Preventive measures used in orthodontic patients by GDPs ... · Preventive measures used in orthodontic patients by GDPs: a clinical audit SPYROPOULOS IOANNIS* (Cavendish Dental Practice)

Preventive measures used in orthodontic patients by GDPs: a clinical auditSPYROPOULOS IOANNIS* (Cavendish Dental Practice)

Standard

The gold standard was based on the findingsof Derks et al12 and Hobson et al13 who examinedhow often do orthodontists use preventivemeasures and concluded the following:1. 100% of the patients receive oral hygieneinstructions2. Dietary advice in 90% of cases3. Prescription to fluoride mouthwash in 60%

4. Prescription of chlorhexidine mouthwash in 40%5. Application of fluoride varnish in 15%6. Recommendation of use of electric toothbrush in10%

Results

The number of orthodontic referrals from22/05/2008 to 01/01/2011 were 255. From thesereferrals, 115 orthodontic patients were identified andincluded who were treated by 8 different GDPs for theperiod between 01/01/2011 and 01/02/2012. The dataextraction resulted into the following findings:1. 100% of orthodontic patients received oral hygieneinstructions2. 35% received dietary advice3. 26% were prescribed a fluoride mouthwash4. 5% were prescribed a chlorhexidine mouthwash5. Application of fluoride varnish was performed in8.6%6. There was no recommendation for use of electrictoothbrushNo other preventive measures were found to be

recorded.

Figure 1: Percentiles of preventive measures used by GDPs and orthodontists OHI: oral hygiene instructions, DA: dietary advice, FM: fluoride

mouthwash CM: chlorhexidine mouthwash, FV: fluoride varnish, ET: electric toothbrush

Figure 2: Number of orthodontic patients received the respective preventive measures

Figure 3: WSLs type II according to classification of Gorelick et al. in the cervical part of 12 and 13 and application of fluoride varnish(Duraphat®) in

the cervical areas

Discussion

The purpose of this clinical audit was to survey thepreventive measures used by dentists in one practicein Barrow in Furness in relation to current practices byorthodontists. The gold standard was set to a levelthat is considered appropriate as orthodontists dealwith WSLs in their everyday practice and it isevidenced that 37% of them have removed bracketsand bands due to the severity of WSLs14.Although oral hygiene instructions were given in all

cases, this audit highlighted the fact that GDPs did notoften give dietary advice and prescribed poorlyadditional preventive treatment regimes fororthodontic patients.

In general, it is considered best practice fororthodontic patients to use fluoride toothpaste incombination with 0.05% fluoride mouthwash daily11.This audit showed that only in 26% of orthodonticpatients fluoride mouthwash was prescribed.Furthermore, the clinical notes from 8 GDPs showedthat little is done to apply in-office measures such asfluoride varnish to reduce or prevent WSLs. This isan interesting finding considering that orthodonticpatients have little compliance with preventiveprotocols and preventive measures that areindependent of patient compliance have to beimplemented15. These findings are in contrast withthe findings of Hamdan et al.14 who found thatdentists in USA applied much more often(69%)fluoride varnish to their orthodontic patients, whichreveals that more education is needed for theprevention of white spot lesions.This audit could not record how appropriately the

preventive measures were given. Another fact is thatit was not to the intention of the author to examine ifWSLs were recorded, however, orthodontic patientseven with good oral hygiene are considered mediumto high caries risk patients due to the difficulty ofcleaning the area around the bands and brackets5.This fact shows the importance of using a strongpreventive program for every orthodontic case. Also,it was restricted in one specific practice, thoughevery dentist had a different level of clinicalexperience. In conclusion, the results of this auditcannot be generalized and they have to berestricted in this specific practice in Barrow inFurness. .

115

40

30

6

10

0 50 100 150

OHI

DA

FM

CM

FV

ETET

FV

CM

FM

DA

OHI

Introduction

White spot lesions(WSLs) have a highprevalence in the oral cavity of orthodontic patientswhich can reach 97%1. WSLs are initial cariouslesions that have been formed because part or thewhole depth of the enamel has demineralized. Lightscattering in demineralized enamel is markedlyhigher due to the increased subsurface porosity,which leads to the whiter appearance ofdemineralized enamel2. WSLs appear mostly on thebuccal surfaces and they are resistant toremineralization so that they can easily become animportant aesthetic issue for the patient3.The main etiologic factor of this clinical condition

is the acidic environment created by the oralmicrobiota of supragingival plaque after sugarconsumption, especially by S. mutans whichincreases significantly after the initiation oforthodontic treatment4. The main risk factors ofwhite spot lesions are orthodontic bands andbrackets, both of which increase plaqueaccumulation, and the reduced patient compliancein daily oral hygiene practices combined withincreased sugar consumption5,6.Nowadays, the preventive measures of white

spot lesions have reached a level where thegeneral dental practitioner(GDP) has the capacity toprescribe a plethora of adjunctive products and toapply an individual preventive program. Althoughdietary advice, use of electric toothbrush, use offluoride and chlorhexidine mouthwash andapplication of fluoride varnish can reducesignificantly the incidence of white spot lesions,excellent compliance in oral hygiene instructionsand use of fluoride toothpaste two times a day withfluoride mouthwash are the main preventionstrategies6-11.

Objectives

To determine whether the GDPs in a four surgerydental practice in Barrow in Furness utilize to thehighest standard, preventive measures for reducingthe development of white spot lesions in orthodonticpatients during their routine recall examination.

Methods

This was a retrospective audit from 01/01/2011 to01/02/2012. This time period was chosen so as toinclude a large sample size of orthodontic patients.The identification of the orthodontic patients and

the data extraction was performed by oneexaminer(IS). Orthodontic patients were identifiedby searching the referral book of the practice from22/05/2008 to 01/01/2011. Confirmation of start ofthe orthodontic treatment was done by looking inthe records of each patient either computerized orhand written and letters from the orthodontistsdescribing the progress of the referral.The data extraction was based on the clinical

notes, mainly searching for abbreviations ordescriptions for the following preventive measures:1. Oral hygiene instructions2. Dietary advice3. Prescription of fluoride mouthwash4. Prescription of chlorhexidine mouthwash5. Application of fluoride varnish6. Recommendation of use of electric toothbrushAny other preventive measures in the form of:

sealants, chlorhexidine varnish, cpp-acp paste,xylitol lozenges.

Conclusions

Preventive measures for the reduction of whitespot lesions were poorly prescribed except for oralhygiene instructions.

Recommendations

Further education for the dentists and advice fromorthodontists is recommended for GDPs in usingpreventive measures for orthodontic patients.A larger clinical audit from the University Hospitals

of Morecambe bay is needed to generalize theresults and increase their validity.

References

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2. Benson PE, Shah AA, Willmot DR(2008). Polarized versus nonpolarized digital images for the measurement of demineralization surrounding orthodontic brackets. Angle Orthod, 78: 288-93.

3. Øgaard B(1989). Prevalence of white spot lesions in 19-year-olds: a study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofac Orthop, 96: 423-7.

4. Rosenbloom RG, Tinanoff N(1991). Salivary Streptococcus mutans levels in patients before, during, and after orthodontic treatment. Am J Orthod Dentofac Orthop, 100: 35-37.

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13. Hobson RS, Clark JD(1998). How UK orthodontists advise patients on oral hygiene. Br J Orthod, 25: 64-6.

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15. Geiger AM, Gorelick L, Gwinnett AJ, Benson BJ(1992). Reducing white spot lesions in orthodontic populations with fluoride rinsing. Am J Orthod Dentofac Orthop, 101: 403-407