1. UNIVERSITY OF GLASGOW
Oral Health & Orthodontics
Personal notes
Mohammed Almuzian
5/2/2013
A decision to undertake orthodontic treatment is based on Best functional, Best
aesthetic Optimal oral health needs. The benefits of treatment must outweigh
the risks.

2. List of Contents
Definition .................................................................................................... 2
Relevant of oral health to orthodontics.......................................................... 2
Signs & symptoms related to poor oral health................................................ 2
Assessment of oral health ............................................................................. 3
1. History..................................................................................................... 3
2. Pre-treatment Assessment......................................................................... 3
A.Caries detection and caries risk ................................................................. 3
1. Definition ................................................................................................ 3
2. Stages of detection of dental caries............................................................ 3
3. Caries risk................................................................................................ 4
B.Periodontal Examination........................................................................... 4
1. Basic Periodontal Examination (BPE) ....................................................... 5
2. Plaque assessment .................................................................................... 6
3. Bleeding .................................................................................................. 7
4. Labial gingivae ........................................................................................ 7
C.Smoking cessation.................................................................................... 8
3. During orthodontic treatment Assessment ................................................. 9
1. Ulceration................................................................................................ 9
2. Oral hygiene ............................................................................................ 9
3. Dietary counselling .................................................................................. 9
4. Fluoride................................................................................................. 10

3. Oral Health & Orthodontics
Definition
The absenceof any pathology relating to
• The teeth
• Their supporting structures
• The softtissues of the mouth.
Relevantof oral health to orthodontics
A decision to undertake orthodontic treatment is based on
• Best functional,
• Best aesthetic
• Optimal oral health needs.
The benefits of treatment must outweigh the risks.
Signs & symptoms related to poor oral health
(Determined clinically and radiographically)
1. Gingival inflammation
2. Periodontal pocketing
3. Caries & decalcification
4. Crown fractures - in heavily restored teeth? Due to trauma or extensive
restoration?
5. Rootpathology
6. Soft tissue pathology e.g ulceration, signs indicating systemic disease
7. Ectopic and impacted teeth

4. 8. Asymmetry due to premature teeth loss.
Assessment oforal health
1. History
It should involve:
 Oral hygiene regime
 Dietary habits
 History of trauma to any teeth
2. Pre-treatment
A. Caries detectionand caries risk
Definition
Caries is a chronic infectious disease involving a series of complex chemical
and microbiological processesinvolving the dental biofilm that result in the
destruction of tooth tissue.
Stagesofdetectionof dental cariesby Pitts and Fyffe(1988),
I. Grade 0
 Sound surface
 No evidence of treated or untreated clinical caries.
 Slight staining may be present in an otherwise sound fissure
II. Grade D1
 Initial caries
 No clinically detectable loss of tooth substance.
 Staining, discoloration or rough spots in fissure that do not catch probemay be
present.
 There may be loss of lustre and white opaque patches on smooth surfaces
III. Grade D2

5.  Enamel caries
 Demonstrable loss of tooth substance in pits, fissures and smoothsurfaces but
no softened floor, walls or undermined enamel.
 The texture of the material in the cavity may be chalky and white but there is no
evidence that the cavitation has penetratedinto dentine
IV. Grade D3
 Dentine caries
 Detectable softened floor, wall or undermined enamel.
 Temporary dressing may be present.
 A proximal lesions detectable with probe
V. Grade D4
 Pulpal involvement
 Deep cavity with probable pulp involvement.
 Usually included in D3 category
Cariesrisk
 Li and Wang (2002) attempted to predict caries in the permanent teeth from
studying caries in the deciduous dentition through an eight-year cohortstudy.
Of children who developed caries in permanent teeth, 94% experienced caries in
the primary teeth and of children who did not have caries in their primary teeth,
83% remained caries free by the age of 12.
 If a child had caries in the primary teeth, they were 3 times more likely to
develop caries in the permanent teeth.
B. PeriodontalExamination
It should be remembered that the following groups of patients are at higher risk
of periodontal disease:
• Patients with poororal hygiene
• Patients with a previous history of periodontal disease
• Diabetics

6. • Smokers
• Patients with osteoporosis
• The immune-compromised or immunosuppressed
BasicPeriodontal Examination(BPE)
• The periodontal probe should have a ball end of 0.5 mm diameter and a
coloured band from 3.5 mm to 5.5 mm.
• The total extent of the crevice should be explored by “walking” the probe
around the crevice.
• At least six areas in each tooth should be examined: mesiofacial, midfacial,
distofacial, and the corresponding lingual and palatal areas.
• The mouth is examined in sextants; the division between sextants is between the
first premolar and canine.
• For each sextant with one or more teeth or implants, only the highest scoreis
recorded. An X is recorded if the sextant is edentulous.
• The CPITNincludes:
A. Code0
 No bleeding or pocketing detected
 No treatment required
B. Code1
 Bleeding on probing;
 no pockets >3.5 mm
 OHI and prophylaxis
C. Code2
 Plaque retentive factors present (includes calculus);
 No pockets > 3.5 mm.
 OHI; removal of calculus and plaque retentive margins on restorations
D. Code3
 Pockets > 3.5 mm and < 5.5 mm in depth

7.  Treatment involves OHI, prophylaxis, removal of plaque retentive factors and
root planning
 Plaque and bleeding scores should be collected at the start and end of treatment
and to monitor treatment progress
E. Code4
 Pockets > 5.5 mm in depth
 Detailed charting involving plaque and bleeding scores, loss of attachment
(pockets, gingival recession and furcation involvement).
 Treatment involves OHI, prophylaxis, removal of plaque retentive factors and
root planning and periodontal surgery.
F. Code*
Added to sextant scorewhen clinical abnormalities are present such as furcation
involvement, mobility, mucogingival problems or recession > 3.5 mm a
comprehensive periodontal examination and charting is normally necessary to
determine an appropriate treatment plan.
Plaqueassessment
• The presence of visible plaque or debris pretreatment is an indication that the
patient’s oral hygiene requires improvement before starting active orthodontic
treatment.
• A simple plaque index is therefore all that is required at the screening
appointment. Each tooth in a sextant is examined and scored using the soft
debris and calculus scores ofGreene and Vermilion (1964). The worst scorein a
sextant is recorded. Foractive orthodontic treatment, scores should be mainly
zeros with perhaps the occasionally scoreof .
A more complex index such as the Simplified Oral Hygiene Index (OHI-S) of
Greene and Vermilion (1964) may sometimes be helpful to demonstrate a
baseline position and subsequent improvement in oral hygiene in the light of

8. treatment. This involves calculating the Debris Index (DI-S) and the Calculus
Index (CI-S) and adding them together to producethe OHI-S.
For Debris:
• 0 = no debris
• 1= debris covering up to 1/3 of the crown
• 2 = debris covering between 1/3 and 2/3 of the crown
• 3 = debris covering > 2/3 of the crown
For calculus:
• 0 = no calculus
• 1= calculus covering up to 1/3 of the crown
• 2 = calculus covering between 1/3 and 2/3 of the crown
• 3 = calculus covering > 2/3 of the crown
Each score(DI-S and CI-S) is calculated by dividing the scored deposits by the
number of tooth surfaces scored and the two scores added together. Scores are
graded as follows:
 excellent= 0
 good= 0.1 to 0.6
 fair = 0.7 to 1.8
 poor = 1.9 to 3.0
Bleeding
• The Gingival Bleeding Index of Ainamo and Bay (1975) is simple and only
requires the noting of the presence or absenceof bleeding.
• Each tooth has four points of measurement: facial, mesioproximal, lingual and
distoproximal.
Labial gingivae
• Allais and Melsen (2003). This investigated whether labial movement of the
lower incisors influenced the level of the gingival margin by creating recession.
This study investigated 150 patients with a mean age of 33 years who had a
mean increase in arch length of 3.4 mm during treatment. This study came

9. about because of the lack of difference in long-term stability in published
studies of on extraction and extraction treatment. The average difference in
recession between the treatment group and the untreated control group was 0.14
mm (0.36 mm- 0.22 mm). The authors concluded that although the difference in
recession was statistically significant, it was not clinically significant and that
therefore controlled increase in arch length could be successfully achieved
without significant risk of recession in the presence of good oral hygiene,
enough gingival biofilm and Symphysis. In fact, new recession occurred in 10%
of patients and the risk factors for this need to clarify.
• In 2005, the same two authors (Melsen and Allais), carried out a study to try
and identify factors of importance in the development of labial dehiscences. In a
study of 150 adult patients pre- and posttreatment, they concluded that gingival
recession did not increase during orthodontic treatment and that in 5% of cases,
recession improved. Risk factors for the development of dehiscences were thin
gingival biotype, visible plaque and the presence of inflammation.
C. Smoking cessation
Given the effects of smoking on general health and on the periodontium and
oral mucosain particular, it is sensible for the orthodontist to strongly support
smoking cessation. Indeed, Options for Change suggests that smoking cessation
should be part of the oral health assessment.
The four A’s model is helpful:
• asking about smoking and the desire to stop
• advising of the value of stopping
• assisting the patient to stop through appropriate support
• arranging follow-up support

10. 3. During orthodontic treatment
1. Ulceration
• Most patients will have some oral ulceration immediately after fitting the
appliance. If the ulceration appears excessive or abnormal, then it is certainly
worthwhile screening patients for haematinic deficiencies (FBC, plasma ferritin,
red cell or whole blood folate and serum vitamin B12).
• Typically 20 - 30% of patients will have an underlying deficiency state which is
a significant predisposing factor. If these tests are all within normal limits then
the options are symptomatic treatment such as chlorhexidine or Difflam and of
courseto minimise any further trauma.
2. Oral hygiene
• Monitoring oral hygiene during orthodontic treatment is important but difficult.
The conditions in the mouth have changed and conventional plaque indices are
not appropriate.
• The most difficult area to clean has shifted from the cervical margin to the area
under the archwire.
• However there is some complicated index like Jackson index for this purpose
but it is complicated.
• OH measure including mechanical and pharmaceutical are important.
3. Dietary counselling
The bestadvice for reducing caries risk in orthodontic patients is to:
1. Avoid sugar containing and acidic foods closeto bedtime
2. To reduce amount of sugar and acidic containing food and drinks
3. To limit the consumption of sugar containing and acidic food and drinks to
mealtimes only
4. Encourage consumption of foods that do not cause, or are known to protect
against, dental decay and erosion such as staple starchy foods (bread, potatoes,

11. pasta and rice), fresh fruit and vegetables and milk and water rather than soft
drinks and fruit juices
5. Advice patients to read manufacturers' labels and follow the instructions for the
dilution of squashes
4. Fluoride
• Fluoride for orthodontic patients is locally or topically applied. Fluoride mouth
rinses are often prescribed to patients undergoing orthodontic treatment and are
usually daily use of 0.025% -0.05% sodium fluoride or weekly fluoride rinse of
0.2% is also available.
• However, the patients most in need of fluoride rinses tend to be the worst
compliers.
• Cochrane review by Benson in 2008 show the effectiveness of daily use of
0.05% fluoride but other method difficult to assess and need more detailed
study.