Dr. Larry White relates the quality of oral hygiene and tooth-brushing regimens to orthodontic outcomes
Dental plaque often gains unusual vigor throughout orthodontic therapy and has the ability to damage the teeth and gingiva irreversibly, which often cancels the esthetics of optimal alignment. Orthodontists have applied several strategies to minimize the destructive effects of caries, decalcification and gingivitis — i.e., oral hygiene instruction, dietary counseling, fluoride varnish and rinses, sealants, and chlorhexidine rinses, etc. — but the results remain equivocal and imprecise. Most of the damage from decalcification, aka, white spot lesions, occurs at the gingival margin of the teeth, and this clearly is the area that needs emphasis in the oral hygiene regimen. Unfortunately, this feature has not received the profession’s attention until now with the development of a specially designed tooth brush that addresses this oral hygiene deficit. This article will display this brush and its unique ability to apply cleansing to this area, while simultaneously showing a dramatic way of bringing this to the patient’s attention.
All of the elements of orthodontic therapy gather plaque — e.g., brackets, bands, elastics, elastomerics, springs, wires, plastic sleeves, etc.,1,2 (Figure 1) — and despite orthodontists’ best attempts to limit the destructive results of plaque such as caries, gingivitis, decalcification with products such as oral hygiene instruction, fluoride varnish and rinses, chlorhexidine, sealants, and dietary restrictions, researchers have discovered that oral bacteria increase significantly during orthodontic therapy.3 Other researchers4-7 discovered how the escalation of Streptococcus mutans during ortho-dontic treatment jeopardizes dental enamel for caries and/or decalcification. Grant8 has further shown how typical mouth bacteria can mutate into pathogenic types during orthodontic therapy, while Matassa9 demonstrated how oral bacteria use as nourishment dental composites with which orthodontists attach brackets to enamel.
Orthodontic clinicians have known for several decades about the relationship between the quality of orthodontic outcomes and the patients’ quality of oral hygiene.10 Also, much research has revealed the relationship of plaque to gingival inflammation,11 which lowers patients’ pain tolerances.12 This lowering of tolerances leads to further neglect of oral hygiene, which ultimately results in a cycling from neglect to plaque accumulation, to gingival inflammation, to lowered pain tolerances, and back again to more neglect. This cycle of neglect contributes greatly to orthodontists’ inability to achieve consistently quality treatment outcomes with patients.13 Ample evidence exists that defines sensitivity among other temperaments as genetic traits14 and may well discourage dental clinicians from trying to seriously alter patients’ tooth brushing behaviors.
Figure 1: A typical example of chronically poor tooth brushing
Commonly used strategies for limiting plaque
Some currently used preventatives against plaque include intensive oral hygiene instructions,15,16 fluoridated rinses,17-20 and/or fluoridated gels/pastes.16,20-23 Others have advocated fluoride varnishes,24-27 fluoride-containing adhesives/primers,19,20 and fluoride releasing/filled sealants,28 and/or antimicrobial varnishes (e.g., chlorhexidine or cetylpyridinim chloride).18,29 Recently, light-cured filled sealants have shown some effectiveness in preventing enamel decalcification.30,31 Although these various techniques have shown effectiveness, they remain somewhat inefficient because some require reapplication by clinicians or recharging of fluoride ions through patient compliance.16,23,27 These features of compliance by both clinicians and patients have limited their clinical adoption. Even more disturbing, Derks, et al.,32 discovered that although orthodontists know about the various demineralization therapies available, few routinely use any of the strategies other than oral hygiene instruction.
A personal observation
Regarding Derks’ study of routinely used anticaries/decalcification protocols by orthodontists, I have worked in 26 orthodontic offices over the past 25 to 30 years for colleagues who have died, had extended illnesses, or absences from their practices for various reasons. This has given me an unusual opportunity to experience firsthand what clinicians do as preventive measures. Outside of brief explanations at the beginning of treatment, little else occurs throughout the patients’ treatments that the clinicians might consider preventive measures. If patients have a lot of plaque or food on the teeth, they may return to the sink to brush — uninstructed. During this time, I have never encountered an office that used plaque stain to reveal to the patients where their brushing deficit existed. Nor have I witnessed any special technique of brushing or a particular toothbrush given to the patient.
Poor tooth-brushing patients are almost without exception highly sensitive patients who display several dental behaviors that limit successful treatment:33
- Resisting wearing removable appliances
- Salivating copiously
- Frequently breaking appliances
- Habitually failing to wear permissibleappliances, e.g., elastics, headgears, etc.
- Hurting easily and frequently complaining of discomfort
- Having poor brushing behaviors because of discomfort caused by the brush against the gingiva
- Gagging easily
- Being predisposed to TMD problems
- Having a susceptibility to apthous ulcers
- Having easily injured feelings and don’t respond well to anything they interpret as criticism
- Having easily fatigued jaw muscles that prevent them from keeping the mouth open during adjustments
These patients present many problems for the clinician with few obvious answers, but the most important to control is gingival inflammation, which requires a special effort and habitual brushing protocol developed by the doctor and staff. Some suggestions that have helped in the past:
- Insist on a thorough prophylaxis.
- Use daily chlorhexidine applications via the toothbrush.
- Teach a specific technique of brushing with a specific toothbrush and monitor and critique the patient actually performing it, while overcoming the two general features of poor tooth brushers — light pressure and slow velocity of the brush.
Once patients habitually control inflammation, many of the chronic destructive behaviors lessen, but since sensitivity is a genetic gift, one should not expect complete cessation of damaging conduct. However, reinforcement of brushing protocols should at least continue during patient office visits. Once patients realize that doctors demand excellent oral hygiene, and that they cannot leave the office without a clean mouth, they will respond favorably to the office protocol.
A new brush design for the susceptible areas
Dr. Salvatore DeRicco has concerned himself with the problem of enamel demineralization or white spot lesions for most of his orthodontic career (Figure 2). To combat this oral hygiene deficit, he has developed a specially designed toothbrush, the Spot Less Brush (Figure 3), which patients can easily and painlessly apply to the susceptible gingival margins of the teeth (www.stopwhitespotsnow.com). It consists of one row of shorter than average bristles, and the handle has a unique design that correctly positions the brush bristles against the gingival one-third margins of the teeth. When the thumb presses against one handle indentation, the bristles have an angle of 45° that accesses the maxillary gingival margins of teeth from the incisors through the molars. When the handle rotates, the bristles of the brush have an angle of 45° that accesses the mandibular gingival margins of teeth from the incisors through the molars (Figures 4A and 4B). Dr. DeRicco has also developed an electric version of the brush, and this augments the brush’s effectiveness even more (Figure 5).
The Spot Less Brush places the brushing emphasis where enamel insults happen most frequently, and patients receive the message that this brush addresses a particular and threatening feature of their orthodontic therapies. When clinicians and/or their staffs give patients a generic toothbrush or tell them they can use any brush they choose, it gives them the perception that this aspect of treatment plays a minor or unimportant role in the overall treatment. When at clinical appointments, patients receive no feedback about their brushing. Whether good or inadequate. They easily surmise that brushing has no importance. If brushing poorly doesn’t matter enough to warrant corrective instruction and supervision, it should not surprise orthodontists that they seldom see improvement in a patient’s oral hygiene and other behaviors. If clinicians want improvement, they have to make brushing matter, at least when patients are in the orthodontic office.
The AAO Bulletin recently published an article that described how the phenomenon of poor oral hygiene and its legal liability are beginning to vex orthodontists from dis-appointed and irate patients and parents at the treatment outcomes that leave teeth with unsightly white spots. The article said that the decalcification of teeth had become a major source of claims for the AAO Insurance Company.
Figure 2: White spot lesions after orthodontic therapy
Figure 4A: Positioned for brushing the maxillary teeth
Figure 5: The electric Spot Less Brush
Figure 3: The Spot Less Brush
Figure 4B: Positioned for brushing the mandibular teeth
Effectively presenting oral hygiene deficits
Highly sensitive patients seem to have a serious visual impairment when it comes to seeing plaque on the teeth and brackets, so they benefit greatly from the use of plaque stain and close supervision of their brushing technique (Figure 6).
Even after staining and brushing, some patients seem incapable of identifying areas where plaque remains by viewing their teeth in a mirror (Figure 7). To overcome the patients’ inability to see even the grossest accumulations, orthodontists and their staffs can use some useful camera techniques to graphically emphasize the quantity, quality, and location of plaque.
I prefer a digital Canon Rebel camera with a ring flash (Figure 8) and an iPad® that will connect to the camera via a wireless memory card. One needs to equip the camera with a wireless secure digital (SD) memory card (e.g., SanDisk Eye-Fi wireless memory card). These cards look identical to a conventional card but establish a WiFi network and allow the quick transfer of photos and videos wirelessly from the camera to a computer, tablet, or smartphone (Figure 9).
The patient’s camera photograph of stained teeth immediately transfers to the iPad where the patient and/or parent can see the plaque effect in magnification on the screen (Figure 10), or the clinician can elect to take the intraoral photograph with the iPad.
However, since iPads do not have a flash, the photograph often has less definition and quality than those made with a digital camera and ring flash.
Figure 6: Stained plaque
Figure 8 :Digital Canon Rebel dental camera.
Figure 10: Camera image transferred and magnified on the iPad
Figure 7: Mirror monitoring of brushing
Figure 9: Eye-Fi wireless memory card
Fifty-eight years of clinical dentistry has convinced me that if patients practice good oral hygiene, they will do just about anything you ask. There are some exceptions to this general observation, but not many. On the other hand, if patients will not brush well, they will hardly ever perform any other task that aids their orthodontic experience. Unfortunately, the emphasis on good oral hygiene remains a low priority in most clinics, and that is an error of the first order. Materials and methods now exist to correct this orthodontic deficit, but it requires a strong commitment from the doctor who must provide the personnel, time, investment, and office discipline to make it work.
- Basdra E, Huber H, Komposch G. Fluoride released from orthodontic bonding agents alters the enamel surface and inhibits enamel demineralization in vitro. Am J Ortho Dentofacial Orthop. 1996;109(5):466-472.
- Bibilova EZ, Stafilov T, Ivkoska AS, Sokolovska. Prevention of enamel demineralization during orthodontic treatment: an in vitro study using GC tooth mousse. Balk J Stom. 2008;12:133-137.
- Bloom RH, Brown LR. A study of the effects of orthodontic appliances on the oral microbial flora. Oral Surg Oral Med Oral Pathol. 1964;17:658-667.
- Gorelick L, Geiger AM, Gwinett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod. 1982;81(2):93-98.
- Artun J, Brobakken BO. Prevalence of caries and white spots after orthodontic treatment with multibonded appliances. Eur J Orthod. 1986;8(4):229-234.
- Ahn SJ, Kho HS, Kim KK, Nahm DS. Adhesion of oral streptococci to experimental bracket pellicles from glandular saliva. Am J Orthod. 2003;124(2):198-205.
- Ahn SJ, Lim BS, Yang HC, Chang YI. Quantitative analysis of the adhesion of cariogenic streptococci to orthodontic metal brackets. Angle Orthod. 2005;75(4):666-671.
- Grant DA, Grant DA, Flynn MJ, Slots J. Periodontal microbiota of mobile and non-mobile teeth. J Periodontol. 1995;66(5):386-3390.
- Matassa C. Microbial attack on orthodontic adhesives. Am J Orthod Dentofacial Orthop. 1995;108(2):132-141.
- DUMMETT CO. Orthodontics and periodontal disease. J Periodontol. 1951;22:33-41.
- Arnim SS. The use of disclosing agents for measuring tooth cleanliness. J Periodontol. 1963;34(3):227-245.
- Dubner R, Sessle BJ, Storey AT. The Neural Basis of Oral and Facial Function. New York, NY: Plenum Press; 1978.
- Whit L. A new oral hygiene strategy. Am J Orthod. 1984;86(6):507-514.
- Aron EN, The Highly Sensitive Person. 1st ed. New York, NY: Carol Publishing Group; 1996.
- White LW. Efficacy of a sonic toothbrush in reducing plaque and gingivitis in adolescent patients. J Clin Orthod. 1996;30(2):85-90.
- Derks A, Katsaros C, Frencken JE, van’t Hof MA, Kuijpers-Jagtman AM. Caries-inhibiting effect of preventive measures during orthodontic treatment with fixed appliances. A systematic review. Caries Res. 2004;38(5):413-420.
- Ogaard B, Rølla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop. 1988;94(1):68-73.
- Ogaard B., Larsson , Henriksson T, Birkhed D, Bishara SE. Effects of combined application of antimicrobial and fluoride varnishes in orthodontic patients. Am J Orthod. 2001;120(1):28-35.
- Bishara SE, Ostby AW. White spot lesions: Formation, prevention and treatment. Semin Orthod. 2008;14(3):174-182.
- Ogaard B. White spot lesions during orthodontic treatment: mechanisms and fluoride preventive aspects. Semin Orthod. 2008;14(3):183-193.
- Erickson RL, Glasspoole EA. Model investigations of caries inhibition by fluoride-releasing dental materials. Adv Dent Res. 1995;9(3):315-323.
- Benson PE, Parkin N, Millett DT, Dyer FE, Vine S, Shah A. Fluorides for the prevention of white spots on teeth during fixed bracket treatment. Cochrane Database Syst Rev. 2004;3:CD003809.
- Benson PE, Shah AA, Millett DT, Dyer F, Parkin N, Vine RS. Fluorides, orthodontics and demineralization: a systematic review. J Orthod. 2005;32(2):102-114.
- Todd MA, et al. Effect of fluoride varnish on demineralization adjacent to orthodontic brackets. Am J Orthod. 1999;116(2):159-167.
- Schmit JL, Staley RN, Wefel JS, Kanellis M, Jakobsen JR, Keenan PJ. Effect of fluoride varnish on demineralization adjacent to brackets bonded with RMGI cement. Am J Orthod Dentofacial Orthop. 2002;122(2):125-134.
- Vivald-Rodrigues G, Demito CF, Bowman SJ, Ramos AL. The effectiveness of a fluoride varnish in preventing the development of white spot lesions. World J Orthod. 2006;7 (2):138-144.
- Staley RN. Effect of fluoride varnish on demineralization around orthodontic brackets. Semin Orthod. 2008;14(3):194-199.
- Soliman MM, Bishara SE, Wefel J, Heilman J, Warren JJ. Fluoride release rate from an orthodontic sealant and its clinical implications. Angle Orthod. 2006;76(2):282-288.
- Al-Musallam TA, Evans CA, Drummond JL, Matasa C, Wu CD. Antimicrobial properties of an orthodontic adhesive combined with cetylpyridinium chloride. Am J Orthod. 2006;129(2):245-251.
- Benham AA, Campbell PM, Buschang PH. Effectiveness of pit and fissure sealants in reducing white spot lesions during orthodontic treatment. A pilot study. Angle Orthod. 2009;79(2):338-345.
- Van Bebber L, Campbell PM, Honeyman AL, Spears R, Buschang PH. Does the amount of filler content in sealants used to prevent decalcification on smooth enamel surfaces really matter? Angle Orthod. 2011;81(1):134-140.
- Derks A, Kuijpers-Jagtman AM, Frencken JE, Van’t Hof MA, Katsaros C. Caries preventive measures used in orthodontic practices: an evidence-based decision? Am J Orthod. 2007;132(2):165-170.
- White, L.W. A new paradigm of motivation. in: McNamara JA Jr, Trotman CA, eds. Creating the Compliant Patient. Craniofacial Growth Series. Center for Human Growth and Development, University of Michigan, Ann Arbor, MI; 1997.