Oral Hygiene for the Orthodontic Patient

Brushing Flossing Fluoride Tools To Help You Caring for Your Retainer Eating Right Dental Visits
If you thought brushing and flossing were important before you got braceswell, you were right. But people undergoing orthodontic treatment need to be even more dedicated to good oral hygiene. "Braces trap food very easily, which contributes to plaque formation," says Thomas Cangialosi, D.D.S. "If plaque is not carefully removed from teeth and from around braces, patients run the risk of developing gum disease, dental decay and bad breath." Dr. Cangialosi is chairman of the Section of Growth and Development and director of the Division of Orthodontics at Columbia University. Plaque is a mixture of bacteria, debris and bits of food. The bacteria feed on sugars and produce acids. The acids can irritate your gums, erode the enamel on your teeth and contribute to bad breath (halitosis). It's important to remove the plaque thoroughly and often. Then, when your braces come off, the surfaces of your teeth underneath the braces will be healthy and strong and look good. Here are some tips to help you.

Brushing
Use a soft-bristle toothbrush. Soft bristles are better than medium or hard bristles at getting into those nooks and crannies around your appliances. They also don't irritate your gums. Some companies make toothbrushes especially for people with braces. Known as bi-level brushes, they have longer bristles on the edges and shorter ones in the middle. This type of brush allows you to clean the area above and below the brackets and the brackets as well. The most important thing is to look for a brush that's soft and approved by the American Dental Association (ADA). After that, the size of the brush, the shape of the handle and other variations are up to you. What about an electric toothbrush? It's not necessary, but if you have one, it's safe to use it on your braces. Just be careful not to hit the plastic back of the brush against the brackets on your braces because it can damage them. Also, it should be used on a moderate setting so as not to break or loosen braces. Brush at least three times a day. It is best to brush after meals to make sure there's no food trapped in or around braces. If you are not able to brush after lunch, at least rinse your mouth with water very thoroughly. Brush for at least two to three minutes each time. It's best to use a watch or timer to make sure you are brushing long enough. "Brushing should be done slowly and carefully," says Dr. Cangialosi. "It's important to brush the braces and all the surfaces of the teeth, that is, the inside and outside surface and the chewing surfaces, too. Pay special attention to the areas between your brackets and your gums."

Flossing
Floss at least once a day. It might seem like you can't possibly floss while you have braces, but you can and you should. Special flossing products can help you get into the space between the wires and your gumline. These include floss threaders and a special kind of floss. When your braces are first put on, someone in your orthodontist's office should review flossing techniques. If you're not sure you're doing it right, ask your orthodontist during your next visit.

Fluoride
Use a fluoride toothpaste. It doesn't really matter which one just make sure it has the ADA seal of approval. Your orthodontist may recommend that you use an over-the-counter fluoride rinse. These rinses usually provide

enough fluoride to help protect and strengthen teeth during orthodontic treatment. However, if you have a history of cavities or are otherwise at risk of decay, your orthodontist may prescribe a rinse that contains more fluoride, Dr. Cangialosi says. Consider an office treatment. You can get more fluoride usually in the form of a gel or varnish from your dentist during a regular visit. If you have a history of decay, your dentist may suggest this type of treatment. During orthodontic treatment, see your family dentist for a complete examination every six months, or as directed by your dentist.

Tools To Help You

Rubber-tipped and end-tuft or single-tuft brushes These are special brushes that help you to get into those nooks and crannies, as well as between your teeth. The end-tuft or single-tuft brushes look something like pipe cleaners. Oral irrigators These instruments shoot small streams of water onto your teeth at high pressure to remove bits of food. "They can be used as an aid in your oral hygiene practice, but not in place of brushing and flossing," Dr. Cangialosi says. They also should be used at a moderate setting so they don't damage the braces. Antibacterial rinses These rinses are fine for adults, but their high alcohol content makes them off-limits for kids. "There are alcohol-free rinses available for children to use," Dr. Cangialosi says. "But some are designed only to freshen breath and not to kill bacteria. Before buying an antibacterial rinse for your child to use, you should ask your orthodontist which rinses he or she recommends." Disclosing solutions or tablets Your dentist may have used these during an office visit to see where you tend to miss spots after brushing. Disclosing tablets and solutions use vegetable dye to highlight plaque or debris in your mouth. "Once you see the spots, you can quickly remove them with your toothbrush," Dr. Cangialosi says. You can find them in a drugstore or get some from your dentist and use them at home. If you have questions about how to use any oral hygiene product, even your toothbrush, call your orthodontist's office or talk to someone there during your next visit.

Caring for Your Retainer

If you have a retainer or other removable orthodontic appliance, it needs to be cleaned regularly, too. After all, it spends a lot of time in your mouth. Brush the appliance daily with your soft toothbrush and some toothpaste. This is especially important for the side that is in contact with the roof of your mouth or gums. Brush your retainer over a wash bowl filled with a few inches of water. That way, if it slips out of your hand it will not be damaged. You also can soak it in a cleaning solution. There are several that are advertised as denture cleaners. If you want to soak your retainer, talk to your orthodontist about which solution to use. Some cleaning solutions can corrode wires or other metallic areas on orthodontic appliances. When brushing or soaking your appliance, never use hot water. It can distort the plastic and make the appliance unusable. When your retainer is not in your mouth, keep it in the case that your orthodontist gave you. Also, keep it away from your pets. Dogs and cats love the plastic and will chew it to bits if they get it.

Eating Right
While you're wearing braces, you need to think twice about eating foods that could increase your risk of cavities. You also should avoid anything that might damage your brackets or wires. Frequently breaking your braces will add to the overall treatment time. Stay away from hard and sticky foods. Caramel, hard candy, gum - you get the idea. They can damage your braces and get stuck in the wires and brackets. While the food's stuck there, it provides lots of sugar for cavity-causing bacteria to munch on. Also, do not chew on ice cubes. Cut down on all sugary foods. You can still have a limited amount of sweets and soda, but the more sugars you eat, the greater your risk of tooth decay. Always brush after eating sugary foods or candy. It's not just what you eat, but also when you eat it. Frequent snacking on sugary foods is worse than eating those foods with a non-sugary meal. Don't eat sugary foods or candy before going to bed without brushing. The more chances you give the bacteria to turn sugars into acids, the higher your risk of decay.

Dental Visits
Don't ignore your dentist just because you're visiting an orthodontist regularly. It is still important to visit your dentist for a checkup and cleaning. You should go at least twice a year, or as often as your dentist and orthodontist recommend.

Last updated May 6, 2010

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Oral hygiene care during orthodontic therapy

05/19/2011 By Maria Perno Goldie, RDH, MS As with any treatment modality, there are risks and complications frequently encountered in orthodontic treatment. There are habits and techniques that can be utilized to minimize such risks and complications in the course of orthodontic treatment. Dental decay usually occurs on smooth surfaces and is a common complication in orthodontics, affecting 2% to 96% of all orthodontic patients.(1) Increased risk of dental decay during treatment is due to several factors, including: the carious lesions are difficult to locate; the resting pH is lowered; there is increased volume of dental plaque; and there is a rapid shift in bacterial flora.(2) This section will review the necessity of oral hygiene care during orthodontic treatment and preventive measures suggested to minimize complications during such treatment. The relationship between decay incidence and oral hygiene during orthodontic treatment has been studied. In one study instruction in toothbrushing was given, and topical application of sodium fluoride was used regularly throughout the experimental period.(3) The average period of treatment was 19 months. Monthly assessments of oral hygiene were performed through partial recordings utilizing the Plaque (PII) and Gingival Index (GI) systems. The results demonstrated a definite correlation between oral health and decay incidence. A more recent study showed the incidence of white spot lesions in patients treated with comprehensive orthodontics was significantly high, and the preventive therapy provided appeared to be ineffective.(4) The authors concluded that this prevalent problem is disturbing and merits considerable attention from both patients and providers that should result in greatly increased emphasis on effective caries and decay prevention. Another study looked at risk factors for the development of incipient decay during orthodontic treatment by retrospectively determining the incidence and severity of white spot lesions. This was done by examining pretreatment and post treatment digital photographs.(5) They found the development of incipient lesions during orthodontic treatment related to risks of young age (preadolescent) at the start of treatment, the number of poor hygiene citations during treatment, unfavorable clinical outcome score, white ethnic group, and inadequate oral hygiene at the initial pretreatment examination. The use of computer software to evaluate digital photos retrospectively is a valid method for assessing the incidence and severity of WSLs on the maxillary anterior incisors, canines, and premolars. Preventive measures to minimize damage include intensive oral hygiene instruction and monitoring, and dietary education. At each visit, oral hygiene and dietary education should be reinforced. Remineralizing agents can be prescribed for daily use to decrease the incidence of decay, such as 0.05% sodium fluoride rinse.(6) Where demineralization is already visible, various methods have been recommended including the use of fluoride toothpaste and adjunctive fluoride mouthwashes (0.05% sodium fluoride daily rinse or 0.2% sodium fluoride weekly rinse) to help remineralization of the affected area. Oral hygiene instruction is essential in all cases of orthodontic treatment, and the use of adjuncts such as power or electric toothbrushes, interproximal brushes, chlorhexidine mouthwashes, fluoride mouthwashes, and regular professional cleaning must be reinforced. However, patient motivation and dexterity are vital in the success of oral hygiene. Experience shows those who are unable to maintain a healthy oral environment in the absence of fixed orthodontics, will fail enormously with brackets and wires in place. In such patients, benefits may therefore significantly outweigh the risks of treatment. Most patients are able to prevent these problems with a combination of proper diet, optimal self care such as tooth brushing and interdental cleaning, and regular checkups. Brushing teeth immediately after eating, using the proper techniques for brushing with braces, and even rinsing vigorously with water is helpful to prevent decay. Excellent oral hygiene and plaque removal are critical, as is avoidance or minimizing consumption of sugar, carbonated beverages and energy drinks, and between meal snacks.

Oral hygiene devices for making the process of cleaning orthodontics appliances are available. Rubber-tipped and end-tuft or single-tuft brushes, oral irrigators like the Waterpik, and antibacterial and fluoride rinses are a few. In one study, the use of a manual toothbrush and the Waterpik Water Flosser with the Orthodontic Tip was compared to manual toothbrushing and flossing with a floss threader on bleeding and plaque biofilm reductions in adolescents with fixed orthodontic appliances. A control group consisted of brushing only.(7) The results showed that a dental water jet with a specialized orthodontic jet tip was effective for adolescents in fixed orthodontic appliances and it demonstrated beneficial results for the reduction of plaque and bleeding.(8)

An in vivo study compared the plaque removal and gingivitis reduction ability for the Sonicare FlexCare (ProResults brush head) and Oral-B P-40 manual toothbrush in orthodontic population.(9) The Sonicare FlexCare demonstrated superior plaque reduction over a manual toothbrush. The Sonicare Flexcare or Sonicare for Kids toothbrushes or the new AirFloss are options for patients.(10)

Manual brushes are available as well. The Oral-B Orthodontic Brush uses V-shaped bristles to remove plaque from braces and teeth. It can be used as a braces toothbrush or as a brush to clean wires and brackets associated with retainers, headgear and other types of orthodontic work. The Oral-B Ortho is recommended for both adults and children with braces, since it is designed to clean around the orthodontic brackets. Regarding the power brush, the Oral-B PowerTip brushhead can be used in conjunction with one of these brushheads to clean around bridges, crowns, or implants. For children, the Oral-B Kids' Power brushhead has extra-soft bristles and a special longer row to clean chewing surfaces.(11,12,13,14) Cleaning removable appliance like aligners and retainers is important as well. Specialty items like FlossFish(15) and the Platypus Orthodontic Flosser(16) are available. Specialty websites are available that specialize in new and innovative high-quality orthodontic products. An example is DentaKit for Invisible Braces & Retainers, for people with "Invisalign-type" aligners.(17) The Sunstar GUM Proxabrush Interdental System is available for cleaning between archwire and teeth and for larger spaces be tween teeth.(18) There is also a GUM Orthodontic toothbrush, with a V trim, and a soft brush that facilitates cleaning around orthodontic appliances such as brackets, arch wires, buttons and ligatures. It is also available as a travel brush with antibacterial protected bristles. Bristles have a patented chlorhexidine antibacterial coating for bristle protection.

Other interdental cleaners may be useful during orthodontic treatment. In one study, dental floss, the recognized gold standard for gingivitis reduction, was matched in performance by flossers and an interdental cleaner with small elastomeric fingers, and surpassed by an interdental brush.(19) All products performed comparably for plaque reduction and removal. Glide dental floss, Butler flossers, GUM Go-Betweens cleaners, and GUM Soft-Picks cleaners were studied.

TePe, a Swedish company, has many suitable products and a brochure: Caring for your braces is a guide to suitable products and home care for orthodontic patients.(20) TePe Interspace is an angled brush with a pointed tuft, is ideal for cleaning critical areas close to the brackets and under the wires.(21) Two different angles can be chosen for optimal access. The TePe Interdental Brush is available in several sizes and in two textures, soft and extra soft. The extra soft brushes have longer filaments, which can be suitable for orthodontic patients. While this is not an exhaustive list, it is a beginning to assist us in helping those undergoing orthodontic treatments to achieve optimal self care. Motivational interviewing is a technique that may help promote compliance with professionals recommendations. References 1. Chang HS, Walsh LJ, Freer TJ. Enamel demineralization during orthodontic treatment. Aetiology and prevention. Aust Dent J 1997; 42:322-7. 2. Yun-Wah Lau P and Wing-Kit Wong R. Risks and complications in orthodontic treatment. Hong Kong Dental Journal2006; 3:15-22. 3. Zaghrisson BU and Zaghrisson S. Caries incidence and oral hygiene during orthodontic treatment. European Journal of Oral Sciences Volume 79, Issue 4, pages 394401, August 1971, Article first published online: 1 OCT 2007. 4. Richter AE, Arruda AO, Peters MC, and Sohn W. Incidence of caries lesions among patients treated with comprehensive orthodontics. American Journal of Orthodontics & Dentofacial Orthopedics - May 2011 (Vol. 139, Issue 5, Pages 657-664, DOI: 10.1016/j.ajodo.2009.06.037. 5. Chapman JA, Roberts WE, Eckert GJ, Kula KS, and Gonzlez-Cabezas C. Risk factors for incidence and severity of white spot lesions during treatment with fixed orthodontic appliances. American Journal of Orthodontics & Dentofacial Orthopedics - August 2010 (Vol. 138, Issue 2, Pages 188-194, DOI: 10.1016/j.ajodo.2008.10.019. 6. Geiger AM, Gorelick L, Gwinnett AJ, and Benson BJ. Reducing white spot lesions in orthodontic populations with fluoride rinsing. Am J Orthod Dentofacial Orthop 1992; 101:403-7. 7. professional.waterpik.com/pdfs/clinical-research/Sharma_orthodontics_021010_v5.pdf. 8. Sharma NC, Lyle DM, Qaqish JG, Galustians J, and Schuller R. Effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent patients with fixed orthodontic appliances. American Journal of Orthodontics & Dentofacial Orthopedics, Volume 133, Issue 4 , Pages 565-571, April 2008. 9. Putt M, Milleman J, Delaurenti M, Jenkins W, Wei J, Strate J. Comparison of plaque removal in orthodontic subjects by Sonicare FlexCare and a manual brush. J Dent Res 87 (spec Iss B): 2044, 2008.www.sonicare.com/professional/dp/pdf/Plaque_FC_2008_DeLaurenti.pdf. 10. www.sonicare.com/professional/dp/DP/Default.aspx. 11. www.oralbprofessional.com/us/products/power/powheads.asp. 12. www.oralb.com/topics/orthodontics-braces.aspx. 13. www.oralb.com/products/electric-toothbrush/. 14. www.dentalcare.com/en-US/products/power.jspx. 15. www.flossfish.com/. 16. www.platypusco.com. 17. www.dentakit.com/. 18. www.gumbrand.com/home-professional.aspx. 19. Yost KG, Sunstar Americas, Inc., Mallatt ME, Indiana State Department of Health, Liebman J, and Hill Top Research. Interproximal Gingivitis and Plaque Reduction by Four Interdental Products. J Clin Dent 17:7983, 2006.www.gumbrand.com/n/pdffiles/content/SoftPicks%20Clinical.pdf. 20. www2.tepe.com/fileadmin/uploads/Printed_Material_eng/patientfolder_ortho_UK_lowres.pdf . 21. www2.tepe.com/user-tips/orthodontics/.

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Plaque, caries level and oral hygiene habits in young patients receiving orthodontic treatment.
Martignon S, Ekstrand KR, Lemos MI, Lozano MP, Higuera C. Source
Caries Research Unit UNICA, Dental Faculty, Universidad El Bosque, Bogot, Colombia. martignonstefania@unbosque.edu.co
Abstract
OBJECTIVE: To assess plaque, caries, and oral hygiene habits amongst patients receiving fixed-orthodontic treatment at the Dental-Clinic, Universidad-El-Bosque, Bogot, Colombia. BASIC RESEARCH DESIGN: Test-group: 74 12-29-year-olds receiving fixed-orthodontic treatment; reference-group: 63 12-29-year-olds before they started the orthodontic treatment. Visual examinations (one examiner) recorded the following: Ortho-plaque-Index (OPI) expressed per patient as good, fair and poor-oral-hygiene. Caries was scored with the modified-ICDAS-II criteria as: 0-sound; 1B/1Wbrown/white-opacity-after-air-drying; 2B/2W-brown/white-opacity-without-air-drying; 3-microcavity; 4-underlying-shadow; 5/6distinct/extensive-cavity. Filled/missing surfaces due-to-caries and caries-lesions on buccal surfaces at three sites around the brackets were recorded. A 7-item self-administered oral-hygiene habits' questionnaire was used.

RESULTS: Chi-square test revealed that the oral-hygiene level was significantly better in the reference group compared to the test group (p < 0.05). The traditional mean DMF-S was 6.7 +/- 6.3 in the test- and 6.2 +/- 5.9 in the reference-group (p > 0.05). When adding modified-ICDAS-II lesions scores 1-4, the figure increased to 23.6 +/- 9.4 in the test- and to 13.6 +/- 10.3 in the reference-group (p < 0.001). A total of 96% had > or = 1 white-opacity in the test group versus 56% in the reference group (P < 0.001). In the test-group the buccal-surfaces accounted for most white-opacities and close to 1/3 of these lesions on the upperanterior teeth were located around the brackets. The questionnaire disclosed that 58% in the test- vs. 44% in the referencegroup did not accept having dental caries lesions during the orthodontic treatment. CONCLUSIONS: The results showed a high prevalence of white-opacities related to orthodontic appliances and indicate the need to implement preventive programmes at the dental clinic