Article! Dipak, Freeland1Periodontics in OrthodonticsJanuary 26, 2013 Introduction: The ﬁeld of dentistry has seen signiﬁcant advances in recent years andorthodontics is no exception. But the issue of oral hygiene in orthodonticshas remained a perplexing problem. Patients seek orthodontic treatment mostly for esthetics issue even ifthey have functional occlusal problems. The orthodontist and parent or pa-tient invests time, material, expense and expertise to achieve beautifulsmiles. When the day for appliance removal is ﬁnally reached, everyonefrom patients, families, and the treating orthodontist and staff are excited.However, this euphoria is short lived when noticeable decalciﬁcation, in theform of white/brown spots, resulting from poor oral hygiene during treat-ment ruin the esthetic value of the case. (Figure 1) Figure 1 Decalciﬁcation and gingival infection post treatment
Article! Dipak, Freeland2 Patients ﬁnd it difﬁcult to brush and ﬂoss around orthodontic appliances.This leads to a reduction in oral hygiene that results in an increased risk fordeveloping decalciﬁcation, decay and gingival infections. The severity ofthe resultant dental caries can range from development of opaque white-spot lesions (WSL) to the lose of surface integrity of enamel, cavitation andoral caries and periodontal bone loss. As a profession, we need to focus onpreventive measures and practices to improve oral hygiene and minimizeadverse sequel to the teeth and periodontium. Orthodontists should be aware of the high risk of WSL and decide at thepatient level whether it is appropriate to start or continue treatment in pa-tients who are already experiencing enamel demineralization and con-tinueal gingival inﬂammation. The risk of developing incipient caries andgingival lesions during orthodontic treatment should not be underestimatedby orthodontists. Research indicates that 49.6% of orthodontic patients exhibit enamelopacities on at least one tooth after orthodontic treatment. There is a sig-niﬁcant risk that 1 in every 10 bonded teeth is likely to have post-treatmentwhite spots with the incidence in banded teeth being slightly more at 1 in 9
Article! Dipak, Freeland3teeth. A signiﬁcant increase in incidence, prevalence and severity ofenamel opacities following orthodontic treatment has also been reported inthe same study. 1 A number of factors are responsible and the authors have attempted tohighlight a few and discuss them. Factor One: Pretreatment patient assessment At the initial exam the doctor should perform a complete periodontalexam that assess the health of the periodontium and the patients oral hy-giene. If the oral exam shows plaque accumulation and gingival bleedingthen this patient should not be considered for orthodontic treatment untilthe gingival tissues are completely healthy. Figure 2 Figure 2: An example of poor oral hygiene pretreatment. This type of patient should not be treated until the gingi- val problems are rectiﬁed.
Article! Dipak, Freeland4 Factor Two: How to identify oral hygiene problem patients With the tooth brush the doctor places the bristles into the sulcus area inthe anterior and posterior areas. If bleeding occurs then there is a hygieneproblem. (Figure 3) Figure 3: A toothbrush is used in place of a periodontal probe. This way the parent/patient can not ac- cuse the practitioner of cutting the gums. Factor Three: How to improve patients oral hygiene. At this time a preventive dental program should be introduced. If the pa-tient still shows gingival bleeding after the program then he/she should notbe placed in orthodontic treatment. This program should be designed to
Article! Dipak, Freeland5enhance the diagnosis so the Doctor and patient can discover the oral hy-giene problems together. The preventive program has ﬁve parts. The ﬁrst two appointments are 1week apart and the proper techniques for oral hygiene are taught and re-viewed. The next three appointments should show complete gingival healthover a 3 months period. If this is not the case then orthodontic treatmentshould be withheld from this individual. It is the responsibility of the ortho-dontist to withhold treatment because if the patient will not take of the teethand gums before treatment there oral hygiene will not improve duringtreatment. 2 A close relationship with the referring dentist and his hygiene staff willfacilitate the efforts of the orthodontist. Making sure the patient sees thedentist/hygienist more often may help reinforce the orthodontist efforts toobtain a disease free mouth.
Article! Dipak, Freeland6 Factor four: Oral hygiene problems during appliance therapy (Fig 5) Figure 5: The appliance system does increase the oral hygiene problems. Once treatment begins the orthodontist is responsible for proper instruc-tion on how to managed the hygiene issues created by the appliances.The proper use of the brush and ﬂoss should be demonstrated by the doc-tor. If the doctor spends the time it will impresses on the parent/patient theimportance of oral hygiene. 3 (Figure 6,7) Figure 6: Flossing should be demonstrated. Espe- cially how the patient gets the ﬂoss into the sulcus.
Article! Dipak, Freeland7 Figure 7: Brushing needs to be taught. The demonstration should include how to get the bristles into the sulcus. The doctor should create an appliance environment that enhances thepatients ability to care for the gingiva and enamel. All ﬂash from bondingand banding should be removed. The use of sealants, such as Proseal, aspart of the bonding procedure should be instituted. The bonding systemshould contain ﬂuoride. The use of mechanics systems and retention sys-tems that make it difﬁcult to clean should be avoided. In the light of the pa-tients past oral hygiene issues during appliance therapy, bonded retainers,should be avoided. As bonded retainers are placed “invisibly on the lingualtooth surfaces, patients’ acceptance is evident. This practice may lead tothe development of carious lesions, favor the formation of plaque and cal-culus around the mandibular retainers, compared to the maxilla.7
Article! Dipak, Freeland8 Zacchrisson, 4 one of the pioneers in the ﬁeld of bonded lingual retain-ers, stressed the importance of daily interproximal cleaning with dentalﬂoss. Despite optimal oral hygiene instructions, calculus formed to agreater extent on the lingual surfaces of the incisors with bonded retainers,compared with incisors without bonded retainers. 7 The patient is responsible for the care of the teeth and gingival tissues.if all efforts have failed and the oral hygiene does not improve then the or-thodontist should consider terminating treatment. Even if it is unilateral de-cision on the orthodontist part: Jerrold 6 explains that the doctor-patient relationship is bilateral andconsensually based. He further elaborates that once in existence, this rela-tionship can be dissolved in 5 ways: (1) both parties agree to end it (acommon example is when the patient is relocating: (2) The patient’s condi-tion is cured, and no further treatment is required: (3) the doctor or patientdies: (4) the patient decides to unilaterally terminate the relationship; or (5),the doctor decides to unilaterally terminate the relationship. Jerrold further elaborates by suggesting that the doctor can unilaterallyterminate the relationship if the patient breaches at least 1 of the 5 dutiesowed to the practitioner under the contract that comprises the doctor-
Article! Dipak, Freeland9patient relationship: (1) the patient is not following the doctor’s instructionsregarding treatment and thus is jeopardizing his own treatment; (2) the pa-tient is not keeping appointments, thus causing interruptions in the continu-ity of care, not to mention the interference with the business aspect of thedoctor’s practice: (3) the patient is not being truthful or forthcoming regard-ing necessary administrative inquires(e.g. his medical history, informationabout those ﬁnancially responsible for his care, his degree of cooperation,signs and symptoms of problems, and so on); (4) the patient is not con-forming to accepted modes of behavior (he is belligerent or abusive to thedoctor or his staff,m or is crating a hostile or unhealthy environment in theofﬁce; and (5) the patient is not paying for services rendered. 6 (Figure 8) Figure 8: A case where the patient would not follow oral hygiene program so treatment was dis- continued. In all fairness to the patient, some patients will exhibit gingival swelling inresponse to the appliances during treatment. It begins within a couple of
Article! Dipak, Freeland10months after placement of the appliances. Fixed appliances predisposeplaque accumulation and colonization of bacteria. When gingival tissuesare enlarged, the tooth surfaces/bracket tooth interface become difﬁcult toaccess, inhibiting good oral hygiene and resulting in an increase in inﬂam-mation and bleeding. The interruption of orthodontic treatment is often ad-vised when gingival enlargement is diagnosed. The temporary removal ofthe irritating factors such as attachments and appliances, debridement,chlorhexidine prophylaxis, and in some patients, surgical intervention as asﬂap/laser surgery, to restore the contour of the enlarged gingival tissues,can facilitate adequate oral hygiene during subsequent orthodontic treat-ment. 4 Conclusion: The beneﬁts to the practice are enhanced in many ways by having allpatients gingiva disease free while under the orthodontic care. Increasedpatient referrals will occur because their cases are ﬁnished on time with abeautiful smile that is enhanced by healthy gingival tissues and teeth freeof decalciﬁcation. 5 Increased referrals from the dental profession will occurwhen their patients are being well taken care of while in the orthodontist
Article! Dipak, Freeland11practice. A study on marketing forces failed to discern or ascertain thedegree/depth of the emotional connection created between the orthodontistand patient. 5 This doctor patient relationship is the most important aspectin ﬁnishing cases with healthy gingival tissues and free of decalciﬁcation. The patient/parent will differentiate services offered by different prac-tices. They will choose the practice that develops the bonds necessary tocreate the healthy oral environment. This will enhance the patient satisfac-tion at the end of treatment. Even if the cases are walk-in/google/patientsreferral cases, because we will be judged by the general dentists at the oralhygiene appointments. Other beneﬁts to the practice are on time ﬁnishes. A healthy oral envi-ronment always ﬁnish on time. The esthetic value is always present so atpost treatment consultations the parents/patients are most willing to refertheir friends to your practice. The time spent trying to improve oral health isone of the best practice building technique. Better then all the marketingtechniques combined. (Figure 9)
Article! Dipak, Freeland12 Figure 9: Completed case where the patient followed the oral hygiene pro- tocol. Not only did she ﬁnish ahead of time she ﬁnished with a great smile. References: 1. Gorelick 2. Barkley RF. Successful Preventive Dental Practice Amazon 3. Yeung 4. Zachrison 5. Beckwith 6. Jerrold 7. Orsborn Authors: Dr Dipak Dr Ted Freeland DDS, MS Past adjunct professor University of De-troit orthodontic department. Twice Board certiﬁed, DirectorAdvanced Education in Orthodontics. Private Practice.