I recently read a description of a research project that was an obvious disappointment to the people involved. It was a simple and well-motivated affair; the researchers wanted to relate excessive adhesive flash to white spot lesions (WSLs). In the end, the project produced negative findings: ie, the amount of flash was not related to WSLs. On the other hand, it is somewhat good to learn that excessive flash (which was well documented) was not related to WSLs. Although this type of result does not really provide much insight and is probably not publishable, a by-product of the project was that it nicely documented a disquieting finding—that 62% of the sample had at least 1 WSL involving the maxillary canines and incisors; more disturbing was that an average of 3.9 lesions were found per patient involving those 6 teeth. Now that is a problem.

In the good old days, particularly in the 1970s, the plan for dealing with decalcification was to adopt a strategy based on offense. Expecting that oral hygiene would be problem, many authors published protocols indicating that their approach was to be aggressive with regard to oral hygiene practices. The armamentarium included toothbrushes, dental floss, interdental brushes, disclosing agents, toothpicks, water irrigators, and chemical cleaning agents (eg, urea peroxide and chlorhexidine). Most of the published reports stated that educating and motivating patients was of upmost importance, so that oral hygiene could be brought under control before treatment started. If it was not, treatment was delayed or not initiated. If treatment had begun and oral hygiene became inadequate, early debanding was most likely. Of course, that was a different time; practices were relatively small (perhaps fewer than 100 patient starts per year), bands needed to be carefully placed (leading to the old adage that “a well-cemented band actually protects the tooth”), the doctor had the time and inclination to personally provide oral hygiene instructions, and the options available to deal with any decalcification were rather limited. The “scars of treatment” were more or less permanent. Of course, even though the problem was mainly due to patient negligence, such negative outcomes were not great practice builders and did not engender the admiration of referring dentists.

Over time, the strategy for dealing with poor oral hygiene in orthodontics has shifted toward a defensive posture. In fact, many new forms of orthodontic treatment now embrace the notion that they will be successful because they do not rely on or require patient compliance. Great efficiencies have thus emerged. Practices are larger (perhaps hundreds of patient starts per year), direct bonded brackets are easier to apply, and they are smaller and can enable better oral hygiene practices, and the options for dealing with decalcification (now called as WSLs) are now many.

Although it is an admitted cynical generalization, it appears that the contemporary goal of many orthodontic practices is to get the appliances on as rapidly as possible, and then the practitioner will deal with the effect of poor oral hygiene during treatment by applying some sort of coating on the teeth as needed to slow the decalcification process or create a physical barrier. Or, after treatment, attempts will be made to remineralize the enamel or hide the defects by bleaching. This shift—from being aggressive with oral hygiene practices (offensive) to being reactive (defensive)—may be expedient, but it does not always serve the best interests of the patient and the practice.

In the good old days, the stated goal was to give patients comprehensive oral hygiene instructions and then motivate them to maintain good oral health throughout treatment and during their entire life. Orthodontists were considered to be in an excellent position to initiate, follow up, and reinforce the learning process. Encouraging patient cooperation was also important in terms of other aspects of orthodontic treatment (eg, wearing headgears and elastics). Getting patients to do things that most normal people would never choose to do on their own was considered an important skill to be learned and then put into practice.

If this argument is to be applied to contemporary practice, hygiene problems should not be dismissed as a matter of patient, parent, or family dentist responsibility. Moreover, the release of responsibility via informed consent should not necessarily be a goal. In reality, every orthodontist and staff member should be involved in the assessment, instruction, motivation, checking, ongoing education, and other aspects of oral home care before, during, and after orthodontic treatment. The opportunity is there to help patients maintain good oral health throughout life. To be fair, the central problem is not really the practitioner but, rather, a lack of education and parental guidance. Still, the practitioner can make a significant difference, unless the issue is ignored.

This need is particularly acute if the patients come from disadvantaged backgrounds. Those so affected are more prone to having an improper diet (high-sugar drinks and foods) and lack basic oral hygiene information. We can put all the coatings on the teeth that we think will help, but it won’t make any real difference in the end if diet and home care are not improved.

So what is it to be when it comes to oral hygiene? Offense or defense? Embrace the practices of the good old days or those of today? The simple answer is “both” to both questions. Take what is good and what works and use it. Furthermore, since the incidence of WSLs is estimated to range from 30% to 70% during orthodontic treatment, it appears that there are approaches to this issue that need improvement as well as protocols that could be modeled for success.

So what is your protocol for oral hygiene? Do you have one? Do you need one? Curiously, the American Association of Orthodontists Clinical Practice Guidelines are silent on this issue, even though every orthodontist must deal with the problem of poor oral hygiene. Fortunately, there are examples of protocols in the literature that are based on the best evidence available. As an example, the protocol developed by Heymann and Grauer in 2013 seems suitable for the contemporary practice of orthodontics because it borrows from the past and recognizes the technology of the present. At the very least, slow down and think about the issue, because it affects your patients and your practice… and the satisfaction that you derive as an orthodontist.

The doctor must be able to tell the antecedents, know the present, and foretell the future—must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm. The art consists in three things—the disease, the patient, and the doctor. The doctor is the servant of the art, and the patient must combat the disease along with the doctor.