Good oral hygiene is vital for orthodontic appliance patients. Daniel Bills and Deborah Lyle reveal why
Good oral hygiene is important for everyone, but the risk of infection is increased for orthodontic patients who must be motivated to maintain higher standards.
The orthodontic team is responsible not only for the treatment but also for persuading the patient of the importance of oral hygiene in achieving, and later supporting, a successful outcome. Patient and clinician must collaborate to devise a simple, effective, daily hygiene protocol which embraces an understanding of how the orthodontic materials will relate to soft tissue.
The orthodontist should insist before commencing treatment that the patient has visited his or her GDP within the previous 6 months, and does not present with overt gingivitis, bleeding or untreated caries.
This insistence emphasises to the patient that they may themselves be responsible if problems occur due to the lack of a conscientious pursuit of their agreed hygiene routine.
All dental professionals are only too aware of the difficulty of convincing patients to maintain an adequate oral health regime, and orthodontic patients face more difficult cleaning tasks. Two typical consequences of poor oral hygiene in orthodontic patients are gingival inflammation and enamel decalcification, or white spot lesions (Figure 2) [1-3 ] Studies have shown decalcification in 50% of teeth treated with brackets. 
Fixed orthodontic brackets predispose plaque and bacteria colonisation, resulting in increased inflammation and bleeding, [4,5] with sustained levels of gingivitis much more likely than in non-orthodontic patients.  Tooth movement is also a factor. 
Undoubtedly the design and constituent material(s) of the appliance have an influence on the hygiene regime. While the orthodontist should always select, the appliance best suited to deliver the optimum correction, where two or more alternatives will deliver equally effective results, the least bulky and easiest to clean is the logical choice for the patient.
In the best interest of the patient, the clinician should also consider how likely he or she will be to conscientiously adhere to a prescribed hygiene programme. For example, the current fashion among younger patients for coloured elastomeric ligature ties  requires higher hygiene standards than for self-ligating appliances, to avoid microbial accumulations and a predisposition to caries or gingivitis.
Higher numbers of cariogenic bacteria have also been found on plastic and ceramic brackets compared to those of gold and stainless steel. 
Although professionals keenly debate the merits and efficacy of different types of appliances, post installation hygiene is rarely a consideration; and yet from the patient’s point of view, this can be a determining factor. While space in this article precludes a comprehensive survey of the ‘hygiene friendliness’ of every type of appliance, the palatal expander exemplifies this point. The palatal expander is an extremely popular appliance with a variety of designs, most of which are a variant derived from the Haas, bonded or hyrax expander.
Haas and bonded expanders feature acrylic covering the teeth and/or palatal tissue, while the well proven12,11,12 hyrax expander is tooth-borne and so is probably easier for a patient to keep clean.
Even the most cavalier patient is likely to ask for cleaning advice for their new appliance. With a huge range of products on the market to tackle arch wires, expanders and the other assorted hardware, the orthodontist should be aware of the benefits and ease of use.
The humble manual toothbrush is the obvious starting point. While brushing techniques differ, patients habitually spend only five out of a paltry total of 50 seconds brushing lingual surfaces,[13,14] removing between 28 and 53% of whole mouth plaque each episode, with repeated brushings not increasing the plaque removal. Manual, V-shaped orthodontic toothbrushes are intended to clean teeth and brackets simultaneously, but there is no evidence to suggest that patients use them for longer or with greater effect.
Although electric toothbrushes have shown 7% greater plaque removal and 17% less gingivitis in non-orthodontic patients, tests involving orthodontic patients have produced mixed results.[16-22] A meta-analysis of five comparative trials reached no firm conclusion.
Fluoride is well known to reduce the risk of dental caries and decalcification during orthodontic treatment, [23,24] but there is no evidence to suggest that one delivery method is more efficacious than any other.
While the importance of interdental cleaning is generally acknowledged by even the most recalcitrant patient, traditional flossing is frequently dismissed as too difficult or too painful, a response heard only too regularly by GDPs and orthodontists alike. All relevant research shows that pursuing this argument leads nowhere and that patients much prefer alternative methods of interdental cleaning, including interdental brushes, which studies show are often more effective.  Although interdental brushes are easy to use and available in many thicknesses, even the narrowest may fail to penetrate every space, and so cannot be universally recommended for orthodontic patients.
The modern, highly effective alternative is a Water Flosser which uses a water jet combination of pulses and pressure to flush and irrigate between the teeth and into every aperture, however small. Extensive research has shown impressive reductions in plaque, biofilm, gingival inflammation and microbial colonisation. [27-36]
A recent study showed the Water Flosser removed 75% of the plaque when used with a manual toothbrush; results for hard to reach places were 59% for marginal areas and 92% for approximal areas. In a study restricted to orthodontic patients, plaque removal was 3 times better than brushing and flossing and 26% more effective for bleeding in favour of the Water Flosser.29 92% of participants aged 11 to 17 agreed the Water Flosser was easy to use and committed to using it every day.
The orthodontist and the practice team’s relationship with the patient is a key component in establishing an effective oral health regime to safeguard the treatment outcome, and since many orthodontic patients are children this factor requires special attention. It’s important to stress from the very beginning that this is a partnership effort, and that the patient’s contribution in keeping their teeth and appliance clean is crucial to success.
Children will be concerned that the process of straightening their teeth will be painful, so time should be set aside to explain how maintaining oral hygiene will help and to demonstrate matters such as brushing techniques or how to use ancillary cleaning tools. Instructions on a practice website can be a useful refresher for both patients and parents.
Another consideration is the cost of auxiliary cleaning aids. While for some patients this will not be an issue, for others, particularly in the present uncertain economic climate, such additional expense may be out of the question. Some orthodontic practices in the US have begun to offer their patients complementary Water Flossers or other devices, either raising their fees to cover the additional costs or regarding it as an investment in reducing treatment time.
Children particularly respond to incentives. If arriving for an appointment with a spotlessly clean mouth wins a token towards a free T shirt, or some other desirable object, trouble-free treatment is much more likely. Inexpensive adult reward schemes have also proved successful ‘across the water.’
The referring dentist is also a member of the orthodontic team and an exchange of information between the practices is vital. When the patient becomes the conduit for communication, it’s useful to introduce an agreed system of signed cards confirming attendance and treatment carried out which can be presented at each appointment.
The last word on a hygiene regime for the orthodontic patient must always be to keep it simple. However keen the patient is to assist in their own treatment, complex, difficult and time consuming home cleaning procedures will ultimately prove a disincentive, and failing hygiene standards are one of the primary causes of compromised orthodontic treatment.
For more information on Waterpik Water Flossers speak to your wholesaler or visit www.waterpik.co.uk.
Daniel Bills, DMD, MS Diplomate, American Board of Orthodontics, Clinical Associate, University of Pennsylvania, Department of Orthodontics, Private Practice in Orthodontics, Sicklerville, New Jersey
Deborah M. Lyle, RDH, MS Director of Professional and Clinical Affairs, Water Pik, Inc. Morris Plains, New Jersey
1. Enaia M, Bock N, Ruf S (2011) White-spot lesions during multibracket appliance treatment: a challenge for clinical excellence. Am J Orthod Dentofacial Orthop 140(1): e17-24.
2. Ogaard B (1989) Prevalence of white spot lesions in 19-year-olds: a study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofacial Orthop 96(5):423-427.
3. Gorelick L, Geiger AM, Gwinnett AJ (1982) Incidence of white spot formation after bonding and banding. Am J Orthod 81(2): 93-98.
4. Lee SM, Yoo SY, Kim HS et al (2005) Prevalence of putative periodontopathogens in subgingival dental plaques from gingivitis lesions in Korean orthodontic patients. J Microbiol 43(3): 260-265.
5. Naranjo AA, Triviño ML, Jaramillo A, Betancourth M, Botero JE (2006) Changes in the subgingival microbiota and periodontal parameters before and 3 months after bracket placement. Am J Orthod Dentofacial Orthop 130:275.e17-275.e22.
6. Başaran G, Özer T, Kaya FA, Kaplan A, Hamamci O (2006) Interleukin-1β and Tumor Necrosis Factor-α levels in the human gingival sulcus during orthodontic treatment. Angle Orthod 76(5):830-836.
7. Forsberg CM, Brattstrom V, Malmberg E, Nord CE (1991) Ligature wires and elastomeric rings: two methods of ligation and their association with microbial colonization of streptococcus mutans and lactobacilli. Eruopean Journal of Orthodontics 13: 416-420.
8. Pellegrini P, Sauerwein R, Finlayson T, McLeod J, Covell DA, Maier T, Machida CA (2009) Plaque retention by self-ligating vs elastomeric orthodontic brackets: Quantitative comparison of oral bacteria and detection with adenosine triphosphate-driven bioluminescence. American Journal of Orthodontics & Dentofacial Orthopedics 135:426.e1-426.e9.
9. Pramod S, Kailasam V, Padmanabhan S, Chitaranjan AB (2011) Presence of cariogenic streptococci on various bracket material detected by polymerase chain reaction. Australian Orthodontic Journal 27:46-51.
10. Garrett BJ, Caruso JM, Fungcharassaeng K, Farrage JR, Kim JS, Taylor GD (2008) Skeletal effects to the maxilla after rapid maxillary expansion assessed with cone-beam computed tomography. American Journal of Orthodontics and Dentofacial Orthopedics 134: 8.e1-8.e11.
11. Lagravere MO, Carey J, Heo G, Toogood RQ, Major P (2010) Transverse, vertical, and anteroposterior changes from bone-anchored maxillary expansion vs. traditional rapid maxillary expansion: A randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics 137: 304.e1-304.e12.
12. Weissheimer A, Macedo de Menezes L, Mexomo M, Dias DM, Santayana de Lima EM, Rizzatto SMD (2011) Immediate effects of rapid maxillary expansion with Haas-type and hyrax-type expanders: A randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics 140: 366-376.
13. Claydon NC (2008) Current concepts in toothbrushing and interdental cleaning. Periodontology 2000 48:10-12.
14. Van der Weijden F, Slot DE (2011) Oral hygiene in the prevention of periodontal diseases: the evidence. Periodontology 2000 55:104-123.
15. Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, Glenny AM, Shaw WC (2005) Manual versus powered toothbrushing for oral health. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD002281.
16. Borutta A, Pala E, Fischer T (2002) Effectiveness of a powered toothbrush compared with a manual toothbrush for orthodontic patients with fixed appliances. Journal of Clinical Dentistry 13:131-137.
17. Silvestrini Biavati A, Gastaldo L, Dessi M, Silvestrini Biavati F, Migliorati M (2010) Manual orthodontic vs. oscillating-rotating electric toothbrush in orthodontic patients: a randomized clinical trial. European Journal of Paediatric Dentistry 11:200-202.
18. Heasman P, Wilson Z, Macgregor I, Kelly P (1998) Comparative study of electric and manual toothbrushes in patients with fixed orthodontic appliances. American Journal of Orthodontics and Dentofacial Orthopedics 114:45-49.
19. Thienpont V, Dermaut LR, Van Maele G (2001) Comparative study of 2 electric and 2 manual toothbrushes in patient with fixed orthodontic appliances. American Journal of Orthodontics and Dentofacial Orthopedics 120:353-360.
20. Costa MR, Silva VC, Miqui MN, Sakima T, Spolidorio DMP, Cirelli JA (2007) Efficacy of ultrasonic, electric and manual toothbrushes in patients with fixed orthodontic appliances. Angle Orthodontics 77:361-366.
21. Trimpeneers LM, Wijgaerts IA, Grognard NA, Dermaut LR, Adriaens PA (1997) Effect of electric toothbrushes versus manual toothbrushes on removal of plaque and periodontal status during orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics 111:492-497.
22. Kaklamanos EG, Kalfas S (2008) Meta-analysis on the effectiveness of powered toothbrushes for orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics 133:187.e1-14.
23. ADA Council on Scientific Affairs (2006) Professionally applied topical fluoride. Evidence-based clinical recommendations. Journal of American Dental Association 137:1151-1159.
24. Chadwick BL, Roy J, Knox J, Treasure ET (2005) The effect of topical fluorides on decalcification in patients with fixed orthodontic appliances: a systematic review. American Journal of Orthodontics and Dentofacial Orthopedics 128:601-606.
25. Benson PE, Parking N, Millett DT, Dyer FE, Vine S, Shah A (2004) Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane Database Systematic Reviews (3):CD003809.
26. Slot DE, Dörfer CD, van der Weijden GA (2008) The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. International Journal of Dental Hygiene 6:253-264.
27. Barnes CM, Russell CM, Reinhardt RA, Payne JB, Lyle DM (2005) Comparison of irrigation to floss as an adjunct to toothbrushing: effect on bleeding, gingivitis, and supragingival plaque. Journal of Clinical Dentistry 16:71-77.
28. Rosema NAM, Hennequin-Hoenderdos NL, Berchier CD, Slot DC, Lyle DM, van der Weijden GA (2011) The effect of different interdental cleaning devices on gingival bleeding. Journal of International Academy of Periodontology 13:2-10.
29. Sharma NC, Lyle DM, Qaqish JG, Galustians J, Schuller R (2008) Effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent patients with fixed orthodontic appliances. American Journal of Orthodontics and Dentofacial Orthopedics 133:565-571.
30. Cutler CS, Stanford TW, Abraham C, Cederberg RA, Boardman TJ, Ross C (2000) Clinical benefits of oral irrigation for periodontitis are related to reduction of pro-inflammatory cytokine levels and plaque. Journal of Clinical Periodontology 27:134-143.
31. Newman MG, Cattabriga M, Etienne D, Flemmig T, Sanz M, Kornman KS et al. (1994) Effectiveness of adjunctive irrigation in early periodontitis: multi-center evaluation. Journal of Periodontology 65:224-229.
32. Flemmig TF, Epp B, Funkenhauser Z, Newman MG, Kornman KS, Haubitz I et al (1995) Adjunctive supragingival irrigation with acetylsalicylic acid in periodontal supportive therapy. Journal of Clinical Periodontology 22:427-433
33. Cobb CM, Rodgers RL, Killoy WJ (1988) Ultrastructural examination of human periodontal pockets following the use of an oral irrigation device in vivo. Journal of Periodontology 59:155-163.
34. Gorur A, Lyle DM, Schaudinn C, Costerton JW (2009) Biofilm removal with a dental water jet. Compendium of Continuing Education in Dentistry 30(Special Issue 1):1-6.
35. Sharma NC, Lyle DM, Qaqish JG, Schuller R (2012) Comparison of two power interdental cleaning devices on plaque removal. Journal of Clinical Dentistry 23:17-21.
Biographical Information for Deborah M. Lyle, RDH, MS
Deborah received her Bachelor of Science degree in Dental Hygiene and Psychology from the University of Bridgeport and her Master of Science degree from the University of Missouri – Kansas City. She has 18 years clinical experience in dental hygiene in the United States and Saudi Arabia with an emphasis in periodontal therapy. Along with her clinical experience, Deborah 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. She has contributed to Dr. Esther M. Wilkins’ 7th, 8th, 9th and 10th editions of Clinical Practice of the Dental Hygienist and the 2nd and 3rd edition of Dental Hygiene Theory and Practice by Darby & Walsh. She has written numerous evidence-based articles on the incorporation of pharmacotherapeutics into practice, risk factors, diabetes, systemic disease and therapeutic devices. Deborah has presented numerous continuing education programs to dental and dental hygiene practitioners and students and is an editorial board member for the Journal of Dental Hygiene, Modern Hygienist, RDH, and Journal of Practical Hygiene and conducted several studies that have been published in peer-reviewed journals. Currently, Deborah is the Director of Professional and Clinical Affairs for Waterpik, Inc.