Amanda Gallie, current President of the British Association of Dental Therapists, discusses the importance of maintaining oral health for orthodontic patients.


It is fair to say that orthodontics is going through a renaissance at present. New treatment modalities and advancing technologies are making treatment quicker, more accessible and convenient. The age demographic of patients is also shifting, with more over 25s taking up treatment.

But another market that is also evolving rapidly is that of soft drinks and convenience foods. Foods containing a lot of sugar now make up a large percentage of carbohydrate energy intake in the under 21s and is ever present in adult diets. While the impact of sugar on obesity levels, diabetes and tooth decay is well documented, the impact of sugar-free soft drinks and fruit juices on enamel erosion is less well accepted among the general population. As a consequence dental practitioners are reporting significantly increased levels of decay and enamel erosion, particularly among teenage patients.

There is a need to educate our patients on healthy dietary habits, especially between meals when the maintenance of a neutral pH is critical.

The Risks

An orthodontic appliance, whether a fixed brace system or clear aligner, favours the build-up of plaque due to multiple plaque retention factors. The appliance may also restrict the self-cleansing properties of saliva, thereby creating an environment which favours the onset of decay and gum disease1,2.

In light of these and other factors the Department of Health and a number of global health agencies have classed orthodontic treatment as a non-negligible risk factor for dental caries3-5.

Let’s briefly consider some of the main indications.

Tooth Decay

Develops over time by the dissolution of tooth enamel by acids produced by the bacterial breakdown of carbohydrates in the diet. Traditionally the teeth most susceptible to demineralisation were the maxillary incisors and the first permanent molars, however with the aforementioned changes to diet we also need to be mindful of interproximal caries formation.

White Spot Lesions

Or initial lesions of the enamel are present in 25–30% of patients who are following an orthodontic treatment plan6. Lesions are most commonly found in close proximity to the bonded brackets and bands. Caught early on these lesions may be reversible with care but are best avoided by investing time educating patients and creating a preventive ethos in the practice.

Gum disease

Early stage gum disease or gingivitis is characterised by red, swollen gums that are prone to bleeding. This gum inflammation is caused by the release of pro-inflammatory toxins, as by product of the bacterial breakdown of sugars. This occurs in approximately 41% of orthodontic patients7. Gingivitis is reversible with a regime of good oral hygiene discipline based on thorough daily cleaning and regular hygiene appointments. However if left untreated gingivitis can develop into periodontitis, which is irreversible and can result in tooth loss. In the case of an orthodontic patient the braces would be removed well before this point to facilitate comprehensive cleaning.


To avoid patients experiencing deterioration in their oral health following the introduction of an orthodontic appliance it is essential to ensure that patients are fully informed of the risks associated with their treatment and instructed in effective home care, including healthy diet choices.

Over the course of the next five issues of Orthodontic Practice I will be presenting a practical guide looking into the key areas orthodontic practices should consider when reviewing their oral hygiene strategy, including:

  • Effective oral hygiene instruction
  • Objective oral hygiene assessment
  • The role of specialist oral hygiene products
  • Establishing and maintaining patient compliance
  • Ethical selling.

Good for patients, good for the practice

It is not uncommon to hear orthodontic practitioners say that they don’t have time for comprehensive oral care or that oral hygiene is the responsibility of the referring GDP. Before signing off for this issue I would like to tell you why I believe oral hygiene should be high up your list of priorities.

For the patient:

Acting in the best interest of the patient, we need to be mindful of how oral health contributes to general health and wellbeing. Good oral health enhances patient’s quality of life, boosts confidence, and directly impacts the duration and overall success of treatment.

For the practice:

A good preventive strategy will enhance the reputation of a practice, increasing referral rates. At the same time practice whose patients present with good oral health are able to see more patients in a day, reducing the overall cost of treatment and increasing practice profitability.

For the team:

A focus on prevention creates new roles and responsibilities, increasing work satisfaction. Additionally patients with clean mouths are more rewarding to treat, reducing stress and creating time for the team to be pro-active. In fact it’s a win, win for all concerned.


  1. Ahn and Kho. Adhesion of strep mutans to bracket pellicle. Am J Orthod Dentofacial Orthop. 2003 Aug;124(2):198-205.
  2. Derks et al. Caries prevention in orthodontic practice. Am J Orthod Dentofacial Orthop. 2007 Aug;132(2):165-70.
  3. Gorton et al. Demineralisation and brackets. Am J Orthod Dentofacial Orthop. 2003 Jan;123(1):10-4.
  4. O’Reilly and Featherstone.Demineralisation. Am.J.Orthod.Dentofacial Orthop. 1987Jul;92(1):33-40.
  5. Travess H et al. Risks in orthodontic treatment. Br.Dent.J 2004 Jan 24;196(2):71-7.
  6. Jordon and Leblanc. Prevention of white spot lesions. Oral.Microb.Immun. 2002;498-502
  7. Dentaid study 2009