The
Oral Hygiene Instructions from the Orthodontist’s Point of View: a Questionnaire
among Syrian Orthodontists
ABSTRACT
Introduction: Little
is known about the presentation of oral hygiene instructions by orthodontists
in
Materials & Methods
The sample of this
study consisted of 100 syrian
dentists specialized in orthodontics. Questionnaire papers were sent to them
including one question:
“What are the oral
hygiene instructions you give to your patients after the placement of the
orthodontic appliance in his/her mouth?”
Results
Our results demonstrated
that almost every orthodontist (97%) in
It was also shown
that the orthodontists recommend Chlorhexidine mouthwashes (38%), Fluoride mouthwashes (53%),
dental floss (12%), disclosing tablets (16%), and the oral irrigator (21%)
as additional aids to maintain the patient’s oral hygiene within high levels.
Conclusion
The concept of
establishing high level of oral hygiene in patients during orthodontic treatment
among the syrian orthodontists in this sample
of study is still not really understood. Further education for orthodontists
in this field is still needed.
Key Words: Oral
Hygiene – Orthodontic Treatment – Toothbrush –Mouthwashes.
A high standard
of oral hygiene (OH) is essential for patients undergoing orthodontic treatment.
Without good oral hygiene, plaque accumulates around the appliance, causing
gingivitis and, in some cases, periodontal breakdown. To avoid such problems,
the orthodontist has a double obligation: to advise the patient about methods
of plaque control and, at routine visits, to monitor the effectiveness of
the oral-hygiene regime. However, despite receiving appropriate advice, many
patients undergoing orthodontic treatment fail to maintain an adequate standard
of plaque control. It is important that the orthodontist is able to communicate
the importance of oral hygiene to motivate patients to maintain a satisfactory
standard of oral hygiene during orthodontic treatment.
Before any orthodontic
treatment an initial diagnosis and referral for treatment to control active
periodontal disease is to be considered. Moreover, any dental and/or periodontal
treatments should be completed before the orthodontic treatment.
Once the orthodontic
appliances are placed in mouth, the patients need to be instructed on how
to manage the new oral environment and how to maintain the health of the dental
and periodontal structures. The orthodontist has to provide the patient with
initial brushing instructions with either a conventional toothbrush or a powered
one when the appliances are first placed.
Manual tooth brushing,
one of the oldest methods of plaque removal, remains the basis of oral hygiene
and plaque control. It is often used as the standard or control against which
other methods of plaque removal are assessed [1] [2]. Instruction should emphasize
the need to use sufficient pressure to remove plaque; a pressure sensitive
toothbrush would be a valuable aid to patients undergoing orthodontic treatment.
A number of studies have evaluated the effect of mechanical aids, as compared
with manual tooth brushing, on oral hygiene in orthodontic patients. They
found that the use of electric toothbrushes brought a significant improvement
in oral hygiene [3] [4].
Chlorhexidine
mouthwashes, as an adjunct to tooth brushing, have been found effective in
the control of gingival inflammation [5], although prolonged use may cause
problems with staining. More recently, pre-brushing rinses have been introduced,
though these show no differences in effect on plaque accumulation or gingival
health [6]. One of the main problems with Chlorhexidine
rinses is that they can potentially stain the margins of composite restorations
that cannot be easily removed. Chlorhexidine is
also useful for patients after orthognathic surgery,
especially if intermaxillary fixation is used.
Fluoride mouth
rinses significantly reduce the extent of enamel decalcification and gingival
inflammation during orthodontic treatment [7] [8].
The orthodontist
can follow some suggestions in order to improve plaque removal by the patient.
Bonding of molars results in better periodontal health than
banding. Whenever possible, the use of single arch wires is recommended.
The removal of excess composite around brackets, especially at the gingival
margin, and avoiding the use of lingual appliances whenever possible are also
important ideas in order to keep healthy periodontal tissue during any orthodontic
treatment [9]. And here comes the question: Does the orthodontist have extensive
education in the field of oral hygiene instructions to be given to patients
during orthodontic treatment phases in order to obtain excellent results?
Our study investigates
how aware orthodontists are of the importance of giving (OH) instructions
from a sample of orthodontists in
Methods:
Sample collection:
The sample of the
study consisted of 100 dentists specialized in orthodontics. The names, addresses
and phone numbers of those dentists could be obtained from “The Medical Index
of Dentists in Syria- Version 2004”.
Unfortunately,
because of the lack of many addresses of orthodontists outside Damascus, the
researcher decided to limit the study to orthodontists in Damascus city (the
capital), and to exclude those who work in other cities in Syria.
Only orthodontists
were who were in the specialty for 5 years or more were selected.
The sample of this
study is referred to as systemic sample, which was obtained by first enumerating
the population (all the dentists’ names listed) and then by selecting the
sample by a preordained periodic process by taking every second name listed
in the index of the dentists.
The questionnaire
preparation:
The questionnaire
paper consisted of one simple question which was:
“What are the oral
hygiene instructions you give to your patients after the placement of the
orthodontic appliance in his/her mouth?”
This question was
followed by several choices:
The
normal manual toothbrush.
The
electric toothbrush.
Chlorhexidine mouthwashes.
Fluoride
mouthwashes.
Dental
floss.
Disclosing
tablets.
The
oral irrigator.
Other
techniques.
None
of the above.
The orthodontists
had to cross out one or more answers from the choices listed above.
Every
questionaire was mailed with a pre-addressed stamped envelope to simplify
the return. .
The questionnaire
papers were sent to the chosen addresses within two weeks.
Results:
After 2 months,
78 letters were returned from the 100 of the orthodontists sampled. Before
analysing the results, the researcher decided to call back -by telephone-
the orthodontists who did not answer the questionnaire in order to get an
instant answer for completing the data collection. The number of the questionnaire
papers then became 100 with full answers.
The results were
subjected to a descriptive statistical analysis in order to demonstrate a
clear view of the ratios.
It was shown that
97% of the orthodontists advise their patients on use the normal manual toothbrush
during the orthodontic treatment phases, while only 6% of mentioned the electric
toothbrush as an aid.
38% of the orthodontists
were shown to advise their patients to use the Chlorhexidine
mouthwashes. 53% of the sample study indicated they adivised Fluoride mouthwashes
as an adjunct during the orthodontic treatment. In the area of additional
aids for the enhancement of oral hygiene during the orthodontic treatment,
12% of orthodontists were shown to advise the use of dental floss, 16% mentioned
the use of disclosing tablets and 21% of the orthodontists indicated the use
of an oral irrigator. 42% of orthodontists mentioned ‘other techniques’ and
none of them (0%) selected the choice of ‘None of the above’.
The results of
the questionnaire are described in table (1).
|
The oral
hygiene technique |
Manual
toothbrush |
Electric
toothbrush |
Chlorhexidine
mouthwashes |
Fluoride
mouthwashes |
Dental
flossing |
Disclosing
tablets |
Oral irrigator |
Other
techniques |
|
Percentage
of orthodontists who advice this sort of use |
97% |
6% |
38% |
53% |
12% |
16% |
21% |
42% |
Table (1): The results of the questionnaire
Discussion:
It is well recognized
that the patients who undergo orthodontic treatment are more likely to suffer
gingivitis and different levels of periodontal breakdown during the orthodontic
treatment phases. In most cases, the patients do not know exactly how they
can maintain the high level of oral hygiene which is conducive to excellent
orthodontic treatment results. It is the orthodontist’s responsibility to
teach his/her patients the right way to perform the different methods needed
for oral hygiene maintenance. However, many orthodontists fail to give the
patient good instruction in appropriate techniques to get the results needed.
The results of
the current study showed that almost every orthodontist (97%) in
Although the use
of electric toothbrushes brought a significant improvement in oral hygiene
as mentioned in many studies, the results of our study demonstrated that only
6% of orthodontists recommend the use of electric toothbrushes. This may be
related to the financial circumstances of the patients themselves.
It was shown that
38% of the orthodontists check the use of Chlorhexidine mouthwashes as an adjunct to maintain the oral
hygiene, and 53% mentioned Fluoride mouthwashes. However, sufficient data
could not be obtained in this study about the dosages of these mouthwashes
prescribed by the orthodontist. Nearly the half of the orthodontists may have
mentioned Fluoride mouthwashes because of the known efficacy of Fluoride in
reducing the prevalence of dental carries and the gingival inflammation.
Although
the self-use of disclosing tablets by the patients to disclose dental plaque
accumulation is well known, our results showed that only 16% of the orthodontists
advised the use of these tablets. However, whether the orthodontist
taught his/her patients how to use the disclosing tablets could not be discovered
in this study. It is possible that the orthodontist himself did not know how
importance of this self-evaluating method for the patients in maintainence
of oral hygiene.
21%
of the orthodontists advise their patients to use an oral irrigator.
The high prices of these devices may explain the low ratio.
Unfortunately,
the results of this study showed that only 12% of the orthodontists in
However, it seems
that oral instructions alone would not be sufficient when a high level of
oral hygiene needs to be achieved during orthodontic treatment.
More studies are
needed to uncover the real factors which determine the relationship between
the dentist and the patient, and also to learn how to control the patient’s
behavior in the dental clinic.
According to the
results of this study, the orthodontists in
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