Oral Health Group

Who is Responsible for Oral Hygiene During Orthodontic Therapy?

March 1, 2014
by Deborah M. Lyle, RDH, BS, MS

Orthodontics is a multi-factorial dental procedure that involves the patient, general dentist, orthodontist, assistant(s), hygienist, treatment coordinator, front desk personnel, and sometimes, an oral surgeon or periodontist. Collaboration and communication between the teams is essential. In most cases, each performs his or her role in isolation from the others, sending an email on occasion. So who is responsible for oral hygiene instruction during treatment? It may be obvious but let’s not assume as that can lead to no one taking charge. The best formula is everyone is responsible and should be in agreement about oral hygiene recommendations.

There are risk factors associated with orthodontic appliances that may impact the final outcome such as white spot lesions (WSL) and others that are exacerbated such as gingivitis which can cause increased bleeding and discomfort. Let’s face it, cleaning around brackets, arch wires, TADs, and other appliances is not easy and expecting that adolescents will become hygiene aficionados is unrealistic. Seriously, the adult population, without braces, barely flosses.


To help the situation there needs to be a consistent message from all involved. What to recommend will differ between professionals and there are some decisions to be made.

The incidence of WSLs associated with orthodontic treatment has been reported in several studies with similar findings demonstrating a higher incidence in orthodontically treated teeth compared to non-treated teeth (Fig. 1).1-7 The incidence of developing at least one WSL during orthodontic treatment ranges from 50 percent to 72.9 percent compared to 11 percent to 24 percent of non-treated teeth.6,7 This may differ depending on other variables such as fluoride use, oral hygiene, and diet. One study reported at least one WSL was seen in 38 percent of subjects within six months and 46 percent within twelve months into treatment compared to 11 percent in the control group.8

FIGURE 1. White spot lesions.

A second problem is gingival inflammation (Fig. 2). Orthodontic appliances provide new areas for plaque accumulation which may be left undisturbed if access with typical oral hygiene devices is insufficient. It has been reported that there is an increase in the colonization of periodontopathic bacteria in gingivitis sites with orthodontic appliances versus gingivitis sites without appliances.9,10 Orthodontic patients are also more susceptible to increased levels of pro-inflammatory mediators due to tooth movement which may produce sustained levels of gingivitis.11

FIGURE 2. Gingivitis.

There are several easy steps that can help the team implement a successful hygiene protocol. Two important components are collaboration and communication; each office delivers the same message and shares patient success or challenges with the other team members. The following steps are a guide to help you get started or modify your current program.

1. Set Expectations:
This usually begins in the orthodontic office at the initial visit. Patients are focused on how long it will take and if it will hurt that they may not actively hear how important good oral hygiene is throughout treatment. Let them know they have an important role in the final outcome of treatment.

2. Allow Time for Education:
Simply stating that ‘you need to do better’ as an aside during an adjustment will go in one ear and out the other. Oral hygiene education can be presented and reviewed by anyone in the office who is trained and familiar with the devices and protocol. Spending time also conveys to the patient that this is important and not something that is glossed over. Include the parents in the instructions and let both parties know that there are risks associated with poor oral hygiene. One of these may be debonding if the oral hygiene poses a significant risk for WSLs. This will increase treatment time but reduce the potential for a poor outcome.

3. Dispensing versus Recommending Devices:
Orthodontists have a few choices to consider regarding the oral care products they recommend. Some simply provide instructions for products required and where they can be purchased. Others may choose to sell the product in the office or include the product as part of the fee for treatment. This is a personal choice but regardless of which way you go it is wise to have samples of the products in the office so proper use can be demonstrated. Additionally, it is advantageous to have the information on your website for downloading or viewing later.

4. Get Everyone Involved:
The best method for success is to get buy-in from everyone. This will require meeting with the referring dentists andstaff. Including the hygienist and assistants is important because they will be the primary people providing oral hygiene instructions. However, don’t forget to include your own staff. Let them try the products and provide feedback. I’m sure you have someone in the office that is currently in treatment and can provide first-hand experience.

Before collaborating with the referring dental office on a home-care routine, it is wise to review the research as it pertains to orthodontic therapy. It comes as no surprise that it is difficult to clean around brackets and arch wires even for individuals who have demonstrated excellent oral hygiene prior to treatment.

Power Toothbrushes
Tooth brushing is the first line of defense for most patients but unless there is attention to placement and positioning of the bristles, plaque may remain on the teeth, especially around the brackets or bands. There is limited data on the efficacy of manual tooth brushing with orthodontic patients. A systematic review on non-orthodontic individuals showed that a single brushing produced an average of 43 percent plaque removal.12 People tend to develop brushing habits and will continue to miss the same area regardless of the number of times they brushed.13 Changing technique and continued adherence will take time.

Numerous studies on the efficacy of power toothbrushes have been published with relatively favorable results: safe to use, good patient acceptance, and more effective plaque removal (Fig. 3).14–16 Conversely, a meta-analysis of five studies with orthodontic patients did not find better plaque removal compared to manual tooth brushing.17 This simply means that the data is not there to support recommending a power toothbrush. However, if you familiarize yourself with the brush and experiment with how it can enhance plaque removal by modifying the angle it may be a good choice.

FIGURE 3. Sonic Toothbrush (Waterpik® Sensonic® Professional Plus Toothbrush, Courtesy of Water Pik, Inc.).

Interdental Devices
I am going to be bold
and say “forget string floss.” I do not make this decision lightly but with decades of experience and research at my fingertips it is a well thought out conclusion. Here is my reasoning. The majority of people do not like to floss. There are many reasons with the most common being: it is time consuming, difficult to do, it is painful, and my gums bleed. Couple this with the results from a systematic review that compared brushing alone to brushing and flossing and found no difference in either the reduction of bleeding, gingivitis or plaque removal between the two groups.18 Likewise, the efficacy of flossing on the reduction of interdental decay was reported in a systematic review and found no benefit even when performed by dental professionals over time.19 All dental professionals have seen the benefits of flossing in individual patients but the expectation that this will be the case in the majority of people is not based in science or reality. Nothing will be effective if they do not use it. It is time to move on to other options.

Interdental brushes are often recommended to clean around orthodontic appliances, as well as, open interdental spaces. Interdental brushes have shown better reductions in plaque and gingival inflammation compared to other devices such as wood sticks and floss in subjects without braces.20 To date there is no evidence to support the use of interdental brushes on orthodontic subjects. There are many different brushes on the market with varying sizes and shapes. It would be useful to experiment with different brushes and see if they may be the right choice for certain patients and situations. Keep in mind that one brush size or design may not work with all areas possibly impacting adherence to cleaning all interdental spaces.

A water flosser (Fig. 4), originally known as an oral irrigator or dental water jet, was introduced five decades ago. The research is extensive demonstrating the benefits of daily irrigation which include significant reductions in bleeding, gingivitis, plaque, and probing pocket depth.21-24 More recently, it was compared to string floss in four studies and consistently demonstrated superior reductions in bleeding, gingivitis and plaque removal.25-28 For orthodontic patients the water flosser was three times as effective at removing plaque and 26 percent more effective at reducing bleeding compared to string floss (Figs. 5 & 6).27 Water flossing is easy and can reach areas that are easily missed by toothbrushes or inaccessible by any other means including interdental brushes, wood sticks, and string floss.

FIGURE 4. Water Flosser (Waterpik® Ultra Water Flosser, Courtesy of Water Pik, Inc.).

FIGURE 5. Specialty Orthodontic Tip irrigating around the brackets and wires (Courtesy of Water Pik, Inc.).

FIGURE 6. The bristles of the Orthodontic Tip are used to clean around the brackets and wires (Courtesy of Water Pik, Inc.).

The benefits of fluoride are well known and it is a key part of any caries reduction protocol.29 Fluoride and good plaque control are important for reducing WSLs. It can be delivered via toothpaste, gels, rinses, and varnishes. Studies suggest it may help reduce or eliminate the incidence of decalcification during orthodontic treatment but no delivery method has been shown to be superior to another.30 One method or several methods may be used based on the risk assessment for each patient.

The key to success is not to provide oral hygiene recommendations in a silo. Make it a team decision with each person, including the patient, responsible for success. Make sure routine dental visits are scheduled and send reports electronically or implement a program that will require the patient to show proof of appointment and oral hygiene results. Be creative by instituting a reward program and give them visibility through social media.

The benefits of orthodontic therapy are obvious. It provides a beautiful smile, increases self-confidence, and provides a foundation for better overall dental and periodontal health. It can also improve speech patterns and function. The last thing anyone wants is to see WSL or cavitated lesions at the end of treatment. Implement a simple, effective, oral health program as a team and enjoy many happy patients and beautiful smiles. OH

Deborah received her Bachelor of Science degree in Dental Hygiene and Psychology from the University of Bridgeport and her Master of Science from the University of Missouri, Kansas City. She has been a full time faculty member at the University of Medicine & Dentistry of New Jersey, Forsyth School for Dental Hygienists and Western Kentucky University and is an editorial board member for the Journal of Dental Hygiene. Currently, Deborah is the Director of Professional and Clinical Affairs for Water Pik, Inc.

Oral Health welcomes this original article.


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