Download Oral Health in Orthodontic treatment: Preventive and Innovative

REVIEW ARTICLE
Oral Health in Orthodontic treatment:
Preventive and Innovative approach
Mayuresh J Baheti*, Nandlal Girijalal Toshniwal**, Saurav D. Bagrecha***
(Baheti MJ, Toshniwal NG, Bagrecha SD. Oral Health in Orthodontic treatment: Preventive and
Innovative Approach. www.journalofdentofacialsciences.com, 2014; 3(3): 39-46).
Introduction
The objectives of orthodontic therapy are to
establish a good occlusion, enhance the health of
the periodontium, and improve dental and facial
esthetics.
In today’s aesthetic world patients
seeking orthodontic treatment is considerably
increasing.1 Outcome of the success of treatment
largely depends on the periodontal status of
patients. Orthodontic treatment with fixed
appliances alters the oral environment, increases
plaque amount,2 changes the composition of the
flora,3 and complicates the cleaning for the
patient.4 Gingivitis and enamel decalcification5,6
around fixed appliances are frequent side effects
when the preventive programs have not been
implemented.7 Oral cleaning becomes more
difficult with the presence of the orthodontic
*P.G. Student, **Professor & Head,***Senior Lecturer,
Department of Orthodontics & Dental Orthopedics, Rural
Dental College, Pravara Institute of Medical Sciences,
Loni, Maharashtra - 413736
Address for Correspondence:
*Dr Mayuresh J. Baheti. Department of Orthodontics &
Dental Orthopedics, Rural Dental College, Pravara
Institute of Medical Sciences, Loni, Maharashtra 413736
e-mail: [email protected]
appliances and their components. Thus, the
elimination of plaque is the main target to prevent
and/or overcome the problems listed above.
Orthodontic
appliances
contribute
to
environmental changes that can result in greater
concentrations of acid-producing bacteria. This
increase in acid production is the predominant
cause of hyperplastic gingivitis. Gingivitis is so
prevalent in orthodontic patients that it is viewed
by many orthodontist as an inevitable by-product
of their therapy.8 The appliances usually contribute
periodontal disease in that they collect
microorganisms.9 Caries risk is related to
appliances which increase the number of sites
where plaque can accumulate, as well as to
changes in the bacterial flora and the age of the
patient.A more recent study showed the incidence
of white spot lesions in patients treated with
comprehensive orthodontics was significantly high,
and the preventive therapy provided appeared to
be ineffective.10 we can elevate our goals and
realize that much can be done to reduce gingivitis,
periodontitis and caries that our patients may
experience during treatment. If young people are
first motivated, then given comprehensive homecare instruction, their chance of maintaining good
oral health throughout life is excellent. Since we
see patients regularly over an extended period,
40
Baheti et al.
orthodontists are in a unique position to initiate
and follow up this important learning process.
Orthodontists customarily explain to their patients
the importance of oral hygiene during treatment.
However, it has been emphasized that the
orthodontist has the opportunity as well as the
obligation to play an even greater role in
preventive dentistry and, specifically, disease
control.
The purpose of this article is to evaluate the
information available on oral hygiene to support
the development of oral hygiene programs for
orthodontic patients.
Periodontal
Treatment
Tissues
in
Orthodontic
Fixed orthodontic appliances would make
brushing procedure difficult hence inability to
completely remove plaque initiates the potential to
cause gingivitis and progress to periodontitis
during tipping and extrusive movements(Figure 1).
Fig.1 Gingivitis Due to Crowding
The gingival pocket deepens and results in
development of pseudo pockets. This pseudo
pockets provides an opportunity for colonization to
subgingival bacteria leading to periodontal
breakdown.11,12 This periodontal destruction
overtime undergoes some degree of degeneration
in PDL. Force applied on such teeth can result in
more periodontal breakdown and regeneration of
periodontal ligament tissues with periodontal
inflammation present are defenseless to bacterial
infection.13
Removable appliances have however not been
shown to cause such periodontal liability because
of ease of cleansing with the appliances.14 Trauma
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from occlusion, one of the major factors causing
periodontal problems should be relieved to avoid
any further progress of the disease. These gingival
problems and periodontal breakdown once
occurred may present themselves in extension or
increments.
However, if effective preventive measures are
taken by the operator and patients during
treatment, no clinically significant damage to the
periodontium will occur.14
The importance of good oral hygiene
Effective plaque removal is the prime
consideration for good oral hygiene. This is
important to the patient from both a periodontal
and a caries standpoint. The detrimental influence
of plaque on the periodontal tissues is becoming
more and more evident. Previously more attention
was given to apical root resorption during
orthodontic treatment. However root resorption
involves limited root surface areas and is not
usually progressive once appliances are removed.
Today more attention is directed to the marginal
periodontal damage from neglected or improper
oral hygiene which not only manifests itself during
orthodontic treatment but continues beyond the
time of appliance removal.15
The relationship between plaque and caries
activity has been demonstrated by studies
indicating the irterp1ay between carbohydrate
consumption and microorganisms in the dental
plaque. Therefore, if the amount of plaque in a
patient’s mouth can be eliminated or at least
controlled, much tissue pathosis can be prevented.
This thrusts a challenge to the orthodontist and his
auxiliary personnel to increase the patient’s oral
hygiene awareness. By so doing, they can not only
reduce the prevalence and severity of iatrogenic
damage but also increase the long-term benefits of
the orthodontic therapy.11
Motivation of the patients and oral hygienic
training; control of oral hygiene
Before the orthodontic treatment it is very
important to inform the patients about the
importance of the improved oral hygiene
concerning orthodontic treatment with fixed
appliance and to explain the causes of caries and
periodontal disease. The dentist can use any
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Baheti et al.
gingival indices and disclosure of the plaque for
the patient to be motivated. The patients need
proper information about the preventive
possibilities concerning fixed orthodontic appliance
after its application. It could be very useful to
check the oral hygiene throughout the complete
orthodontic therapy. Beside of the use of fluoride
containing toothpaste and brushing with
conventional brushes also during the treatment at
least twice a day, additional methods could be
suggested helping to improve oral hygiene.
Recording and documentation of the improvement
in oral hygiene in the patient’s chart is also
necessary. Although motivation and oral hygiene
training represent the most important points before
the orthodontic treatment, it can be repeated as
frequently as it is needed not only before but
during the active orthodontic treatment as well.
After finishing the orthodontic treatment the
orthodontist also has to advice the patients to
maintain proper oral hygienic habits. Few studies
in the literature evaluated the oral hygiene
motivation methods (OHMM) in orthodontic
patients using various methods. These methods
are generally classified as verbal,16 written,17 or
visual based (videotapes).17,18
Treatment Program
Every patient should be properly screened and
after initial diagnosis, referral for treatment to
control active periodontal disease and caries
should be done. Patients should be explained
about the treatment, their responsibilities and risk
during orthodontic treatment. Proper instructions
and positive reinforcement about management of
new oral environment and its maintenance must
be emphasized.
Plaque Removal
41
However, a number of new investigation
comparing the roll technique with the horizontal
scrub, vibratory (Bass, Charter’s), and circulatory
(Fone’s) methods indicate that the roll method is
inferior to, or no better than, the other methods
with respect to plaque control.19 The aforemention
studies clearly clearly showed the difficulties in
cleansing the interproximal tooth surfaces by
toothbrushing, and none of the methods cleaned
these surfaces to a satisfactory degree.
No reports have been made concerning the
clinical effectiveness of the various recommended
methods or toothbrushing in orthodontic patients.
However, (i) good cleansing along the gingival
margins is of paramount importance in
orthodontic patients to prevent gingivitis20 and
deminera1izations21 and vertical brushing has been
found inadequate along the gingival tooth areas;
(ii) horizontal brushing methods imply active
brushing all the time, as no time is lost for
replacement of toothbrush position. On the basis
of available evidence, it seems justifiable,
therefore, to recommend horizontal brushing with
either the scrub or the Bass technique as the
method of choice for patients wearing orthodontic
appliance. A modified bass method with bristles at
45 degrees to sulcus would be more beneficial in
patients with deepened pockets. Patients should be
made to demonstrate the method of brushing and
must be made aware when appliances are shiny
are clean. A clinician should properly train the
patient in brushing habits (Figure 2).
Fig. 2A: Placing
bristles where
gums and teeth
meet.
Toothbrushing
Methods of Toothbrushing: Toothbrushing is
the most common method of removing deposit of
oral debris and plaque from the teeth. Only a few
well documented and controlled c1inical
experiments have been made to compare the
effectiveness of the different techniques employed,
and controversy still exists as to the efficiency of
the various methods. Previously, the ro1l method
was the one method most often advocated.
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Fig 2B:
Circular and
gentle vibratory
motions
around gum
lines on each
tooth.
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42
Baheti et al.
Fig 2C. Slow
brushing on
palatal/lingual
surfaces of each
tooth.
Fig 2D. Brush
from gum line to
occlusal surface.
Frequency of toothbrushing: The optimal
frequency of plaque removal depends upon a
number of individual factors, such as the physical
and chemical properties of the diet, eating habits,
individual resistance, and the composition of the
microflora.2 Since there exists no evidence that
proper, frequent toothbrushing is harmful to the
teeth or gingivae, it seems unnecessary to place an
upper 1imit on the frequency of toothbrushing. It
should be stressed, however, that the qua1ity of
the toothbrushing is as important as is the
quantity.
Brush at least three times a day. It is best to
brush after meals to make sure there's no food
trapped in or around braces. If patients are not
able to brush after lunch, ask them at least rinse
their mouth with water very thoroughly.
abrasion because of smaller
diameter bristles.21,22 However due
to cost effectiveness it was often
neglected by the patients(Figure 3).
It is important to brush the
braces and all the surfaces of the
teeth, that is, the inside and outside
surface and the chewing surfaces,
too. Pay special attention to the
areas between your brackets and
your gums.
Tools to Help Patients
Fig. 3
Electronic
Toothbrush
(Rotadent)
A) Rubber-tipped and end-tuft or single-tuft
brushes – These are special brushes that help
patients to get into those nooks and crannies, as
well as between their teeth. The end-tuft or singletuft brushes look something like pipe cleaners.
B) Oral irrigators – These instruments shoot
small streams of water onto the teeth at high
pressure to remove bits of food. "They can be used
as an aid in your oral hygiene practice, but not in
place of brushing and flossing." Oral irrigator with
regular tap water at high pressure with a
conventional irrigator tip can aid as a very effective
method in periodontal maintenance.Use of
chlorhexidine with specially modified irrigating tips
called as ‘Pik Pocket (Teledyne Corporation)’ can
be used to directly to irrigate the pockets with
medium pressure if gingival bleeding on probing
persists [Figure 4].23
Toothbrushes: Both manual and electronic
brushes are available in the market.
A) Manual toothbrushes: Some companies
make toothbrushes especially for people with
braces. Known as bi-level brushes, they have
longer bristles on the edges and shorter ones in the
middle. This type of brush allows you to clean the
area above and below the brackets and the
brackets as well.
B) Electric toothbrushes: The Rotadent electric
toothbrush with short pointed bristles was found to
be more effective than conventional toothbrushes
in orthodontic patients. It was seen to remove the
interproximal plaque more effectively with least
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Fig.4:
Oral
Irrigator
C) Flossing: It might difficult to floss while having
braces, but one can and one should. Special
flossing products can help to get into the space
between the wires and gumline. These include
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Baheti et al.
43
floss threaders and a special kind of floss. When
braces are first put on, orthodontist’s should
review flossing techniques. (Figure 5) Flossing
should be done least once a day.
Fig. 5: Flossing Technique
Fig. 5A: Thread unwaxed
floss between braces &
wire.
Fig 5B: Floss around
braces.
Fig 5C: Floss around
gum areas.
D) Disclosing solutions or tablets: The home
use of plaque disclosants has been recommended
as a helpful adjunct to improve oral hygiene.
Disclosing tablets and solutions use vegetable dye
to highlight plaque or debris in the mouth
E) Chemical Cleaning:
a) Chlorhexidine: Chlorhexidine remains one of
the most effective antimicrobial mouthwashes
because it acts not only against gram-negative
bacteria, but also against yeasts and gram-positive
bacteria.24 It is particularly suitable for the
inhibition of plaque formation as it has the ability
to maintain effective concentrations for prolonged
periods of time, by way of binding to soft and hard
tissues, a process known as substantivity.25
Repeated studies have shown that a 0.1 to 0.2 per
cent solution of chlorhexidinegluconate used as a
one minute rinse (10 ml) twice daily inhibits the
development of gingivitis. A three month use of
0.12% chlorhexidine approximately reduced 65%
plaque, 77% gingival bleeding. (26) One of the
main problems with its use was potential staining
b) Anti-Plaque Agents: In addition to
toothbrushes and chlorhexidine number of agents
as Stannous fluoride, Tryclosan, and Listerine help
to maintain the hygiene. Stannous fluoride gels are
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found to be more effective against gingivitis. It is
found to be very useful to prevent decalcification
in orthodontic patients by using daily, topical and
in low concentration of 0.05% or 0.4% in gel
form.27 Continued use for 6 months after appliance
removal helps to remineralize areas of
decalcification that may have occurred during
treatment. It was found 15-20% patients develop
mild staining with its use in 3-6 months of use, but
yet its effectiveness largely depends on patient’s
compliance.
Listerine rinse contain 26% alcohol and should
be rinsed twice daily for one minute for antigingivitis effect without dilution. Tryclosan
toothpastes have good anti-gingivitis effect, good
taste and good control against supragingival
calculus. They should be the standard toothpastes
for all orthodontic patients with fixed appliances.
Few products such as baking soda toothpastes
which might also contain peroxides are marketed
as antiplaque agents. If fluoride content is present,
they too can be used for orthodontic patients.
Sanguinaria, baking soda and peroxide used as
antiplaque agents are not FDA or ADA
approved.28
Decalcification Treatment
Decalcification is evident in form of white or
yellow stains clinically with possible roughness.
Best method to prevent is use of fluoride
toothpaste without rinsing with water or by using a
topical fluoride rinse or gel twice daily during
orthodontic treatment. Fluoride increases the initial
rate of remineralization of early enamel lesions and
slows down the progress of carious process by
reacting with the minerals present in the surface of
the lesion. Enamel can be remineralized with
meticulous toothbrushing twice per day, with
fluoridated
dentifrice.
Additional
fluoride
application
can
further
enhance
the
remineralization process. This regime helps in 50%
reduction in discoloration. Enamel can also be
remineralized with Casein PhosphopeptideAmorphus Calcium Phosphate preparations. CPPACP is capable to be absorbed through the
enamel surface and could affect the carious
process.29
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Baheti et al.
Post
orthodontic
treatment,
moderate
decalcified areas may present as larger areas of
color changes in yellow-brown form with definite
roughness [Figure 6]. But when a severe
decalcified area is present, patient might have to
have a restoration placed.
movement if in labial direction, may require soft
tissue graft. If teeth having thin tissue are going to
be moved lingually, there is potential for the tissue
to move coronally and become thicker. In this case
any grafting of soft tissue should be postponed
until active tooth movement is completed. In cases
of bony defects, teeth can be moved
orthodontically provided the remaining bone and
periodontuim are brought to healthy states.29, 30
Fig 6: Decalcification post orthodontic
treatment
To prevent these problems few steps by the
clinicians, as bonding of molars than banding, in
periodontal compromised patients can be helpful.
Use of single archwires whenever possible and
removal of excess composite around brackets,
especially at gingival margins can aid in additional
maintenance.
Gingival Recession
Gingival recession is found to be more in
periodontally compromised patients undergoing
orthodontic treatment [Figure 7]. A clinician
should be aware of this fact and have an
interdisciplinary treatment plan. Force applied on
periodontally compromised teeth can result in
more periodontal breakdown and regeneration of
such periodontal ligament tissues is difficult. As a
result, with loss of bone support, center of
resistance of the involved tooth moves more
apically resulting in teeth being more prone to
tipping movements than required bodily
movements. Supra gingival plaque can shift to
subgingival position in a plaque infected
tipped/tilted teeth inducing an apical shift of the
connective tissue attachment and formation of
pockets and further loss of attachment. Due to risk
of having more PDL attachment loss, very light
forces must be applied.16
Areas of thin gingiva are usually noted as having
washboard appearance of prominent roots and a
narrow width of attached gingiva. Tooth
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Fig 7: Gingival recession during orthodontic treatment.
Retention
Post orthodontic treatment removable or fixed
retainers are necessary to prevent any relapse of
the treatment and allow time for reorganization of
the gingival and periodontal tissues.31 As instructed
by the clinician, patients should be made aware of
its importance and motivated for proper use of
retainers to avoid any possible damage to the
tissues. If patient have a retainer or other
removable orthodontic appliance, it needs to be
cleaned regularly, too. After all, it spends a lot of
time in your mouth. It is very difficult to keep the
removable appliance totally free of plaque.
Different cleaning methods arerecommended
mainly for home care. The orthodontist can
suggest to clean with toothbrushand toothpaste (or
soap) under running water or to clean the
appliance in water bath containing a cleanser
tablet.
Conclusion
The number of orthodontic treatments among
them the frequency of treatments with fixed
appliances is increasing nowadays. In some cases
orthodontic treatments mean caries preventive
interventions when tooth movements may relieve
crowding or other anomalies thus can contribute
the effectiveness of proper oral hygiene. On the
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Baheti et al.
other hand these treatments may have causative
effect on plaque induced oral diseases. For these
patients effective preventive oral health care is
needed and orthodontists have to be responsible
for helping to keep proper oral hygiene in their
patients.
Increase
of
motivation
among
orthodontic patients regarding sustainable oral
hygiene regime might result in better oral health
outcomes and prevent complications. Because of
the increasing number of patients in need of
orthodontic appliances, this is important and
useful not only for orthodontists, but general
dentists or periodontists and as well.
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