October is National Orthodontic Health Month. The key? Oral irrigation.
WRITTEN BY
Carol A. Jahn, RDH, MS
October is a perfect opportunity to reflect on the impact that dental professionals have on the lives of patients undergoing orthodontic treatment. According to the American Association of Orthodontics (AAO), nearly five million people in the United States and Canada are in orthodontic treatment. One in five, or about one million, is over the age of 18. Some are in their 50s, 60s, or older. The AAO states that healthy teeth can be moved at almost any age, and that between 40 and 75 percent of people could benefit from some type of orthodontic care.1
Helping people have a successful orthodontic outcome can be a win-win situation for both the patient and your dental practice. Whether adolescent or adult, this is a prime time to establish and maintain relationships to ensure that the orthodontic patient of today becomes your patient for life. Successful orthodontic outcomes hinge not just on keeping regular visits with the orthodontist and general dentist, but via a targeted approach that helps patients prevent caries, make wise nutritional choices, and maintain good gingival health. Because dental professionals often see patients more frequently than physicians, they are positioned to play a critical role in helping people establish habits that contribute to both good oral health and an overall healthy lifestyle.
Preventing caries
Dental caries is a problem that continues to plague both children and adults. According to the Centers for Disease Control (CDC), even though prevalence is declining, tooth decay still affects nearly 60 percent of adolescents and 95 percent of adults.2,3It has long been observed and understood that those undergoing orthodontic therapy are considered to be at higher risk for caries.3 While poor plaque control may be a contributor, improvements in oral hygiene have not been demonstrated to have a significant effect on controlling or arresting decay.4
The primary intervention for reducing decay is fluoride exposure.2,3,4 The amount, type, and frequency should be determined by risk.3 Unfortunately, many practices still use a cookie cutter approach to fluoride use. To effectively prevent decay in all patients, a customized fluoride program is required. For some individuals, a combination of over-the-counter products, toothpaste, and mouthrinse, along with regular professional fluoride treatments, may be sufficient. For others, higher-concentration products that are available by prescription may be necessary.3
Making good nutritional choices
Making good nutritional choices is emerging as an important public health topic in today’s society. According to the CDC, the number of children and teens aged 6 to 19 who are overweight nearly tripled from 1980 to 2002.5 Similarly, overweight and obesity is a growing problem with adults. One of the strongest contributing factors is increased calorie intake. It is estimated that Americans eat 15 percent more calories than they did in the past.6 Specifically, increased consumption of sugar-laden beverages, such as soft drinks, has been demonstrated to contribute to both increased weight and the incidence of type 2 diabetes.7
In the past, nutritional counseling for individuals with orthodontic appliances consisted of informing the patient about foods that should be avoided, such as sticky or sugary items and hard foods like popcorn. Today, soft drink consumption must be considered. To bring this issue to the forefront, begin by asking about soda/sugar-laden drink consumption on the medical history form. If the patient is an adolescent, ask him or her as well as the caregiver, because the answers may vary. People are often unaware of the volume of intake until they are asked to account for it. Many practitioners have observed an increase in decay from increased soft drink consumption, although the literature remains inconsistent on this.8,9 Importantly, it has been shown that soda often replaces milk.8 Emerging evidence demonstrates a link between obesity and poor periodontal health in young adults.10
Maintaining good gingival health
Attarzadeh has noted that “in spite of good toothcleaning, most orthodontic patients develop generalized moderate gingivitis of an edematous type within one to two months after the placement of a fixed orthodontic appliance.”11 It has been suggested that in addition to increased subgingival plaque, the mechanical irritation of bands and/or cement may be a contributing factor.12 Regardless, for many people in orthodontic treatment, gingivitis is a problem that can easily escalate. For example, an orthodontic patient might experience discomfort from tender or edematous tissue. The discomfort may lead the patient to avoid regular self-care, which in turn leads to increased inflammation and increased discomfort.
A common approach to reducing inflammation is to help the patient improve brushing and flossing habits. However, if discomfort is a part of the problem, this may not produce the desired effect. A better first choice might be to try gentle brushing coupled with a dental water jet on low pressure. Dental water jets have a proven track record in reducing bleeding and gingivitis.13 Recently, a study conducted at the University of Nebraska found that a dental water jet coupled with either a manual or power toothbrush produced superior results when compared to routine brushing and flossing, and therefore is an effective alternative to traditional dental floss.14 Once the dental water jet begins to lessen inflammation, the pressure can be increased and a power toothbrush may be added. For others with less severe or localized gingivitis, a dental water jet can also be beneficial as can easy-to-use interdental cleaners such as interproximal brushes and power flossers. Many have been shown to be as effective as dental floss, and preferred over traditional floss.15
When evaluating gingival health, it is important not to overlook tobacco use or the risk/presence of diabetes. Both are risk factors for periodontal disease. Overall, smoking rates for U.S. adults and teens are about 22 percent, including 10 percent of middle school students. However, rates vary by gender, race, and geographic region.16 Orthodontic patients (as well as all patients) should be assessed for tobacco use, and those found to be users should be advised to quit. Dental professionals are well-positioned to dispense advice as well as refer patients to tobacco cessation programs.
Diabetes is on the rise, so it is likely that more of your patients - including those in orthodontic treatment - will have this disease. One-third to one-half may not be aware they have it. This rise is related to increased cases of type 2 diabetes. Previously, type 2 diabetes occurred most often after age 40 and was most prevalent in those aged 65 and over. Today, due to increasing rates in overweight and obesity, type 2 diabetes is occurring much earlier, including in children, adolescents, and young adults.17 Individuals with poorly controlled diabetes tend to have more severe periodontal disease, and children with diabetes have been shown to be more prone to gingivitis.18
Conclusion
Successful orthodontic outcomes require a committed effort by the entire dental team. Differing risk factors for decay, an unhealthy weight, excess soda consumption, along with the potential for poor oral hygiene influenced by environmental or systemic factors such as smoking or diabetes, make counseling individuals in orthodontic treatment much more complex than in the past. Dental professionals who partner with patients to address these issues and find acceptable solutions have an opportunity to increase patient satisfaction as well as personal satisfaction in the treatment outcome. ■
References
1 National Orthodontic Health Month. American Association of Orthodontists. www.braces.org/dentists/nohm. Accessed Sept. 7, 2005.
2 Oral health: Preventing cavities, gum disease, and tooth loss. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Coordinating Center for Health Promotion. www.cdc.gov. Accessed Sept. 7, 2005.
3 Recommendations for using fluoride to prevent and control dental caries in the United States MMWR 2001; 50(RR14); 1-42. www. cdc.gov/oral health.
4 Holz PR. Dental plaque control and caries. in Lang NP, Attström R, Löe H.: Proceedings of the European Workshop on Mechanical Plaque Control, Berlin, Quintessence, 1998; 35-49.
5 Children and teens told by doctors they were overweight - United States, 1999-2002. MMWR 2005; 54:848-849. www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a3.htm.
6 Goldsmith C. Obesity: public health dilemma. Access 2004; 18:26-30.
7 Schulze MB et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA, 2004; 292:927-934.
8 Marshall TA et al. Dental caries and beverage consumption in young children. Pediatrics, 2003; 112:184-191.
9 Heller KE et al. Sugared soda consumption and dental caries in the United States. J Dent Res 2001; 80:1949-1953.
10 Al-Zahrani MS et al. Obesity and periodontal disease in young, middle-aged, and older adults. J Periodontol 2003; 74:610-615.
11 Attarzadeh F. Water irrigating devices for the orthodontic patient. Int J Orthodon 1990; Spring/Summer: 17-22.
12 Atack NE et al. Periodontal and microbiological changes associated with the placement of orthodontic appliances: A review. J Periodontol 1996; 67:78-85.
13 Jahn C. Evidence for self-care products: Mouthrinsing and oral irrigation. J Practical Hyg 2004; 13:21-25.
14 Barnes CM et al. Comparison of irrigation to floss as an adjunct to toothbrushing: effect on bleeding, gingivitis, and supragingival plaque. J Clin Dent 2005; 16(3): In Press.
15 Jahn C. Evidence for self-care products: Power brushing and interdental aids. J Practical Hyg 2004; 13:24-29.
16 Smoking 101 Fact Sheet. American Lung Association. www.lungusa.org. Accessed Sept. 8, 2005.
17 Moore PA et al. Diabetes: A growing epidemic of all ages. JADA 2003; 134:11S-15S.
18 Mealey BL. American Academy of Periodontology position paper: diabetes and periodontal diseases. J Periodontol 2000; 71:664-678.
Carol A. Jahn, RDH, MS
Ms. Jahn is the educational programs manager for Waterpik Technologies. She provides continuing education courses on periodontics and diabetes. She can be reached at [email protected] or (800) 525-2020, Ext. 8565.
