Prevention in Orthodontics

Question 1

What are the aims of orthodontic treatment?

Answer 1

• improvement in function
• improvement in dental health
• improvement in aesthetics and psychological wellbeing

Question 2

What are some risks of orthodontic treatment?

Answer 2

• demineralisation
• root resorption
• pulp damage
• gingivitis/periodontal problems
• soft tissue damage e.g. ulcer
• other factors

Question 3

How can demineralisation be prevented?

Answer 3

• diet and plaque control may need attention
• during treatment, may necessitate a shortened treatment plan or immediate discontinuation
• after treatment, may require measures to remineralise lesions to improve appearance
  All patients should be warned of the possibility of demineralisation as part of the consent process

Question 4

List prevention measures for demineralisation:

Answer 4

• OHI
• dietary advice
• fluoride mouthwash for duration of treatment
• identify, prevent, remove stagnation areas
• reduce flash around brackets
• use glass ionomer cement on bands, due to fluoride release

Question 5

What is root resorption in orthodontics?

Answer 5

• on average, about 1-2mm of root length will be lost during treatment
• incisors most commonly affected
• some patients more susceptible to marked resorption >5mm, more resorption with higher forces, longer treatment duration
• rarely affects longevity of teeth
• can be detected pre, mid and post treatment by a PA

Question 6

What are some risk factors of root resorption?

Answer 6

• previous resorption prior to treatment
• previous trauma
• family history
• if trauma occurs during treatment and root canal therapy required, a calcium hydroxide dressing should be placed until ortho treatment is complete, root should be left for 3 months before continuing ortho treatment
• if a root filling was laced prior to ortho commencing, wait 6 months before starting ortho treatment

Question 7

How can you prevent risk of root resorption?

Answer 7

• dental and family history: trauma, previous ortho treatment
• radiographs: review pre-treatment lengths
• light forces during treatment and minimise treatment length
• if patient at risk, repeat radiographs 6 months into treatment

Question 8

How is pulp damage related to orthodontics?

Answer 8

Nearly all patients experience pain when orthodontics are fitted
- some may be due to pulpal ischaemia as tooth movement starts, disruption to blood supply
- pulp death/damage is very uncommon
- tooth movement may be responsible for flare up of a pre-existing periapical area

Question 9

What are some risk factors for pulpal damage?

Answer 9

• pulp vitality needs to be monitored in previously traumatised teeth, may be at risk of pulpitis
• if teeth are traumatised during treatment, pulp vitality should be monitored with thermal or EPT
• care should be taken when using rotary instruments incase heat damages pulp chamber

Question 10

How can we manage pulp damage?

Answer 10

• pulpal ischaemia is transient and little can be done to prevent it
• patient must be warned that pain is likely and can last between 2-7 days after appliance is fitted or adjusted
• paracetamol and ibuprofen effective in reducing pain
• in patients with heavily restored dentition, some discussion on the risk of periapical abscess may be appropriate

Question 11

How can gingival/periodontal problems arise from ortho treatment?

Answer 11

• increased gingival inflammation due to poorer access for cleaning
• some apical migration of periodontal attachment and alveolar bony support during course of treatment
• poor gingival health prior to starting treatment –> unsuitable for treatment
• adults may seek treatment due to periodontal drift
• pseudo-pocketing due to inflammation may give a false pocket
• poorly controlled diabetes or anti-epileptic medications are more at risk of gingival overgrowth

Question 12

How is periodontal problems managed?

Answer 12

• OHI
• obtain good gingival health before treatment begins
• maintenance regime: regular periodontal monitoring and 3 monthly scales
• because of altered soft tissue balance in perio patients, may need permanent retention after treatment (bonded retainer on back of teeth)

Question 13

How can soft tissue damage occur and be prevented?

Answer 13

• traumatic ulceration
• friction against components of appliance
• archwire ends not tucked away, clumsy instrumentation
• provide patient with vegetable wax to cushion soft tissues
• chlorhexidine mouthwash can be effective at relieving the discomfort of oral ulceration