Preventive measures used in orthodontic patients by GDPs: a clinical audit SPYROPOULOS IOANNIS* (Cavendish Dental Practice) Standard The gold standard was based on the findings of Derks et al 12 and Hobson et al 13 who examined how often do orthodontists use preventive measures and concluded the following: 1. 100% of the patients receive oral hygiene instructions 2. Dietary advice in 90% of cases 3. 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 in 10% Results The number of orthodontic referrals from 22/05/2008 to 01/01/2011 were 255. From these referrals, 115 orthodontic patients were identified and included who were treated by 8 different GDPs for the period between 01/01/2011 and 01/02/2012. The data extraction resulted into the following findings: 1. 100% of orthodontic patients received oral hygiene instructions 2. 35% received dietary advice 3. 26% were prescribed a fluoride mouthwash 4. 5% were prescribed a chlorhexidine mouthwash 5. Application of fluoride varnish was performed in 8.6% 6. There was no recommendation for use of electric toothbrush No 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 the preventive measures used by dentists in one practice in Barrow in Furness in relation to current practices by orthodontists. The gold standard was set to a level that is considered appropriate as orthodontists deal with WSLs in their everyday practice and it is evidenced that 37% of them have removed brackets and bands due to the severity of WSLs 14 . Although oral hygiene instructions were given in all cases, this audit highlighted the fact that GDPs did not often give dietary advice and prescribed poorly additional preventive treatment regimes for orthodontic patients. In general, it is considered best practice for orthodontic patients to use fluoride toothpaste in combination with 0.05% fluoride mouthwash daily 11 . This audit showed that only in 26% of orthodontic patients fluoride mouthwash was prescribed. Furthermore, the clinical notes from 8 GDPs showed that little is done to apply in-office measures such as fluoride varnish to reduce or prevent WSLs. This is an interesting finding considering that orthodontic patients have little compliance with preventive protocols and preventive measures that are independent of patient compliance have to be implemented 15 . These findings are in contrast with the findings of Hamdan et al. 14 who found that dentists in USA applied much more often(69%) fluoride varnish to their orthodontic patients, which reveals that more education is needed for the prevention of white spot lesions. This audit could not record how appropriately the preventive measures were given. Another fact is that it was not to the intention of the author to examine if WSLs were recorded, however, orthodontic patients even with good oral hygiene are considered medium to high caries risk patients due to the difficulty of cleaning the area around the bands and brackets 5 . This fact shows the importance of using a strong preventive program for every orthodontic case. Also, it was restricted in one specific practice, though every dentist had a different level of clinical experience. In conclusion, the results of this audit cannot be generalized and they have to be restricted in this specific practice in Barrow in Furness. . 115 40 30 6 10 0 50 100 150 OHI DA FM CM FV ET ET FV CM FM DA OHI Introduction White spot lesions(WSLs) have a high prevalence in the oral cavity of orthodontic patients which can reach 97% 1 . WSLs are initial carious lesions that have been formed because part or the whole depth of the enamel has demineralized. Light scattering in demineralized enamel is markedly higher due to the increased subsurface porosity, which leads to the whiter appearance of demineralized enamel 2 . WSLs appear mostly on the buccal surfaces and they are resistant to remineralization so that they can easily become an important aesthetic issue for the patient 3 . The main etiologic factor of this clinical condition is the acidic environment created by the oral microbiota of supragingival plaque after sugar consumption, especially by S. mutans which increases significantly after the initiation of orthodontic treatment 4 . The main risk factors of white spot lesions are orthodontic bands and brackets, both of which increase plaque accumulation, and the reduced patient compliance in daily oral hygiene practices combined with increased sugar consumption 5,6 . Nowadays, the preventive measures of white spot lesions have reached a level where the general dental practitioner(GDP) has the capacity to prescribe a plethora of adjunctive products and to apply an individual preventive program. Although dietary advice, use of electric toothbrush, use of fluoride and chlorhexidine mouthwash and application of fluoride varnish can reduce significantly the incidence of white spot lesions, excellent compliance in oral hygiene instructions and use of fluoride toothpaste two times a day with fluoride mouthwash are the main prevention strategies 6-11 . Objectives To determine whether the GDPs in a four surgery dental practice in Barrow in Furness utilize to the highest standard, preventive measures for reducing the development of white spot lesions in orthodontic patients during their routine recall examination. Methods This was a retrospective audit from 01/01/2011 to 01/02/2012. This time period was chosen so as to include a large sample size of orthodontic patients. The identification of the orthodontic patients and the data extraction was performed by one examiner(IS). Orthodontic patients were identified by searching the referral book of the practice from 22/05/2008 to 01/01/2011. Confirmation of start of the orthodontic treatment was done by looking in the records of each patient either computerized or hand written and letters from the orthodontists describing the progress of the referral. The data extraction was based on the clinical notes, mainly searching for abbreviations or descriptions for the following preventive measures: 1. Oral hygiene instructions 2. Dietary advice 3. Prescription of fluoride mouthwash 4. Prescription of chlorhexidine mouthwash 5. Application of fluoride varnish 6. Recommendation of use of electric toothbrush Any other preventive measures in the form of: sealants, chlorhexidine varnish, cpp-acp paste, xylitol lozenges. Conclusions Preventive measures for the reduction of white spot lesions were poorly prescribed except for oral hygiene instructions. Recommendations Further education for the dentists and advice from orthodontists is recommended for GDPs in using preventive measures for orthodontic patients. A larger clinical audit from the University Hospitals of Morecambe bay is needed to generalize the results and increase their validity. References 1. Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl- Andersen B(2005). Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res, 39: 41-47. 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. 5. Gorelick L, Geiger AM, Gwinnett AJ(1982). Incidence of white spot formation after bonding and banding. Am J Orthod, 81: 93-8. 6. Van Loveren C, Duggal MS(2001). The role of diet in caries prevention. Int Dent J, 51: 399-406. 7. 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. 8. Farhadian N, Miresmaeili A, Eslami B, Mehrabi S(2008). Effect of fluoride varnish on enamel demineralization around brackets: an in vivo study. Am J Orthod Dentofac Orthop, 133: 95-98. 9. Madléna M, Vitalyos G, Márton S, Nagy G(2000). Effect of chlorhexidine varnish on bacterial levels in plaque and saliva during orthodontic treatment. J Clin Dent, 11: 42-46. 10. Kossack C, Jost-Brinkmann PG(2005). Plaque and gingivitis reduction in patients undergoing orthodontic treatment with fixed appliances- comparison of toothbrushes and interdental cleaning aids. A 6-month clinical single-blind trial. J Orofac Orthop, 66: 20-38. 11. Benson PE, Shah AA, Millett DT, Dyer F, Parkin N, Vine RS(2004). Fluorides, orthodontics and demineralization: a systematic review. J Orthod, 32: 102-14. 12. Derks A, Kuijpers-Jagtman AM, Frencken JE, Van't Hof MA, Katsaros C(2007). Caries preventive measures used in orthodontic practices: an evidence-based decision? Am J Orthod Dentofac Orthop, 132: 165-70. 13. Hobson RS, Clark JD(1998). How UK orthodontists advise patients on oral hygiene. Br J Orthod, 25: 64-6. 14. Hamdan AM, Maxfield BJ, Tüfekçi E, Shroff B, Lindauer SJ(2012). Preventing and treating white-spot lesions associated with orthodontic treatment: A survey of general dentists and orthodontists. J Am Dent Assoc, 143: 777-83. 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
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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
1. Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B(2005). Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res, 39: 41-47.
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.
5. Gorelick L, Geiger AM, Gwinnett AJ(1982). Incidence of white spot formation after bonding and banding. Am J Orthod, 81: 93-8.
6. Van Loveren C, Duggal MS(2001). The role of diet in caries prevention. Int Dent J, 51: 399-406.
7. 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.
8. Farhadian N, Miresmaeili A, Eslami B, Mehrabi S(2008). Effect of fluoride varnish on enamel demineralization around brackets: an in vivo study. Am J Orthod Dentofac Orthop, 133: 95-98.
9. Madléna M, Vitalyos G, Márton S, Nagy G(2000). Effect of chlorhexidine varnish on bacterial levels in plaque and saliva during orthodontic treatment. J Clin Dent, 11: 42-46.
10. Kossack C, Jost-Brinkmann PG(2005). Plaque and gingivitis reduction in patients undergoing orthodontic treatment with fixed appliances-comparison of toothbrushes and interdental cleaning aids. A 6-month clinical single-blind trial. J Orofac Orthop, 66: 20-38.
11. Benson PE, Shah AA, Millett DT, Dyer F, Parkin N, Vine RS(2004). Fluorides, orthodontics and demineralization: a systematic review. J Orthod, 32: 102-14.
12. Derks A, Kuijpers-Jagtman AM, Frencken JE, Van't Hof MA, KatsarosC(2007). Caries preventive measures used in orthodontic practices: an evidence-based decision? Am J Orthod Dentofac Orthop, 132: 165-70.
13. Hobson RS, Clark JD(1998). How UK orthodontists advise patients on oral hygiene. Br J Orthod, 25: 64-6.
14. Hamdan AM, Maxfield BJ, Tüfekçi E, Shroff B, Lindauer SJ(2012). Preventing and treating white-spot lesions associated with orthodontic treatment: A survey of general dentists and orthodontists. J Am Dent Assoc, 143: 777-83.
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
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