Concern for oral hygiene should be constant, not only among all practitioners, but also among patients. Throughout the treatment period the patient should successfully maintain a satisfactory level of oral hygiene despite the hindrance of the appliance.
At the bond up appointment the patients should be given comprehensive one-to-one induction in effective oral hygiene by a suitably trained member of the team. This should cover use of all recommended oral hygiene products, frequency and usage. It is advisable to re-enforce this with written instruction and a video tutorial, films produced by Dent-O-Care are available for both fixed braces and aligners. You can view the videos here.
The quality of the brushing is of optimal importance and co-operation and compliance is essential. The following points should be considered:
- The patient’s ability to physically remove the plaque
- Brushing technique
- Whether the brushing is causing gingival bleeding
- Cause of bleeding i.e. inflammation or aggressive brushing
- The patients’ ability to differentiate between healthy and inflamed tissue
A method of brushing teeth should be taught which takes into account the patient’s age, dexterity and any disabilities (Zuhal, 2006). Electric brushes may be preferred if the patient is unable to achieve correct oral hygiene by simple mechanical brushing (Costa et al, 2007).
Tooth brushing should be carried out in conjunction with toothpaste containing a minimum of 1450ppm fluoride, as it is widely accepted that fluoridated toothpastes exert a cariostatic effect (Arnold et al, 2006). The use of fluoridated toothpaste containing an anti-microbial such as cetlypyridinium chloride (CPC) appreciably reduces bacteria levels in the dental bio-film, further reducing caries risk and gingival inflammation. It is recommended that patients brush for 4 minutes, 3 times daily. If compliance is good and the patient has the time and facilities, then brushing after each meal is advisable.
Following initial bond-up it is recommended that patients disclose their teeth daily for a week and then once a week there after to help them identify areas of unremoved plaque.
The interdental surfaces of the teeth and orthodontic interface with the tooth will need cleaning with an interdental brush. The use of a fluoride gel should be considered to ease movement of the brush and provide site specific fluoride therapy.
The advice should be site specific, as teeth move and gaps open and close, the size of brush will change as it needs optimal interproximal contact to remove the plaque. For fixed brace patients a two stage process should be directed, firstly clean all of the interdental spaces and then secondly with a larger brush clean around the brackets and bands.
Manual dexterity should be checked to ensure effective cleaning. Patients unable to clean effectively with interdental brushes should be advised to use a water irrigator, which are undeniably effective at removing food debris and form an excellent adjunct to mechanical brushing.
Patients should be taught to keep an eye on persistent bleeding and to report it to the practice if the condition does not resolve. Bleeding gums are an indicator of gingivitis and healthy gums do not bleed per se.
During orthodontic treatment the movement of teeth can result in discomfort due to inflamed, sore gums. It is recommended that patients are encouraged to use a single tufted brush to gently massage the gums. This process soothes the gums by stimulating blood circulation, while simultaneously helping to dislodge dental bio-film from around the gum margin.
Aside from toothpaste the use of fluoridated mouthwashes is one of the common methods of fluoride delivery. Fluoridated mouthwashes are effective in reducing demineralisation and increase remineralisation of the enamel, particularly around orthodontic bands and brackets. There are several different ways to use fluoridated mouthwashes; our recommendation is ‘little and often’. Administered in low doses (225ppm) once or twice a day for 1 minute will increase fluoride levels in saliva for 2–4 hours. For maximum efficacy and protection it is recommended that this be carried out at intervals between brushing, including after snacks.
Fluoride varnishes should be used in all patients, and in particular the poorly motivated patients as part of an intensive treatment schedule. The varnishes are used as a preventive measure to reduce demineralisation of the enamel around the cemented brackets, promote the remineralisation of the carious lesions and prevent further lesions. The most vulnerable sites are the proximal edges and cervical surfaces.
These varnishes were developed to adhere to the enamel surface for long periods and release their fluoride slowly on the enamel surfaces, so reducing the time spent by the patient in the dentist’s chair. Fluoride varnishes are usually applied four times a year on specific areas with incipient lesions on smooth surfaces.
A further option for patients exhibiting signs of caries and enamel erosion is the use of Xylitol, a 5 carbon sugar pentitol. It is non-cariogenic and reduces the growth, adhesion and metabolism of streptococcus mutans and other bacteria (Anderson JADA 1993). There are several delivery mechanisms available, including supplements and pastilles.
Professional tooth debridement and prophylaxis
All orthodontic patients are potentially high caries patients and should be encouraged to have their teeth professional cleaning at 3 monthly intervals (Axelson et al 1991). The studies show that professional tooth cleaning is extremely effective in preventing caries and white spot lesions on tooth surfaces which are difficult to clean; such as approximal and occlusal surfaces. (Baderstan et al.1975) and (Carvalho et al 1992). Prevention, regular motivation and assessment are key to successful treatment, as such orthodontic specialists are advised to refer their patients to a hygienist either directly or via the referring dentist.
Oral hygiene should be appraised at each scheduled appointment, with the patient given feedback. This helps to ensure that patients understand the level of expectation and this can also act as a strong motivator. In some particularly unfavourable cases, where the quality of hygiene is inadequate or even severely lacking, the orthodontic treatment should be discontinued with no hesitation, temporarily or definitively, based on an assessment of the likelihood of achieving a healthy oral state, adequate motivation and improved oral hygiene and eating habits. This approach will forestall the occurrence of not only caries but also parodontal lesions which can take various forms e.g. hyperplasic gingivitis, receding gums, etc..
Aligners act as an ideal breeding ground for bacteria, with candida and staphylococcus detected in 66.7% and 50% of appliances (Pratten, J. et al 2004). It is recommended that aligners be cleaned at least twice a day with a brush soak brush method. Ideally patients should have a separate toothbrush for this purpose. Once a day the aligner should be soaked in luke warm water containing a VITIS effervescent cleaning tablets for 20 minutes, this will help ensure that all the bacteria and other organisms are removed from the surfaces.
- Arnold, W.H; Dorow, A.; Langenhorst, S.; Ginter, Z.; Banoczy, J. & Gaengler, P. Effect of fluoride toothpastes on enamel demineralization. BMC Oral Health 2006;Vol 6, n°8: 1-6.
- Costa, M.R.; Silva, V.C.; Miqui, M.N.; Sakima, T.; Spolidorio, D.M.& Cirelli, J.A. Efficacy of ultrasonic, electric and manual toothbrushes in patients with fixed orthodontic appliances. Angle Orthod. 2007; Vol 77, n°2: 361-366.
- Pratten, J. Composition of in vitro dental plaque biofilm and the susceptibility to antifungals FEMS Microbiology Letters 242, 2005.
- Zuhal, Y.A. Appropriate Oral Hygiene Motivation Method for Patients with fixed appliances. Ang. Orthod. 2006; Vol 77, n°6:1085–1089