dr. freeland article jan. 2013

Periodontics in Orthodontics

January 26, 2013

Introduction:

The field of dentistry has seen significant advances in recent years and

orthodontics is no exception. But the issue of oral hygiene in orthodontics

has remained a perplexing problem.

Patients seek orthodontic treatment mostly for esthetics issue even if

they have functional occlusal problems. The orthodontist and parent or pa-

tient invests time, material, expense and expertise to achieve beautiful

smiles. When the day for appliance removal is finally reached, everyone

from patients, families, and the treating orthodontist and staff are excited.

However, this euphoria is short lived when noticeable decalcification, in the

form of white/brown spots, resulting from poor oral hygiene during treat-

ment ruin the esthetic value of the case. (Figure 1)

Article! Dipak, Freeland1

Figure 1 Decalcification and gingival infection post treatment

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 for

developing decalcification, decay and gingival infections. The severity of

the resultant dental caries can range from development of opaque white-

spot lesions (WSL) to the lose of surface integrity of enamel, cavitation and

oral caries and periodontal bone loss. As a profession, we need to focus on

preventive measures and practices to improve oral hygiene and minimize

adverse sequel to the teeth and periodontium.

Orthodontists should be aware of the high risk of WSL and decide at the

patient 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 and

gingival lesions during orthodontic treatment should not be underestimated

by orthodontists.

Research indicates that 49.6% of orthodontic patients exhibit enamel

opacities 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-treatment

white spots with the incidence in banded teeth being slightly more at 1 in 9


teeth. A significant increase in incidence, prevalence and severity of

enamel opacities following orthodontic treatment has also been reported in

the same study. 1

A number of factors are responsible and the authors have attempted to

highlight a few and discuss them.

Factor One: Pretreatment patient assessment

At the initial exam the doctor should perform a complete periodontal

exam that assess the health of the periodontium and the patients oral hy-

giene. If the oral exam shows plaque accumulation and gingival bleeding

then this patient should not be considered for orthodontic treatment until

the 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.

Factor Two: How to identify oral hygiene problem patients

With the tooth brush the doctor places the bristles into the sulcus area in

the anterior and posterior areas. If bleeding occurs then there is a hygiene

problem. (Figure 3)

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 not

be placed in orthodontic treatment. This program should be designed to


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.

enhance 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 1

week apart and the proper techniques for oral hygiene are taught and re-

viewed. The next three appointments should show complete gingival health

over a 3 months period. If this is not the case then orthodontic treatment

should 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 teeth

and gums before treatment there oral hygiene will not improve during

treatment. 2

A close relationship with the referring dentist and his hygiene staff will

facilitate the efforts of the orthodontist. Making sure the patient sees the

dentist/hygienist more often may help reinforce the orthodontist efforts to

obtain a disease free mouth.


Factor four: Oral hygiene problems during appliance therapy (Fig 5)

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 the

importance of oral hygiene. 3

(Figure 6,7)


Figure 5: The appliance system does increase the oral hygiene problems.

Figure 6: Flossing should be demonstrated. Espe-cially how the patient gets the floss into the sulcus.

The doctor should create an appliance environment that enhances the

patients ability to care for the gingiva and enamel. All flash from bonding

and banding should be removed. The use of sealants, such as Proseal, as

part of the bonding procedure should be instituted. The bonding system

should 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 lingual

tooth surfaces, patients’ acceptance is evident. This practice may lead to

the development of carious lesions, favor the formation of plaque and cal-

culus around the mandibular retainers, compared to the maxilla.7


Figure 7: Brushing needs to be taught. The demonstration should include how to get the bristles into the sulcus.

Zacchrisson, 4 one of the pioneers in the field of bonded lingual retain-

ers, stressed the importance of daily interproximal cleaning with dental

floss. Despite optimal oral hygiene instructions, calculus formed to a

greater 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 and

consensually based. He further elaborates that once in existence, this rela-

tionship can be dissolved in 5 ways: (1) both parties agree to end it (a

common 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 patient

dies: (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 unilaterally

terminate the relationship if the patient breaches at least 1 of the 5 duties

owed to the practitioner under the contract that comprises the doctor-


patient relationship: (1) the patient is not following the doctor’s instructions

regarding 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 the

doctor’s practice: (3) the patient is not being truthful or forthcoming regard-

ing necessary administrative inquires(e.g. his medical history, information

about 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 the

doctor or his staff,m or is crating a hostile or unhealthy environment in the

office; and (5) the patient is not paying for services rendered. 6 (Figure 8)

In all fairness to the patient, some patients will exhibit gingival swelling in

response to the appliances during treatment. It begins within a couple of


Figure 8: A case where the patient would not follow oral hygiene program so treatment was dis-continued.

months after placement of the appliances. Fixed appliances predispose

plaque accumulation and colonization of bacteria. When gingival tissues

are enlarged, the tooth surfaces/bracket tooth interface become difficult to

access, 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 of

the irritating factors such as attachments and appliances, debridement,

chlorhexidine prophylaxis, and in some patients, surgical intervention as as

flap/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 all

patients gingiva disease free while under the orthodontic care. Increased

patient referrals will occur because their cases are finished on time with a

beautiful smile that is enhanced by healthy gingival tissues and teeth free

of decalcification. 5 Increased referrals from the dental profession will occur

when their patients are being well taken care of while in the orthodontist


practice. A study on marketing forces failed to discern or ascertain the

degree/depth of the emotional connection created between the orthodontist

and patient. 5 This doctor patient relationship is the most important aspect

in 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 to

create the healthy oral environment. This will enhance the patient satisfac-

tion at the end of treatment. Even if the cases are walk-in/google/patients

referral cases, because we will be judged by the general dentists at the oral

hygiene 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 at

post treatment consultations the parents/patients are most willing to refer

their friends to your practice. The time spent trying to improve oral health is

one of the best practice building technique. Better then all the marketing

techniques combined. (Figure 9)


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, Director

Advanced Education in Orthodontics. Private Practice.


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.

Research Paper! Last Name 13

dr. freeland article jan. 2013

Documents