Addressing the oral care challenges posed by braces
By Katie Melko, RDH, MSDH
Braces, braces, braces—I don’t know about you, but I used to cringe when I got these patients in my chair. I knew that my appointment was going to be filled with poor oral hygiene and floss threaders galore. Now I welcome the changeup and don’t mind treating these patients, because I have finally found great resources and tools for both the patient and myself. As you know, orthodontics is an expensive process and it’s important for us to be able to educate parents and patients on all its aspects, from oral hygiene to nutrition.
Here’s a short overview of my recommendations: Always use an ultrasonic scaler; recommend the GumChucks flossing tool (OralWise, Inc.), a water flosser, and an electric toothbrush; provide education on a floss threader and Super Floss; and fluoride varnish at a recall appointment.
My must-have products for these appointments (with a little overlap with the suggestions I just mentioned) are: GumChucks, the Cavitron (Dentsply), 2pro disposable prophy angles (Premier Dental), Vera Advanced Bright prophy paste (Young Dental), and the Varnish Pen (Young Dental). These products help make appointments painless for the patient and provider.
If you use GumChucks during your appointments, not only are you introducing them to the parent and child during the visit by using it to floss, but you can also use it for oral health instruction and recommend this product for use at home. The company makes autoclavable handles for hygienists to use chairside; the consumer packages come with plastic handles.
The Cavitron makes it easy to remove plaque and biofilm around brackets and provide gingival tissue with a lavage treatment to push out inflammatory fluid. It will also remove calculus buildup more easily than hand scaling around brackets. I also hand scale afterward, but always start with the Cavitron.
The 2pro angles are my favorite for braces. I polish lingual and second molars first, then remove the cup and polish around brackets with the smaller tip. The smaller tip is also great at removing stubborn stain around brackets. I usually use Vera Advanced Bright polish for orthodontic patients because the baking soda will help neutralize the pH of the saliva and brighten the enamel. It helps remove stubborn stains as well.
My last must-have is the Varnish Pen by Young Dental. Its thin formula goes on clear and doesn’t clump. The teenagers really love the taste and I have not been getting the same complaints and resistance teens give me with other varnishes. I can control the amount with ease and have a hand to retract and use suction. Teens really love the bubblegum flavor!
Recare—I think four-month recalls are important for orthodontic patients for a few reasons. First and foremost, caring for teeth is a struggle for children to begin with—add a bunch of metal, and we are really in trouble. Adding an extra cleaning to the year helps me minimize severe gingivitis, increase oral hygiene instruction, and help keep decay at bay. Most parents agree. It also helps keep the parents on top of the children at home.
Home care—When doing oral hygiene instruction, I teach both patient and parent how to properly use a toothbrush, threaders, Super Floss, and an interproximal brush. Threaders and Super Floss are great ways to clean under brackets and work like regular floss, while the interproximal brush works to clean teeth from the sides. I recommend both wire and rubber interproximal brushes and let the patient decide which works and feels better for them. I also inform them that as they use the interproximal brush, they will need progressively larger brushes as the gingival tissue gets healthier.
As I mentioned above, I also recommend an electric toothbrush, water flosser, and GumChucks. Not everyone can afford these options, so I like to make sure my home care recommendations are financially realistic for patients and their families. For toothpaste, I like Arm and Hammer Truly Radiant or Colgate with Baking Soda; I feel the baking soda’s neutralizing effect on pH is very important to help decrease bacteria in the mouth, decay, and gingivitis. For mouthwash, I recommend Listerine Agent Cool Blue to help patients see the plaque they are missing, and also Listerine Zero. Both of these products help maintain good oral health and increase good oral hygiene at home.
If the patient is at high risk for caries, I recommend using Act Fluoride Rinse a couple times a week before bed. Otherwise, I recommend fluoride treatments in the office when they come in for prophy appointments. Another item I recommend, depending on the patient’s oral health and bacteria load, is a tongue scraper. Some of my orthodontic patients have heavy white biofilm buildup on their tongues and don’t even realize there is something that can be done about it. I don’t know how many times a mom complains that her child has bad breath. If the patient is compliant, usually a tongue scraper will eliminate bad breath and help boost their confidence as well.
Nutrition—The top five foods to avoid are candy, especially those that are sticky or chewy; popcorn; gum; chips; and hard crackers or cookies. When wearing braces, the foods the patient eats directly affect the success of the braces. Many children come in with missing brackets or broken wires because they were eating foods they shouldn’t have been! Or they might come in complaining of a mouth sore, usually directly from the broken wire cutting into the gingiva or cheek. I have seen popcorn kernels getting stuck and causing the gingiva to swell, because the patient can’t get it out.
One of my favorite things to say to patients on this topic is that every time they break something or pop off a bracket, the longer they will have braces on their teeth. Usually it takes only one such experience, but there are always those patients with chronic listening problems. I also have alternative snacks that I recommend for patients who keep craving things they can’t have. Patients can have fruit and vegetables as long as they cut them up, don’t bite with the front teeth, and chew the food in the back of the mouth. I just remind them to brush, brush, brush!
Consider an orthodontic patient’s home-care level, family education level, and medical history during treatment. I usually find that the first appointment after braces are placed requires much more OHI and education than anything else, for both parents and patients. After that, if the patient is compliant, your role is mostly just helping them tweak the care routine or modify their flossing or brushing to help increase oral health.
One tool I have that helps with OHI is a puppet with a set of big teeth that have braces on them. I can demonstrate what I am trying to teach, and the patient can even try it out. Once the patient gets the hang of it, I give the patient a mirror and ask him or her to practice, so I can see the technique and help. I love praising patients for their efforts; I feel this helps motivate them to keep trying, and I remind them that it does take a while to get down the motion. Whatever I can do to decrease frustration and increase compliance, I’m all for.
Picking the methods that work for you will all depend on what you have to offer and what you’re comfortable with. I strongly recommend trying out these ideas and seeing what works for you. I love working with children, and I always find myself learning something new while treating them. Enjoy taking care of them, and as always, continue to help brighten their smiles and their day!
Katie Melko, RDH, MSDH, is a public health hygienist at Community Health Center Inc. She graduated from Fones School of Dental Hygiene at the University of Bridgeport in 2016 with an MSDH. She has practiced dental hygiene since 2009.