhexidine
mouthrinse as an antimicrobial agent. J Prosthet Dent. 1998
Dec;80(6):685–90.
41. Leyes Borrajo JL, Garcia Varela L, Lopez Castro G, RodriguezNunez I, Garcia Figueroa M, Gallas Torreira M. Efficacy of
chlorhexidine mouthrinses with and without alcohol: a clinical
study. J Periodontol. 2002;73(3):317–321.
42. Arweiler NB, Netuschil L, Reich E. Alcohol-free mouthrinse
solutions to reduce supragingival plaque regrowth and
vitality. A controlled clinical study. J Clin Periodontol. 2001
Feb;28(2):168 74.
43. Mankodi S, Bauroth K, Witt JJ, Bsoul S, He T, Gibb R, Dunavent
J, Hamilton A. A six-month clinical trial to study the effects of a
cetylpyridinium chloride mouthrinse on gingivitis and plaque.
Am J Dent. 2005 Jul;18 Spec No:9A–14A.
44. Van Strydonck DA, Timmerman MF, van der Velden U, van
der Weijden GA. Plaque inhibition of two commercially
available chlorhexidine mouthrinses. J Clin Periodontol. 2005
Mar;32(3):305–9.
45. Kluemper GT, Hiser DG, Rayens MK, Jay MJ. Efficacy of a
wax containing benzocaine in the relief of oral mucosal pain
caused by orthodontic appliances. Am J Orthod Dentofacial
Orthop. 2002 Oct;122(4):359–65.
46. Bass JK, Fine H, Cisneros GJ. Nickel hypersensitivity in
the orthodontic patient. Am J Orthod Dentofac Orthop.
1993;103:280 285.
47. Ramadan AA. Effect of nickel and chromium on gingival tissues
during orthodontic treatment: a longitudinal study. World J
Orthod. 2004;5(3):230–234.
48. Schiff N, Boinet M, Morgon L, Lissac M, Dalard F, Grosgogeat
B. Galvanic corrosion between orthodontic wires and brackets
in fluoride mouthwashes. Eur J Orthod. 2006 Jan 20; [Epub
ahead of print].
49. Ellis PE, Benson PE. Potential hazards of orthodontic treatment
— what your patient should know. Dent Update. 2002
Dec;29(10):492–6. Review.
8
Author Profile
Michael Florman, DDS
Dr. Florman received his dental degree
from the Ohio State University and
completed his post graduate training
in Orthodontics at New York University. Dr. Florman is a Diplomate of
the American Board of Orthodontics,
and has been practicing dentistry since
1991. He is highly respected as both an orthodontist and an
educator. He has authored over forty scientific publications
in the field of dentistry and medicine. Dr. Florman is the
Executive Program Director for PennWell, a national dental
continuing education organization. He is also an active clinical advisor to many pharmaceutical and dental companies.
He is a member of the American Dental Association, California Dental Association, and the American Association of
Orthodontists. His hobbies include golf, running, hiking,
bicycling, photography, and computer graphic design.
Disclaimer
The author of this course has no commercial ties with the
sponsors or the providers of the unrestricted educational
grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.
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Questions
1. Depending on the specific type and
severity, malocclusion is known to be
associated with:
a.
b.
c.
d.
Speech problems and mouth breathing
Poor self-esteem
Inadequate oral hygiene
All of the above
2. Orthodontic treatment is prescribed
to patients of all ages. Nonetheless, the
majority of cases are still carried out
on ______, an age group renowned for
noncompliance with oral hygiene.
a.
b.
c.
d.
Juvenile delinquents
Healthy adolescents
Adults
Geriatric patients
3. Acceptance of orthodontic
treatment means:
a. Patient commitment to a regimen of increased
attention to oral hygiene
b. Patients exposing themselves to increased risk of
future oral disease
c. Exclusive in-office oral healthcare
d. a and b
4. A direct statistically significant correlation
was found between poor oral hygiene and
duration of treatment. Factors include:
a.
b.
c.
d.
Planned or delayed extractions
Poor elastic wear or the male gender
A broken/loose bracket or maxillary crowding
All of the above
5. Upon the completion of active
orthodontic treatment, to prevent
relapse, the patient should potentially
use a retainer for:
a.
b.
c.
d.
Five years
Every other night for ten years
Life
One year
6. Orthodontic patients often experience
a decrease in the number of microbes
present in their mouth as well as a
compositional change of the microbial
load resulting in gingival inflammation.
a. True
b. False
7. With respect to Strep. mutans and caries
risk, recolonization by Strep. mutans
following antimicrobial therapy is:
a. Significantly higher in teeth with brackets
and bands
b. Significantly lower in teeth with brackets and bands
c. Nonexistent in teeth with brackets and bands
d. Identified as periodontal pathogenic bacteria
8. The presence and intra-oral carriage of
Candida albicans and coliform bacteria
have been found to be promoted by
fixed appliances.
a. True
b. False
9. Gingival hyperplasia necessitates care on
the part of the patient to ensure:
a. The occurrence of a shift to more anaerobic flora
b. Pseudopockets are present
c. No differences in gingival or plaque indices
take place
d. Plaque retention within pseudo pockets does not
result in deterioration of soft and hard tissues
10. Poor oral hygiene during orthodontic
treatment leads to:
a.
b.
c.
d.
Potential for subsequent periodontal disease
Development of incipient and frank carious lesions
Gingivitis of increasing severity
All of the above
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11. The use of ______ has been shown
to result in lower plaque index when
compared to plaque indices of patients
with ______.
a.
b.
c.
d.
Brackets and bands; permanent retainers
Resin system aligners; fixed orthodontic appliances
Removeable retainers; permanent retainers
Fixed orthodontic appliances; resin system aligners
12. In as little as one month, decalcification
around orthodontic banding has b een
shown to occur, and in the absence of any
preventative program, up to ___ percent of
orthodontic patients experience white spots.
a.
b.
c.
d.
25
35
50
65
13. What did patients regard — and associate with pain — to be the most negative
aspect of their treatment?
a. Gingival bleeding while brushing under fixed
orthodontic appliances
b. Increased plaque retention
c. Tightening of brackets and addition of
connective bands
d. Pocket formation
14. If treatment is more damaging than
discontinuation due to a patient’s unwillingness or inability to perform appropriate
oral care, discontinuation can help manage
and reduce the risks of litigation on the
part of the patient or their parents.
a. True
b. False
15. Plaque removal and control during
orthodontic treatment can be achieved:
a.
b.
c.
d.
Mechanically
Chemically
By the clinician alone
a and b
16. Due to their speedier plaque
removal, what may be more effective
for patients who do not spend enough
time on oral hygiene?
a.
b.
c.
d.
Frequent trips to the dentist
Mouthrinses
A water pik
An electric toothbrush
17. Interdental cleaning can be effectively
achieved through:
a. A floss threader adjacent to the area being flossed
b. A floss with a thickened end
c. Clear instructions and education by
dental professionals
d. All of the above
18. Although various methods exist by
which to successfully achieve plaque
removal, it can be concluded that results
attained will depend upon patient education and preference.
a. True
b. False
19. What are used as chemical agents for
plaque control?
a.
b.
c.
d.
Pastes
Gels
Varnishes and mouthrinses
All of the above
20. Chlorhexidine mouthrinse effectively
reduces plaque and gingival indices with
a continued effect for up to ______ on the
gingival index following cessation of use
in orthodontic patients.
a.
b.
c.
d.
Five minutes
50 minutes
Five hours
Five days
21. One study conducted on children aged
11–17 used 0.12 percent chlorhexidine for
30 seconds every morning and evening.
This study resulted in a reduction in
plaque and gingival indices of ______ and
______, respectively.
a.
b.
c.
d.
30 percent; 33 percent
58 percent; 60 percent
64.9 percent; 60 percent
75.6 percent; 77 percent
22. A short-term use of chlorhexidine is
associated with increased staining and
temporary taste disturbances.
a. True
b. False
23. The use of alcohol-containing rinses
should be avoided in:
a.
b.
c.
d.
Children
Immunocompromised patients
Patients undergoing head and neck radiation
All of the above
24. Because of alcohol’s drying effect, a
relative contraindication would be:
a.
b.
c.
d.
Inflammation of the tongue
Xerostomia
Numbness in taste buds
All of the above
25. Oral irritations and ulcerations
are common:
a. Around brackets, clasps, and bands
b. As a result of brushing with a soft-bristled
toothbrush
c. With the use of an electric toothbrush
d. When flossing occurs only periodically
26. What helps to protect the mucosa
and assists in the prevention of irritation and friction in an orthodontic
patient’s mouth?
a.
b.
c.
d.
Saliva
Orthodontic wax
Chewing gum
Mouthrinses
27. The use of ______ should be included
when considering pain relief and
healing for an orthodontic patient with
fixed appliances.
a.
b.
c.
d.
Locally applied pastes
Rinses
Locally applied gels
All of the above
28. What percentage of the population has
hypersensitivity to nickel?
a.
b.
c.
d.
25
30
35
40
29. Recent research has found an interaction
between fluoride mouthrinses and
orthodontic materials, resulting in
corrosive products with the potential for
local allergic reactions.
a. True
b. False
30. Allergic reactions by patients to
orthodontic materials may include:
a.
b.
c.
d.
Latex
Titanium
Cobalt-chromium
All of the above
9
ANSWER SHEET
Soft-Tissue Maintenance During Orthodontic Treatment
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
)
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Mail completed answer sheet to
Educational Objectives
1. Understand oral-healthcare guidelines that need to be stressed and explained to an orthodontic patient, as well as
practiced by the patient, to maintain oral health during treatment
2. Understand the sequelae of poor oral hygiene during orthodontic treatment, including plaque retention, bleeding,
and pain
3. Understand methods for plaque removal during orthodontic treatment that encompass types of toothbrushes,
interdental cleaning, oral irrigators, and mouthrinses
4. Understand the oral irritations that may be inflicted on an orthodontic patient during treatment and list types of
products available that aid in combating, managing, and healing these oral reactions to ensure continual oralhealthcare
home maintenance by the patient
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
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Exp. Date: _____________________
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Objective #2: Yes No
Objective #3: Yes No
Objective #4: Yes No
2. To what extent were the course objectives accomplished overall?
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Charges on your statement will show up as PennWell
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
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___________________________________________________________________
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___________________________________________________________________
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AGD Code 016
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER
The author of this course has no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
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This course was made possible through an unrestricted educational grant. No
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All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
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survey included with the course. Please e-mail all questions to: [email protected].
10
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
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© 2008 by the Academy of Dental Therapeutics and Stomatology, a division
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