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Caries preventive measures used in orthodontic practices: An evidence-based decision?

Caries preventive measures used in orthodontic practices: An evidence-based decision?



American Journal of Orthodontics and Dentofacial Orthopedics, 2007-08-01, Volume 132, Issue 2, Pages 165-170, Copyright © 2007 American Association of Orthodontists


Introduction: Although it is well known that treatment with fixed appliances increases the risk of enamel demineralization, little information is available about preventive measures that orthodontists actually use. This study was executed to survey measures used in orthodontic practices to prevent decalcifications during fixed appliance treatment, and to compare these measures with the available evidence-based information. Methods: A questionnaire was sent to all privately practicing orthodontists in the Netherlands who were affiliated with the Dutch Dental Association. Results: Of 229 orthodontists, 178 (78%) returned the questionnaires. Most of the orthodontists had a basic practice protocol for preventing demineralizations at the start of treatment. This protocol nearly always included oral hygiene instructions. If demineralizations occurred, 99% of the orthodontists took extra measures. Comparing the measures applied in the orthodontic practices with the evidence from a systematic review, a number of differences became apparent. The additional use of chlorhexidine or toothpaste with a high fluoride concentration (which has been demonstrated to have an inhibitive effect) is rarely prescribed. Fluoride rinse is prescribed most often, although there is not any high-quality, long-term study that demonstrates a caries preventive effect in orthodontic patients. Sixty-eight percent of the orthodontists considered it necessary to develop a practice guideline for preventing demineralizations. Conclusions: Orthodontists do not implement the available evidence in order to prevent enamel demineralizations during fixed-appliance treatment. A practice guideline incorporating this information should be developed.

Orthodontic treatment with fixed appliances causes an increased risk of enamel demineralization. Brackets, archwires, ligatures, and other orthodontic appliances complicate the use of conventional oral-hygiene measures. This often results in significant plaque accumulation around the bracket bases. Demineralization of enamel around brackets can be an extremely rapid process and appears most frequently on the cervical and middle thirds of the buccal surfaces of the maxillary lateral incisors, the mandibular canines, and the first premolars. Demineralized enamel can remineralize after debonding under favorable conditions. The prevalence of new enamel lesions in orthodontic patients treated with fixed appliances and using fluoride toothpaste is reported to be 13% to 75%.

Recently, 2 systematic reviews were published on the prevention of enamel demineralization during fixed-appliance treatment. However, little information is available about measures that are really used in orthodontic practices to prevent demineralization. There is only some information available from 1993 about preventive measures used by orthodontists in the United Kingdom. Therefore, the purposes of this study were (1) to survey the preventive measures used in orthodontic practices in the Netherlands and relate these measures to the available evidence-based information, and (2) to assess the need for a practice guideline on the prevention of demineralization during orthodontic treatment with fixed appliances.

Material and methods

The study group consisted of all orthodontists with a private practice working in the Netherlands and affiliated with the Dutch Dental Association. The questionnaire included 5 parts, mainly containing multiple-choice questions.

Part A was an assessment of the measures used to prevent demineralizations at the start of and during orthodontic treatment, and those taken to treat demineralizations after orthodontic treatment. Part B consisted of questions on the material used to bond brackets. The manufacturer’s product information was inspected to see whether the bonding material of the reported brand name released fluoride. The compliance and motivation of patients to follow the instructed preventive measures and the orthodontists’ opinions on the need for a protocol to prevent caries lesion development constituted parts C and D. Background information on each orthodontist was requested in part E.

The questionnaire was piloted on 5 staff members of the Department of Orthodontics at Radboud University Nijmegen Medical Centre in the Netherlands and was subsequently modified. The questionnaire was mailed in May 2004 to all 229 orthodontists. A reminder was mailed a month after the deadline of 2 weeks. The first author (A.D.) called orthodontists who had not returned the questionnaire within 3 months to ask the reasons for not responding. This was done by telephone on 4 days at 4 different times. Another copy of the questionnaire was sent, if requested.

Statistical analysis

Practice characteristics are described in frequencies. To study the influence of the background variable “year of finishing orthodontic training” on the measures used to prevent demineralizations at the start of orthodontic treatment and the extra measures taken during and after orthodontic treatment in case of demineralizations, Pearson correlation coefficients were calculated with software (version 12.0.1, SPSS, Chicago, Ill).

Results

General

Completed questionnaires were returned by 178 (78%) of the 229 orthodontists. The main reasons for not responding were “I am too busy” (n = 21) and “I never return questionnaires” (n = 17). Of the nonrespondents, 10 could not be reached by phone, 2 were retired, and 1 suffered from a long-term illness. On average, the orthodontists had started their practices 17 years ago (SD, 8 years), and 22% had received their orthodontic education abroad.

Oral-hygiene instructions

Irrespective of a basic practice protocol on demineralizations, oral-hygiene instructions for cleaning teeth with fixed appliances and for plaque removal were given by 98% of the orthodontists. Of the respondents, 91% always gave these instructions, and 7% informed their patients only if oral hygiene was not optimal. The most frequently recommended dental aid was the manual (orthodontic) toothbrush (83%), followed by the interproximal brush (71%) and the electric toothbrush (54%). Twelve percent of the respondents always and 40% never instructed their patients on the use of an electric toothbrush. Seventeen percent of the orthodontists advised the use of dental floss, and 17% advised other additional dental devices such as toothpicks and disclosing tablets.

Bonding materials

The questions about the bonding material used to bond the brackets were answered by 173 of 178 respondents. After we checked the product information, 11% of the 82 orthodontists who reported using a fluoride-releasing bonding material actually used one without fluoride-releasing properties. Twenty-seven percent of the 71 orthodontists who reported that they did not use a fluoride-releasing bonding material were actually mistaken and did use a bonding material with fluoride-releasing properties. Of the 20 orthodontists who did not know whether the product they used had fluoride-releasing characteristics, 25% used one with fluoride-releasing properties. In total, 56% of the orthodontists used a bonding material with fluoride-releasing properties according to the product information. Only 3 orthodontists used a glass ionomer bonding material.

Preventive measures at the start of treatment

Of the responding orthodontists, 91% used a basic practice protocol for oral-hygiene measures and the prevention of demineralizations at the start of fixed-appliance treatment. Table I shows the frequencies for measures that were part of such a protocol at the start of orthodontic treatment with fixed appliances. More than 1 answer was possible. In most cases (95%), the protocol contained oral-hygiene instructions. Fifty-two percent of the orthodontists always prescribed a fluoride mouth rinse. Fluoride gel or fluoride varnish and chlorhexidine rinse or chlorhexidine varnish were rarely prescribed. The orthodontists who finished their orthodontic training more recently gave oral-hygiene instructions (r = 0.19, P = .02) and prescribed fluoride rinse more often (r = 0.21, P = .008) than those who finished their training a longer time ago.

Table I
Frequencies (% of orthodontists) for measures that were part of the prevention protocol at the start of orthodontic treatment with fixed appliances
Protocol/guideline at start of orthodontic treatment Always Usually Sometimes Never
Oral-hygiene instruction 95.1% 4.3% 0.6% 0.0%
Fluoride rinse 51.5% 5.6% 23.6% 19.3%
Fluoride gel application 6.2% 1.9% 16.1% 75.8%
Fluoride varnish application 0.6% 0.0% 13.7% 85.7%
Chlorhexidine rinse 0.0% 2.5% 50.9% 46.6%
Chlorhexidine varnish application 0.0% 0.6% 26.1% 73.3%
Other 10.6% 4.4% 4.4% 80.6%

Preventive measures during treatment

If demineralizations develop during orthodontic treatment, 99% of the orthodontists took extra measures. Table II shows the frequencies for extra measures in addition to the basic protocol during orthodontic treatment with fixed appliances when demineralizations develop. More than 1 answer was possible. Information on the consequences of poor oral hygiene and additional oral-hygiene instructions were most frequently given. Fifty-two percent of the orthodontists always prescribed fluoride rinse, and 23% never prescribed it. If demineralizations developed during orthodontic treatment, most orthodontists never used fluoride gel, fluoride varnish, chlorhexidine rinse, or chlorhexidine varnish. The orthodontists who finished their orthodontic training more recently terminated the orthodontic treatment (r = 0.23, P = .003) and sent a letter to the parents or guardians (r = 0.16, P = .03) more often than did those who finished their training a longer time ago.

Table II
Frequencies (% of orthodontists) for extra measures taken in addition to a basic protocol during orthodontic treatment with fixed appliances when demineralizations develop
Measurements during treatment Always Usually Sometimes Never
Explanation of consequences 92.5% 6.3% 0.6% 0.6%
Extra oral-hygiene instruction 86.9% 9.1% 2.3% 1.7%
Fluoride rinse 52.0% 8.6% 16.6% 22.8%
Fluoride gel application 4.0% 1.7% 20.0% 74.3%
Fluoride varnish application 2.9% 2.9% 18.2% 76.0%
Chlorhexidine rinse 5.1% 9.1% 38.9% 46.9%
Chlorhexidine varnish application 2.9% 4.6% 19.4% 73.1%
Stop orthodontic treatment 4.0% 10.3% 83.4% 2.3%
Continue orthodontic treatment with removable appliance 0.0% 1.1% 44.9% 54.0%
Letter to parents or guardians 24.6% 25.1% 22.9% 27.4%
Other 20.1% 22.5% 6.3% 51.1%

Measures after orthodontic treatment

If demineralizations were diagnosed after debonding, 83% of the orthodontists took extra measures. Table III shows the frequencies for extra measures in addition to the basic protocol after orthodontic treatment with fixed appliances in case of demineralizations. More than 1 answer was possible; 60% gave additional oral-hygiene instructions. In this situation, 19% of them instructed their patients to continue using the fluoride mouth rinse, whereas 56% never gave this advice. Most orthodontists never applied fluoride gel or varnish or chlorhexidine rinse or varnish. One third of the orthodontists referred patients with demineralizations to their dentists. Orthodontists who finished their training a longer time ago polished the white spots more frequently (r = 0.17, P = .04) than did those who finished their education more recently.

Table III
Frequencies (% of orthodontists) for extra measures in addition to the basic protocol after orthodontic treatment with fixed appliances in case of demineralizations
Measurements after treatment Always Usually Sometimes Never
Extra oral-hygiene instructions 60.1% 16.9% 6.1% 16.9%
Fluoride rinse 18.9% 12.8% 12.2% 56.1%
Fluoride gel application 5.4% 3.4% 13.5% 77.7%
Fluoride varnish application 1.4% 1.4% 7.4% 89.8%
Chlorhexidine rinse 0.0% 3.4% 19.6% 77.0%
Chlorhexidine varnish application 2.0% 1.4% 10.1% 86.5%
Referral to dentist 33.1% 25.7% 28.4% 12.8%
Letter to parents or guardians 12.2% 12.2% 22.3% 53.3%
Polishing of white spots 0.7% 6.8% 23.6% 68.9%
Other 13.8% 9.0% 2.1% 75.1%

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