Orthodontic preventive care
Johnson & Johnson Ltd. is delighted to bring you this article, with the aim of supporting the ongoing Enhanced CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.
This article is equivalent to one hour of Enhanced CPD.
To provide feedback on this article, please contact [email protected]
Learning Outcomes: A | C
Aims and objectives
The aim of this article is to explore the oral health implications of orthodontic treatment and the kind of preventive care between appointments that may help orthodontic patients control plaque biofilm.
On completing this Enhanced CPD session, the reader will:
- Understand the popularity of orthodontic treatment in the UK
- Understand how common it is for orthodontic patients to experience some alteration in biofilm accumulation following the bonding of orthodontic appliances
- Understand the risks where proper mechanical biofilm control is not performed effectively by the orthodontic patient
- Understand what actions may help minimise and manage potential hazards that can occur during orthodontic treatment.
This article explores the oral health implications of orthodontic treatment and the kind of preventive care between appointments that may help orthodontic patients control plaque biofilm.
According to the British Orthodontic Society (BOS), around 200,000 children and teenagers in England and Wales have treatment within the NHS every year1 with growing numbers of adults and young people seeking treatment on a private basis.2
‘Zoom Boom’ stats from the BOS offer further insight, with 84% of orthodontists reporting an increase in adult patients. This survey, conducted in 2021, also indicated that 60% of orthodontists who responded have seen a larger than expected demand for treatment in the last 12 months, due to rising patient expectations and social factors (55%) and heightened awareness of adult orthodontics (65%).2
Orthodontic treatment cannot be carried out in isolation; there is no doubt that achieving and then maintaining oral health during the process is essential for long-term success and must be communicated to patients.3
Biofilm and braces
As stated by Bergamo et al (2019): ‘… 60% of all orthodontic patients experience some alteration in biofilm accumulation after the bonding of orthodontic appliances.’4
They continued: ‘Studies investigating microbial contamination during orthodontic treatment have evaluated the species that are related to dental caries or periodontal disease.’4
Adding to this, Haas et al (2014) wrote: ‘High gingivitis prevalence is commonly found in orthodontic patients. The presence of brackets, bands and other accessories, as well as composite resin restorations and cements used to bond them, facilitate biofilm build up and hinder its removal by patients, favouring enamel demineralisation and gingivitis, and promoting quantitative and qualitative changes in the oral microbiota. Several studies have shown an association between placement of braces and an increase in biofilm.’5
Looking to add to the evidence base, Bergamo and colleagues (2019) aimed, ‘To assess periodontal parameters and microbial species levels after orthodontic appliance placement in patients who received oral hygiene instructions and who were monitored and motivated throughout the study.’4
They concluded that: ‘A dynamic change in microbial levels was found. The decrease in the levels of complexes present was only possible because of the mechanical method of oral hygiene implemented in this sample.’4
What then might good oral hygiene between appointments look like for the orthodontic patient?
According to Haas and colleagues (2014), ‘Properly performed daily mechanical biofilm control is the most important prevention strategy for periodontal diseases. However, proper mechanical biofilm control is not performed effectively by the majority of the population, mainly due to lack of motivation and of manual dexterity. Local biofilm retention factors may aggravate home oral hygiene quality.’5
This challenge also led Walsh and Healey (2019) to consider, ‘…practical ways to lower the risk of hard tissue loss from dental caries during orthodontic treatment’.6
After all, ‘When undertaking oral hygiene education for the orthodontic patient, the question arises as to what aids in addition to manual tooth brushing need to be used for the particular patient. Using manual tooth brushing alone is unlikely to be effective in the vast majority of patients, if the goal is effective plaque control.’6
Offering a possible solution to this problem, Walsh and Healey (2019) wrote: ‘A powered brush provides important benefits over a manual toothbrush, but even more so when special orthodontic heads are used, since the bristle patterns and bristle materials have been optimised for use around orthodontic appliances. If a powered brush is recommended, an appropriate dedicated orthodontic brush head should be used, since these have been found to outperform regular brush heads.’6
Also looking to overcome the limitations of mechanical cleaning, Haas et al (2014) conducted a systematic search in the literature on antiseptics used to control supragingival biofilm and gingivitis in orthodontic patients.5
They were able to demonstrate: ‘Current evidence shows that when chemical agents are used as adjuvants to brushing and flossing, they can promote additional advantages compared to mechanical control alone, as regards […] plaque […] reduction.’5
However, it remains important to note, as stated by Walsh and Healey (2019), that, ‘…individual recognisance with brushing still remains the single biggest factor in maintaining the necessary quality of oral hygiene during treatment.6
Narayanan and colleagues (2021) wrote: ‘Advocating measures of meticulous oral hygiene and dietary advice is essential in all phases of treatment – before, during and after orthodontic treatment.’7
Furthermore, as stated by the BOS, ‘A good balanced, healthy diet and excellent oral hygiene are very important during orthodontic treatment to maintain strong and healthy teeth.’3
To that end, patient-friendly advice to be shared with someone undergoing orthodontic treatment may include:8,9
- Brushing the teeth for two minutes with a fluoride toothpaste at least twice daily, as well as in-between those times to clean food deposits after meals
- Use a small interdental brush or floss designed for brace wearers to help remove plaque from between the teeth
- Use an alcohol-free fluoride mouthrinse once a day
- Chew a disclosing tablet from time to time, to show the areas of the mouth that may need extra attention
- Avoid sugary snacks and sweet drinks between meals and before bed
- Avoid hard, sticky and chewy food that might damage brace brackets.
The cornerstone of success
Offering succinct overview of the situation, Narayanan and colleagues (2021) concluded: ‘Good oral hygiene and motivation are the cornerstones of successful orthodontic treatment outcomes, especially in complex cases which tend to benefit more from fixed orthodontic treatment. This starts with the correct assessment from the patient’s dentist and a discussion with the patient about their responsibilities and duties during orthodontic treatment.’7
They continued: ‘Expectations should be managed and operators should always work within their competencies. Good case selection, sound clinical judgement and more importantly, the patient’s understanding of the risks involved and the treatment implications, help minimise and manage potential hazards that occur during the course of the treatment.’7
1. https://www.bos.org.uk/BOS-Homepage/Orthodontics-for-Children-Teens/Why-Orthodontics. Accessed 1 March 2022
2. ‘The Zoom Boom’ BOS stats reveal a surge in demand for orthodontics during the pandemic. BOS 2021; https://www.bos.org.uk/news-and-events/news. Accessed 1 March 2022
3. Patient information leaflet. Teeth and brace-friendly food and drink. BOS 2019
4. Bergamo AZN et al. Orthodontic appliances did not increase risk of dental caries and periodontal disease under preventive protocol. Angle Orthod 2019; 89(1): DOI: 10.2319/022118-139.1
5. Haas AN et al. Mouthwashes for the control of supragingival biofilm and gingivitis in
orthodontic patients: evidence-based recommendations for clinicians. Braz Oral Res 2014; 28(Spec Iss 1): 1-8
6. Walsh LJ, Healey DL. Prevention and caries risk management in teenage and orthodontic patients. Australian Dental Journal 2019; 64:(1 Suppl): S37–S45
7. Narayanan P et al. Role of the general dental practitioner in managing the risks of orthodontic treatment. BDJ 2021; 231(11): 682-688
8. Patient information leaflet. Fixed appliances. BOS 2019
9. The BOS Guide. Better teeth for life. https://www.bos.org.uk/Portals/0/Public/docs/General%20Guidance/Final%20version%20of%20Better%20teeth%20for%20life.pdf