Orthodontic Preventive Care

Biofilm and braces

As stated by Bergamo et al (2019): ‘… 60% of all orthodontic patients experience some alteration in biofilm accumulation after the bonding of orthodontic appliances.’⁴

They continued: ‘Studies investigating microbial contamination during orthodontic treatment have evaluated the species that are related to dental caries or periodontal disease.’⁴

Adding to this, Haas et al (2014) wrote: ‘High gingivitis prevalence is commonly found in orthodontic patients. The presence of brackets, bands and other accessories, as well as composite resin restorations and cements used to bond them, facilitate biofilm build up and hinder its removal by patients, favouring enamel demineralisation and gingivitis, and promoting quantitative and qualitative changes in the oral microbiota. Several studies have shown an association between placement of braces and an increase in biofilm.’⁵

Looking to add to the evidence base, Bergamo and colleagues (2019) aimed, ‘To assess periodontal parameters and microbial species levels after orthodontic appliance placement in patients who received oral hygiene instructions and who were monitored and motivated throughout the study.’⁴

They concluded that: ‘A dynamic change in microbial levels was found. The decrease in the levels of complexes present was only possible because of the mechanical method of oral hygiene implemented in this sample.’⁴

What then might good oral hygiene between appointments look like for the orthodontic patient?

According to Haas and colleagues (2014), ‘Properly performed daily mechanical biofilm control is the most important prevention strategy for periodontal diseases. However, proper mechanical biofilm control is not performed effectively by the majority of the population, mainly due to lack of motivation and of manual dexterity. Local biofilm retention factors may aggravate home oral hygiene quality.’⁵

This challenge also led Walsh and Healey (2019) to consider, ‘…practical ways to lower the risk of hard tissue loss from dental caries during orthodontic treatment’.⁶

After all, ‘When undertaking oral hygiene education for the orthodontic patient, the question arises as to what aids in addition to manual tooth brushing need to be used for the particular patient. Using manual tooth brushing alone is unlikely to be effective in the vast majority of patients, if the goal is effective plaque control.’⁶

Offering a possible solution to this problem, Walsh and Healey (2019) wrote: ‘A powered brush provides important benefits over a manual toothbrush, but even more so when special orthodontic heads are used, since the bristle patterns and bristle materials have been optimised for use around orthodontic appliances. If a powered brush is recommended, an appropriate dedicated orthodontic brush head should be used, since these have been found to outperform regular brush heads.’⁶

Also looking to overcome the limitations of mechanical cleaning, Haas et al (2014) conducted a systematic search in the literature on antiseptics used to control supragingival biofilm and gingivitis in orthodontic patients.⁵

They were able to demonstrate: ‘Current evidence shows that when chemical agents are used as adjuvants to brushing and flossing, they can promote additional advantages compared to mechanical control alone, as regards […] plaque […] reduction.’⁵

However, it remains important to note, as stated by Walsh and Healey (2019), that, ‘…individual recognisance with brushing still remains the single biggest factor in maintaining the necessary quality of oral hygiene during treatment.⁶

Patient-friendly advice

Narayanan and colleagues (2021) wrote: ‘Advocating measures of meticulous oral hygiene and dietary advice is essential in all phases of treatment – before, during and after orthodontic treatment.’⁷

Furthermore, as stated by the BOS, ‘A good balanced, healthy diet and excellent oral hygiene are very important during orthodontic treatment to maintain strong and healthy teeth.’³

To that end, patient-friendly advice to be shared with someone undergoing orthodontic treatment may include:^8,9

• Brushing the teeth for two minutes with a fluoride toothpaste at least twice daily, as well as in-between those times to clean food deposits after meals
• Use a small interdental brush or floss designed for brace wearers to help remove plaque from between the teeth
• Use an alcohol-free fluoride mouthrinse once a day
• Chew a disclosing tablet from time to time, to show the areas of the mouth that may need extra attention
• Avoid sugary snacks and sweet drinks between meals and before bed
• Avoid hard, sticky and chewy food that might damage brace brackets.

The cornerstone of success

Offering succinct overview of the situation, Narayanan and colleagues (2021) concluded: ‘Good oral hygiene and motivation are the cornerstones of successful orthodontic treatment outcomes, especially in complex cases which tend to benefit more from fixed orthodontic treatment. This starts with the correct assessment from the patient’s dentist and a discussion with the patient about their responsibilities and duties during orthodontic treatment.’⁷

They continued: ‘Expectations should be managed and operators should always work within their competencies. Good case selection, sound clinical judgement and more importantly, the patient’s understanding of the risks involved and the treatment implications, help minimise and manage potential hazards that occur during the course of the treatment.’⁷