Let’s talk Oral Health – Orthodontics and Home Based Oral Care

June 30, 2022

We are back with a digest of the latest episode in our Let’s talk Oral Health webinar series for oral care professionals. Each month, we explore another dental specialty, discussing patient demands, challenges, and opportunities related to home based oral care. After our first episode, dedicated to periodontology, we continued our series on the 5^th of May with an episode on orthodontics. Continue reading below to find out what the two experts, Prof. Dr. Maria Cadenas and Ms. Alina Fintineanu, had to say.

How to clean and care for your orthodontic appliances

Starting with the first type of orthodontic appliances, clear aligners, Ms. Fintineanu points out why it is so important first to keep your teeth clean while wearing them: “The problem is that your patients are at a slightly increased risk of developing caries while they’re undergoing clear aligner treatment. And this may sound like a surprise to them, but if you look at the aligner, you see how much of the tooth is covered by it, particularly all those occlusal and interproximal surfaces. That means tongue movement isn’t really cleaning around there, and saliva, with its buffering effect, cannot reach those surfaces. So, bacteria and food debris stuck there are basically going to ferment”. She continues with some practical tips on how to properly clean the aligners:

• Watch for food debris/plaque buildup in the cusp tips of the aligners and along incisal edges; brush carefully in these spots to prevent demineralization
• Brush and clean interdentally after every meal before replacing aligners, to ensure all food, sugar and harmful bacteria is removed
• NEVER soak in mouthwash or bleach, use only cold or lukewarm water to rinse or clean them; hot water will distort the aligner. You can soak them in denture cleaner or cleaning crystals if provided. Brush with a manual toothbrush and dish soap, some toothbrushes can be too abrasive and cause scratches and a dull sheen which makes them more visible. Rinse thoroughly
• At night, brush your teeth with fluoridated toothpaste, do not rinse, then place aligners on top for nighttime
• Rinse with fluoride mouthwash and place aligners on top

Prof. Cadenas continues with tips about how to care for fixed appliances, discussing fixed appliances, fixed lingual appliances and fixed expanders:

Fixed appliances:

• Be thorough but careful to avoid detaching of appliances. Make sure you remove your intermaxillary elastics and wax
• To brush fixed appliances, the modified Bass technique is often used, for which the brush is angulated 45 degrees towards the gingiva
• Make sure you brush over and below the braces/bands. If you don’t use the Brass technique, it can be useful to use a[RC1] V-shape toothbrush with longer fibers in the outside and shorter in the inside, to allow for the brackets in the middle.
• Additionally, to clean underneath the wire, use an interdental brush or water irrigator.

Fixed lingual appliances:

• Make sure you brush on top of them and angle your interdental brush to get underneath the wire
• Caries is less likely to develop when wearing lingual appliances because of the cleaning action of the tongue and the anatomy of the teeth (Wiechmann et al., 2015)

Fixed expanders:

• After brushing your teeth, use a large, angled conic interdental brush and give it a curved form with your fingers. This will fit between the gum and the expander and can also be used to clean the buccal sides of the bands. The brush is soft, doesn’t hurt and makes sure food is no longer trapped between the expander and the teeth/gums. If the gums swell up, they will end up hurting.

Fixed retainers:

• In general: don’t floss, it’s better to choose interdental brushes
• Recommend a professional cleaning at least once a year and check regularly whether the retainer is actually still fixed on all points, since this can lead to relapse and activity of the retainer, leading to undesired tooth movement
• Oral habits can lead to detachment or activity of retainers, especially tongue interposition and nail-biting

White Spot Lesions (WSL) / Decalcification during orthodontic treatment

One of the reasons why it is so important that your patients take care of their appliances, is because you want to prevent one of the biggest nightmares in orthodontics: White Spot Lesions (WSL) / decalcification. Prof. Cadenas sheds her light on the basics of this important issue: “When plaque accumulates and doesn’t get removed properly, the bacteria in the plaque are starting to produce acids, which causes demineralization of enamel. These lesions look like chalk, whiter than the teeth’s surface, hence their name White Spot Lesions. Ideally, WSL are prevented, because after their onset, they are very difficult to solve. There are some strategies to remineralize the lesions, but although you see some clinical improvements in some cases, the literature is not clear about the efficacy of these methods (Hu et al., 2020; Kamber et al., 2021). Some patients are more prone to WSL, often due to anatomy and histology of the teeth, or genetic factors. But saliva plays an important role also, as well as brushing and dietary habits, since carbonated drinks and sugary foods are not helping. If WSL are already present before orthodontic treatment, then for me it’s a no-go to start. Also, debonding fixed appliances in the presence of WSL should be done very carefully, since it can contribute further to the cavitation of the surface”.

Being a dental hygienist and having much experience in prevention, Ms. Fintineanu dives deeper into risk prevention: “There’s a shocking statistic that says around 90-95% of patients undergoing orthodontic treatment will have some sort of white spot lesion, and they can develop as quickly as four weeks, with a rapid incidence increase in the first six months of treatment. This means in the first six months, it’s crucial to stay on top of your patients, and one way to do so is to tell them that a WSL is actually a cavity starting to form”. In her experience, self-ligating brackets are less prone to the development of WSL. In terms of risk prevention, Ms. Fintineanu summarizes: “mechanical plaque control is key, make sure the patients have really great oral hygiene. Topical fluoride is always a great thing, fluoride varnish, fluoride mouth rinse or gel, whatever you can do to really increase the enamel’s resistance to those microbial acids”. She also recommends to change toothbrush frequently: “Because of all the wear and tear that’s happening due to the bristles rubbing against metallic parts, toothbrush bristles are wearing down a lot quicker”.

Hypertrophic/hyperplastic gingiva during orthodontic treatment

Other complications that are a danger to your orthodontic treatment are hyperplastic and hypertrophic gingiva, which both cause enlargement of the gingiva. Prof. Cadenas shares her insight into the basics again, starting with the difference between the two conditions: “Histologically, hyperplastic means that the number of cells in the tissue is increased, while hypertrophy means that the size of the cells is increased. The enlargement is mainly caused by plaque accumulation, but there are other causes, such as asthma medication, hormonal changes such as in teenagers or during pregnancy, mouth breathing. And sometimes these factors cannot be changed, so unlike for plaque accumulation, don’t be too hard on those patients. Sometimes, patients have other dental conditions like amelogenesis imperfecta”. It is important to tailor your advice on how to brush to the aetiology of the gingivitis. Ms. Fintineanu agrees: “You can often guess what the root cause of it is by way of elimination. So first off let’s say we’ve eliminated amelogenesis imperfecta and medication, then this is just your typical patient. Important is to take note whether the amount of plaque corresponds with the amount of the inflammation that you’re seeing or not.” She continues with looking back at a few cases of her own that required removal of braces to let gums heal. Sometimes, gingivectomy or gingival contouring may even be needed. Beyond the usual chairside instructions, such as brushing, and cleaning interdentally, plaque-disclosing solution can help emphasizing your message. There are some more interesting ways to motivate your patients: set up active daily reminders from the office, such as automated messages for patients, focusing on encouragement instead of warnings. Consider setting up a reward system, where you agree with the child that they receive some sort of reward or incentive when plaque is at a controlled level, to continue good behaviour.