Clinical interview
Initially a clinical interview of the patient should be conducted to determine their patterns of behaviour, eating and drinking habits, dental hygiene and, if possible, the history of any fluoride treatments they have undergone.
In the adult patient a three day diet diary including times and amount of intake and a diary of drinks and alcohol intake should be completed and analysed by a dental professional in your practice.
A diet counselling and caries risk assessment appointment should be carried out to predict risk and repeated again at 6-12 weekly intervals to measure compliance. Click here to download a sample diet sheet which patients can complete prior to undergoing treatment.
In the case of children, this interview can also assess the degree to which their families are ready, willing and able to help the treatment succeed, an essential factor in ensuring a good quality follow-up of the different treatments proposed.
These interviews should be followed by a full clinical examination.
Click here to download a sample Caries Risk Assessment for Adults & Children of 8 yrs+.
Clinical examination
From the outset the patient’s oral health status should meet certain criteria to facilitate exemplary orthodontic treatment and not be likely to cause any local complications which could be wrongly interpreted as being directly due to the orthodontic treatment itself.
It is essential that the orthodontic practitioner undertakes a systematic search for disorders and abnormalities, both visible and invisible, and make a complete assessment of them.
The dental report should:
- State the number of teeth present, absent, and treated; record all the clinically visible carious lesions and their complications;
- Identify any structural abnormalities liable to contribute to biofilm retention, stagnation, etc.
- Verify gum disease status
Radiological examination
In addition to the dental examination, an accurate oral radiological examination should be performed.
Its aim should be:
- To determine the extent of any carious lesions and their possible complications;
- To visualise any failing restorations;
- To monitor the progress of, or identify any areas of apical pathology
Saliva test
Saliva flow rates and pH is an indicator of the patients’ natural cario-protective status. Ideally patients should have a resting pH between 6.0-7.5, with a flow output of 0.3ml/min for un-stimulated and 1.5ml/min for stimulated saliva.
In the case of fixed brace patients it is advisable to use a saliva testing kit to check pH level and flow. Once flow rates and pH have been tested and measured, an individual action plan can be formulated which could include rehydration and adding extra mineral and cariostatic chemicals e.g. fluoride varnish, xylitol supplements, etc.
Due to the physical barrier presented by an aligner all patients undergoing this type of treatment will have severely restricted flow and saliva measurements should be considered necessary for all patients.
Dental care treatment
After these examinations, an appropriate treatment plan should be drawn up to carry out any dental care therapies needed before the orthodontic treatment can be initiated. This pre-orthodontic dental preparation is an essential step.
The orthodontist should be personally involved at this stage and ensure that all preventive precautions are taken and all necessary treatment is carried out, in co-ordination with the patients’ general practitioner.
The following should be performed:
- Treatment of all caries
- Treatment of all pulpal/ apical pathology due to caries
- Restore all restorations to full functionality
- Preventive sealing of grooves, pits and crevices in all permanent teeth
Education and motivation
Before undertaking curative and preventive treatment, prime importance should be given to dietary recommendations; patients should be informed and made aware of the cariogenic potential of foods and sugary beverages. Bad eating habits such as snacking need to be discouraged and patients advised to eat sensibly.
In addition, motivation and awareness of optimal oral hygiene should be emphasised in the treatment plan. The patient should display a satisfactory level of oral hygiene before the orthodontic treatment is started, and be expected to maintain this level of hygiene throughout the treatment. The rules of good hygiene should become a routine habit and be reinforced regularly during appointments.
Guidelines for Children
Caries control is similar in delivery for nearly all age groups of children and adults. However, up until the patient is 12 years old, it is the parents or guardian of the child who plays the key role in habitual change, compliance, motivation and behaviour.
On commencement of orthodontic treatment caries control strategies need to be planned with an adult providing supervision. Caries in that child will be a direct result of actions and decisions taken by the adult. Therefore before the treatment planning stage takes place, we would recommend a pre-clinical appointment with the child and parents/guardian to discuss attitudes and oral hygiene behaviours. This will ascertain the needs and education which may need to be employed to prevent caries and achieve good oral hygiene.
The following topics need to be assessed and discussed:
- Do the parents supervise tooth brushing, snack and drink selection?
- Parent’s knowledge and attitudes to caries and diet
- Family issues which may be an obstacle to supervision of brushing and a healthy diet?
- Previous caries experience in the family
- Parent’s willingness and ability to make changes
In contrast, the adolescent patient will be making their own choices about diet and oral care and will need to take responsibility. Here, constant reinforcement of good brushing, a low sugar diet and fluoride use is essential. With regular exposure to you and your team, this presents and ideal opportunity to reinforce the message. If a hygienist is not on staff it is advisable to train one of the nursing team to disclose and tutor the patient in an effective oral care regime.
Again, with children and adolescents, regular professional tooth cleaning should be encouraged.
Guidelines for Adults
The orthodontic interface may present challenges during treatment and post operatively in the retention phase. Adult patients are non-growing individual and may present with a heavily restored dentition which increases plaque retention. There may be ceramic teeth, bridgework and implants to consider, not to mention loss of attachment and challenging compliance.
Previous gum disease and loss of attachment does not preclude orthodontic treatment. Active unstable periodontal disease will need to be treated and a period of post-operative stabilisation must take place before any orthodontic interface is introduced.
A bleeding score should be carried out three monthly and should be under 15% in a presence/absence percentage value.
