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Let's get this straight!

By Eileen Morrissey, RDH, MS

Today's column speaks to a phenomenon that I've been aware of for a long time but have never written about. Since college students are now off for the summer, many are showing up in the general dental office where I spend two days each week in practice. As I reacquaint myself with the students, there is a trend I see in this age group that bothers me.

I observe the beautiful dentitions of these 19- to 22-year-olds, most of whom underwent orthodontia while they were in middle or high school. Invariably, it appears that as much as 80% of them exhibit signs of lower anterior crowding. (The exceptions are those who are wearing a permanent wire bonded to the lingual of Nos. 22 through 27.) Mind you, there are others not wearing a wire that do not show any crowding, but they are the minority. I routinely ask all client patients if they are wearing their retainers, and the overwhelming majority shake their heads and respond in the negative.

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The conclusion I have reached is that while these students are under the roofs of their parents, they use their retainers. Once left to their own devices, they stop wearing their retainers for a time, and then, even if they try to resume, the retainers are uncomfortable or no longer fit.

Some come to my treatment room aware that their teeth have shifted, yet they do not seem to understand the correlation between the shifting and the lack of retainer usage. This trend bothers me terribly. As the parent of a 21-year-old who escaped the need for orthodontia, I have nothing but hygienist empathy for parents who spend $6,000 plus, and watch their child go through a great deal of time and aggravation while undergoing the orthodontic process. There is nearly universal angst at seeing what was previously an excellent result go awry.

So the following questions and potential solutions are running through my head and I will share them with you here. Then I will share the response from an orthodontist expert.

I wonder why some orthodontists place the permanent orthodontic wires that are bonded to the lingual of the lower anteriors, and others do not? Is this decision made on a case-by-case basis? As much as I hate the calculus that seems to magnetize toward the bonding that keeps the wire in place, the wires appear to prevent the teeth from shifting. Why is it that some wires are placed coronally on the teeth so that threaders and other interproximal cleaning devices can be inserted, while more are positioned closer to the tissue so access is not allowed? This is a source of ongoing frustration for my patients and me.

Another question I have is: Do orthodontists tell happy teenagers (and parents) who have just had their braces removed that they should be prepared to wear retainers at night for the remainder of their lives? When I ask these folks what was relayed to them, not a single one has a response. Were all parties too euphoric to remember the final clinical discussion?

Here is a common sense solution to this conundrum. (I offer this understanding that I am pontificating from a place of ignorance and will happily defer to and share what I hear from orthodontic experts.) Why couldn't every teenager have a permanent lower wire bonded to their anterior lingual upon removal of their orthodontic bands? The wire would be bonded closer to the incisal edge so that the interproximal areas could be maintained. The teenager would be told that when he (or she) is about 25, he can return to the office to have it removed, provided he can commit to wearing his removable retainer a minimum of alternating overnights for the remainder of his life! Note: Since this is my hypothetical fantasy, I arbitrarily chose the age of 25, which could be adjusted in either direction.

To get straight answers (did you get that?), I turned to Dr. James Isaacson, an orthodontist who practices in West Long Branch, New Jersey. Here's his response:

"…Personally I place bonded retainers at a patient's request only after I try to talk them out of it. I believe that an orthodontist places them based on education and clinical experience. Location is important for the placement of a bonded retainer. Patient compliance is often a problem with the patient not taking ownership of personal responsibility, i.e., cleaning or wearing of retainers.

"There are pros and cons to bonded retention, and these are just a few. Pros: They remove some of the patient compliance (wearing the retainer at the prescribed time). A fixed retainer is in the mouth 24 hours per day. Cons: They only keep the teeth they are bonded to 'straight.' It is difficult for the patient, hygienist, and dentist to clean the teeth.

"The patient may not know when a tooth debonds, leading to risks of movement and hygiene problems. There is more!

"I personally do not place them and I understand the frustration with them. Retention with removable retainers usually includes 24 hours per day minus eating and brushing time for some months before reduction to nighttime wear. The day the appliances are removed, we explain retainer wear, how to take care of them, and give the patient an appointment to continue to monitor their care.

"A bonded retainer needs to be checked by the person who placed it. A retainer should also be made if the posterior teeth have been moved and worn in addition to a bonded retainer. The bonded retainers are only placed on anterior teeth..."

It is helpful to hear that orthodontists experience the same frustrations that we do with regard to all this. My thanks to Dr. Isaacson for his response. Onward we go; it is in our hearts' core! RDH

EILEEN MORRISSEY, RDH, MS, is a practicing clinician, speaker, and writer. She is an adjunct dental hygiene faculty member at Burlington County College. Eileen offers CE forums to doctors, hygienists, and their teams. Reach her at eemorrisseyrdh@aol.com or 609-259-8008. Visit her website at www.eileenmorrissey.com.

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