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Orthodontic-Related Decalcifications & Caries

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Orthodontic-Related Decalcifications & Caries

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Decay risk exists for all patients to varying degrees in occlusal pits and fissures, interproximal surfaces and facial surfaces. Orthodontic treatment increases the risk of decay for a variety of reasons. Oral hygiene is more difficult; wires are in place for two to three years or longer with little opportunity to obtain bitewing radiographs; excess resin around brackets acts as a plaque trap; patients sometimes believe that because they are being seen regularly at the orthodontic office, they don’t need to visit their regular dentist until treatment is completed.
Reprinted with permission of the Ontario Dental Association and Ontario Dentist, 2012.

Decay risk exists for all patients to varying degrees in occlusal pits and fissures, interproximal surfaces and facial surfaces. Orthodontic treatment increases the risk of decay for a variety of reasons. Oral hygiene is more difficult; wires are in place for two to three years or longer with little opportunity to obtain bitewing radiographs; excess resin around brackets acts as a plaque trap; patients sometimes believe that because they are being seen regularly at the orthodontic office, they don’t need to visit their regular dentist until treatment is completed.
Reprinted with permission of the Ontario Dental Association and Ontario Dentist, 2012.

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Orthodontic-Related Decalcifications & Caries

  1. 1. upfront Opinion Ian McConnachie DDS MS Orthodontic-Related Decalcifications and Caries: It’s Time for a Shift in Outcomes W e all have patients who pleted. Reports indicate that decalci- at-home use, with the support of the complete a comprehensive fication can start within the first orthodontic office. The communica- course of orthodontic care month after bracketing;1 on facial sur- tion must be ongoing and three-way. and look forward to enjoying the faces, it mostly occurs around and Preventive strategies depend on pleasure of a beautiful new smile. It gingival to the brackets.2 The devel- level of risk and fall into two general is deeply disturbing when our patient opment of decalcification and decay categories: diagnostic techniques and instead faces unsightly decalcifica- with these patients is a failure equally therapeutic interventions. All ortho- tions and decay. One such case is one of the orthodontic team, the primary dontic patients should have a com- too many. A leading orthodontic care team, and the family. Solutions prehensive oral examination, speaker, Dr. Gerry Samson, suggests to this problem equally lie with this including bitewing radiographs, com- the desired orthodontic outcome is same triad. pleted pre-treatment. During active good function, esthetics and stability. When orthodontic treatment is treatment with fixed appliances, up- When there is decalcification and scheduled to start, the primary care dated bitewings must be scheduled at decay, this is a failure to achieve the dental office and the orthodontic of- appropriate intervals; this may neces- esthetic outcome. This situation is to- fice should begin a collaboration and sitate co-ordination of visits such that tally preventable and I believe it is communication triad with the patient the orthodontist removes the wires so time to make the necessary adjust- to achieve the desired outcomes. bitewings can be taken then replaces ments in care to achieve that. Gone are the days when adolescent the wires after. A very interesting and Decay risk exists for all patients to patients received essentially the same promising complementary diagnostic varying degrees in occlusal pits and treatment and preventive measures in technique is the use of the Canary fissures, interproximal surfaces and fa- the dental office. We know now that System, a laser-based device that cial surfaces. Orthodontic treatment these interventions should be the re- quantifies levels of decalcification on increases the risk of decay for a vari- sult of a thorough risk assessment. all tooth surfaces, including inter- ety of reasons. Oral hygiene is more That risk assessment should be docu- proximal. Frequencies of diagnosis difficult; wires are in place for two to mented and shared with the patient should depend on the level of risk. three years or longer with little op- and the orthodontic office. If the or- Determining this risk requires ongo- portunity to obtain bitewing radi- thodontic office is unaware of the pa- ing monitoring of hygiene levels and ographs; excess resin around brackets tient’s risk level, it should either do its for evidence of decalcification at the acts as a plaque trap; patients some- own risk assessment or request one orthodontic office and, possibly, at times believe that because they are from the general dentist. Once risk the primary care provider as well, being seen regularly at the orthodon- level is established, the general den- with corresponding communication. tic office, they don’t need to visit their tist must create a comprehensive pre- Therapeutic interventions again be- regular dentist until treatment is com- ventive protocol for in-office and long with all three parts of the triad. 14 Ontario Dentist • May 2012
  2. 2. Opinion The home care program with measures such as high fluo- ride toothpaste or oral rinses, flossing and proxy-brushes must be reinforced by the parents. The primary care office must schedule appropriate office visits for fluoride varnish, oral hygiene reinforcement and, in the high-risk situation, consider using anti-microbials such as povidone iodine topically together with the fluoride varnish to dramatically Photo courtesy of Reliance Orthodontics lower Strep mutans counts.3 The orthodontic office should consider fully sealing the entire facial enamel surface, not just the surface under the bracket, at the time of bracket placement. This should be done with a specially designed fluoride-releasing sealant material such as Reliance’s Pro Seal and Opal Orthodontic’s Opalseal. The retention status of these materials should be monitored and the sealant re- applied as necessary. What is briefly described here is a strategy to prevent what is now a serious problem. For its success, the strategy Enamel decalcification in a teen-aged orthodontic patient. depends on commitment to current evidence-based diag- nosis and treatment planning and effective three-way com- munication and collaboration. If the primary care provider and the orthodontic provider are unsure that this can be achieved and maintained, then there needs to be serious References discussion as to whether or not the orthodontic treatment 1. Ogaard B. et al.Orthodontic appliances and enamel dem- should even be started. We all are seeking successful out- ineralization Part 1: Lesion development, AJODO 1988 Aug; comes of function, esthetics and stability for our patients. 94(2) 113-128 Twenty-first century oral health care demands no less. 2. Robertson M.A. et al .MI Paste Plus to prevent demineraliza- tion in orthodontic patients: A prospective randomized controlled trial AJODO 2011 140(5): 660-668 Dr. Ian McConnachie is an ODA Past-President and a member 3. Milgrom P., Tut O.K., Mancl L.A. Topical Iodine and Fluoride of the Ontario Dentist Editorial Board. He is a pediatric Varnish Effectiveness in the Primary Dentition: A Quasi- dentist based in Ottawa. Dr. McConnachie may be contacted at Experimental Study. J Dent Child (Dec 2011) ian.mcconnachie@bellnet.ca. May 2012 • Ontario Dentist 15

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