CHAPTER 20
Oral Hygiene: Possible Problems and Complications
“First, do no harm” is a fundamental guiding principle in medicine and dentistry. All too often orthodontists are confronted with having to consider this principle with a patient who develops poor oral hygiene partway through the orthodontic treatment. Clearly the placement of orthodontic brackets, wires, etc. creates a challenging environment for maintaining good oral hygiene. While there are measures that can be used to maintain or improve a patient’s hygiene, these may not always be effective for reasons most often related to patient compliance. If unaddressed, the accumulation of bacterial plaque associated with poor hygiene may lead to demineralization of enamel and the appearance of white spot lesions, an early sign of caries formation. In addition, the bacteria growing on the teeth and orthodontic appliance will cause inflammation of the gingival tissues, a process demonstrated by enlargement or overgrowth of interdental papillae and gingival margins. Although gingivitis is reversible in most individuals, there are situations in which patients are particularly prone to gingival overgrowth (e.g., caused by genetic variations in the response of gingival tissue or side effects of medications needed for systemic health). For these patients, resumption of good oral hygiene may be inadequate, making other procedures necessary to restore normal gingival architecture. Lastly, with increasing numbers of adults seeking orthodontic treatment, more patients will have had or will need periodontal treatment prior to orthodontics, and the orthodontist will be confronted with coordinating the timing of orthodontic treatment following periodontal therapy. The questions that follow relate to the areas briefly described above and should be useful for the appreciation of some aspects of the relationship between orthodontics and periodontology.
1 What are evidence-based recommendations regarding the most effective means of preventing white spot lesions in orthodontic patients?
Systematic reviews have concluded that toothpastes with fluoride concentrations of 1500 to 5000 ppm demonstrate greater preventive effects for white spot lesion formation than those with a concentration of 1000 ppm.< ?xml:namespace prefix = "mbp" />
2 Do mouth rinses impact gingivitis?
A number of oral rinses and dentifrices have been tested in clinical trials.
Side effects of chlorhexidine digluconate include tooth and tongue staining, increased calculus deposits, bitter taste, mouth and throat irritation, mouth sores (ulcers), coated tongue, and changes in taste of food and beverages.
If properly used, the addition of a topical antiplaque agent to a gingivitis treatment regimen for patients with deficient plaque control will likely result in the reduction of gingivitis.
3 Is oral hygiene better using a power toothbrush compared with a manual toothbrush?
Powered brushes have been defined as toothbrushes with a mechanical movement of the brush head. Powered brushes have been divided into six groups depending on their mode of action
Numerous clinical trials have compared manual and powered toothbrushes for their effectiveness in improving oral health, and the results are often conflicting.
The systematic reviews just described used studies of general populations and were not orthodontic specific.
4 Which oral prophylaxis technique is better for orthodontic patients: air-powder polishing system or rubber cup and pumice technique?
The conventional rubber cup prophylaxis (RCP) and the air powder polishing (APP) system (Prophy Jet) are both effective professional techniques for plaque and stain removal without detrimental effects on tooth structure and gingival tissues when used correctly.
5 Are there ways to prevent periodontal complications during orthodontic treatment?
The use of steel rather than elastic ligatures has been recommended on brackets, including tooth-colored (“esthetic”) brackets, because elastomeric rings have been shown to attract significantly more plaque than steel ligatures.
It is evident in adults with a reduced but healthy periodontium that orthodontic tooth movement can be performed without further periodontal deterioration.
6 When can orthodontic treatment be started on a patient who has been treated for periodontitis?
Following active periodontal treatment, patients in the maintenance phase of periodontal therapy should be observed for 4 to 6 months before initiating orthodontic treatment. This provides time for full expression of the benefits of the periodontal therapy and for monitoring of the patient’s oral hygiene and motivation.
7 Are patients who have been previously treated for periodontal disease more likely to lose periodontal attachment if they receive orthodontic treatment?
Tooth movement in adults with reduced but healthy periodontium does not result in further significant loss of attachment.