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Your Patients, Orthodontics, and Gingival Inflammation

There has never been a better time to consider orthodontic treatment, especially for children and adolescents. Orthodontic brackets are smaller and less noticeable than ever before, new materials make tooth movement faster and more comfortable, and, socially, having orthodontic appliances has become the rule rather than the exception.


Challenges to Orthodontic Treatment

Some things about orthodontic treatment, however, have not changed, particularly the need for meticulous cleaning around brackets and archwires. Emphasis on proper orthodontic cleaning is significant, not only in encouraging successful treatment, but also in encouraging oral hygiene compliance after the appliances are removed. There are, however, numerous challenges to proper oral hygiene to be considered, perhaps the most obvious being the hardwire itself. Adapting oral hygiene devices, particularly dental floss, around and through brackets and archwires is not only difficult for young hands, but time-consuming and tedious—something an active adolescent may resist.

A second challenge involves the common timing of orthodontic treatment. Given that most patients begin the process between the ages of 9 and 16, it is likely treatment will coincide with puberty for many adolescents. The influx of hormones associated with this age group can make dental tissues more vascular and prone to bleeding and inflammation. It is also worth noting that puberty can be a confusing and difficult time, and sometimes even the most compliant child may have moments of uncooperativeness.


Developments in Hygiene Technology

Fortunately, current dental technologies offer several successful solutions. The past twenty years have produced newer, more effective power toothbrushes that can simplify cleaning for any orthodontic patient. Whether the choice of mode is sonic or oscillating, using a power brush can make brushing easier, as the user no longer has to worry about brushing action, only proper placement. While this cannot guarantee more effective brushing, it may increase the likelihood, since correcting one behavior (ie, bristle placement) is easier than correcting two (ie, placement and motion). It is well established that power toothbrushes can improve plaque removal and reduce gingivitis. In some cases, they may even enhance compliance in those with poor oral hygiene.

No matter how efficient and effective the power toothbrush, most patients with orthodontic appliances need some type of interdental cleaning to prevent potential periodontal breakdown during orthodontic treatment (Figure 1). Fortunately, there are many clinically proven alternatives to dental floss, which are easy to use and patient-friendly. Interdental brushes, picks, wooden sticks, and power flossers are easy to use and have scientific data demonstrating comparable efficacy to traditional flossing.1 These welcome alternatives to floss provide orthodontic patients with choice—and personal choice can be a powerful motivational tool.

Two other, often overlooked alternatives to dental floss are rinsing and oral irrigation.1,2 An essential oil mouthrinse has been shown to work as well as dental floss in reducing plaque and gingival inflammation.3 Oral irrigation via a pulsating dental water jet with water has shown comparable effectiveness to dental floss in two separate studies.3,4 Using a standard jet tip, a dental water jet paired with either a manual or power toothbrush reduced plaque as effectively as flossing, was up to 93% more effective in reducing bleeding, and was up to 52% more effective at reducing gingivitis (Figure 2).3 A second study used a tapered tip with soft bristles and removed three times more plaque than brushing and flossing and five times more plaque than brushing alone. Bleeding was reduced 85% from baseline, a 26% better reducing than with floss.4 A dental water jet has the potential to reach places no other device can access. Most will accommodate an essential oil mouthrinse.



Because orthodontic treatment is most common in pre-adolescents and teenagers, satisfactory hygiene compliance can arise as an issue. Good oral hygiene, however, is integral to successful orthodontic treatment, and advantages should be taken in regard to the new technologies intended to clean effectively and increase compliance. By suggesting youth-friendly devices and alternative techniques to traditional brushing and flossing to patients, dental practitioners can not only emphasis proper orthodontic care, but encourage a lifetime of effective oral hygiene long after the appliances have been removed.


*Fort Collins, Colorado



  1. Asadoorian J. Flossing: CDHA position paper. CJDH 2006;40(3):1-10.
  2. Asadoorian J. CDHA position paper on commercially available over-the-counter oral rinsing products. CJDH 2006; 40(4):1-13.
  3. Barnes CM, Russel CM, Reinhardt RA, 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):71-77.
  4. Sharma et al. The effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent patients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop 2008 Apr;133(4):567-571; quiz 628.e1-2.
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