Volume 5, No. 1 • April 2003 Helping Orthodontic Patients In This Issue Achieve Optimum Oral Health
It is well established that an individual with orthodontic appliances
has a unique and challenging self-care situation. From a practical perspective, bands, brackets and other hardware are difficult to
effectively clean resulting in an increase in plaque accumulation,
which may lead to gingivitis. Additionally, studies have shown that the
subgingival biofilm in individuals with subgingivally placed orthodonticbands may shift to one that favors periodontal pathogens.1,2 At the sametime, Attarzadeh has noted that "in spite of good tooth cleaning, mostorthodontic patients develop generalized moderate gingivitis or an edematous type within one to two months after the placement of a fixedorthodontic appliance."3 It has been suggested that in addition toincreased subgingival plaque, the mechanical irritation of bands and/orcement may be responsible.4
Fortunately, in both adolescents and adults who are healthy, the effect
of orthodontic treatment does not appear to produce any long-term damage periodontally.5,6 However, for individuals who may have a compromised immune system4 or other significant risk factors for periodontal disease, the outcome is less well-known. Therefore, it is
extremely important for all individuals in orthodontic treatment to practice good oral hygiene. Additionally, significantrisk factors for periodontal disease, such as smoking or diabetes, may be present in adolescents as well as adult orthodontic patients, and should be addressed as a part of optimal therapy. Evaluating Risk Factors
Research now indicates that smoking and diabetes are strong risk factors for periodontal disease.7,8 Once the burden of
adult patients, an increase in both childhood and adolescent smoking (Table 1) and Type 2 diabetes (Table 2) indicatesthat these risk factors can be present in many younger orthodontic patients. While the periodontal effects of youthsmoking have not been well studied, there is research to indicate that children with diabetes have more inflammationand more severe gingivitis than their counterparts without diabetes, even when a similar amount of plaque is present.11
Life cycle changes are another factor that may influence the amount of inflammation that an orthodontic patient
experiences. Puberty, pregnancy, and post-menopause have all been associated with an increase in gingival bleeding,often times with no increase in plaque accumulation.12,13 Importantly, patients of any age may take prescription andover-the-counter medication, which can effect the oral cavity. It has been noted that of the top twenty prescribed drugs inthe year 2000, thirteen had the potential for causing xerostomia. While many of the drugs, such as Lipitor®, Celebrex™or Vioxx®, are targeted towards an adult population, others such as the asthma drug, Albuterol, or the antihistamine,Claritin®, may be utilized by adolescents. Preventive Measures
Studies have found that rather than the presence of bleeding, it is the absence of bleeding that has clinical
predictability. In sites that did not bleed or rarely bled, researchers found a 98% chance that the site would continue toremain healthy.15,16,17 Based on this information, the reduction of bleeding is still an important goal, especially fororthodontic patients.
For many, powered devices such as toothbrushes, flossers and oral irrigators may need to be a first choice rather
than an optional consideration for orthodontic patients. The use of all three devices by a patient can provide a multi-pronged approach in preventing or arresting and reversing bleeding and gingivitis.18 Importantly, these devicesare readily available at variable prices making them affordable for most patients. Table 1: Adolescent Smoking Statistics9 Helping Orthodontic Patients Achieve Optimum Oral Health (continued)
• 4.5 million US adolescents are cigarette
The evidence for power brushes shows that they are effective in
removing plaque and reducing gingivitis and bleeding. In many cases
• 90% of smokers begin before the age of 21;
these reductions have been superior to manual toothbrushes.18-20
From low-cost disposables (Figure 1) to state-of-the-art sonic speedbrushes (Figure 3), there is an effective power brush to meet the needs
• 28% of all high school students and 11% of
and budget of most orthodontic patients. Power flosser evidence shows that these devices are capable of
• Daily, 4,800 adolescents smoke their first
removing plaque and reducing gingivitis and bleeding similar to
manual floss.18,21,22 They can be of great benefit to the orthodontic
patient not only because they are effective, but also they make interdental cleaning quick, easy, and hassle free. (Figures 4 & 5).
Table 2: Diabetes Among Youth Statistics10
For maximum patient benefit, the addition of oral irrigation
(Figure 2) to brushing and flossing can further enhance gingivitis and
bleeding reductions23-30 as well as control subgingival bacteria25 and
modify the host immune response.23,24 Importantly, a recent study
has shown that individuals with diabetes who added twice daily
• Type 2 diabetes in children and adolescents
water irrigation to their oral care routine improved both oral and
systemic health parameters better than those who only brushed andflossed.23 For orthodontic patients, oral irrigation can access areas
• 80% of youth diagnosed with type 2 are
that brushing and flossing cannot. A study by Burch et al
demonstrated that oral irrigation added to either a manual or power
brushing routine could reduce bleeding (BAP) and gingivitis (GI)
better than manual brushing alone.30 (Graph 1)
Hispanic and Latino children and adolescents
In addition to improving plaque removal and reducing gingivitis,
power products have been shown to be well accepted and preferredby many patients.22,31 This is an especially important considerationwhen trying to enhance compliance. The many different types ofproducts available can be overwhelming to patients, and many willlook to their dental professional for guidance on which product bestsuits their needs. While many professionals seek to find which product is best, once clinical efficacy has been established, the bestproduct generally becomes the one that the patient likes and will use
When trying to guide patients to the best product(s) for them,
there are some things that should be kept in mind. Foremost, what isthe patient willing to spend? Once this is established, then productsin this price category can be evaluated. Second, is the patient
Graph 1: Results from Burch Study30
interested in using a power product? If there is reluctance, it may be
better to start with a low-cost disposable brush as a gateway product.
Another consideration is the oral health values of the patient. Can
they be motivated by better oral health or would an emphasis onwhiter teeth and fresher breath work more effectively? Finally,
remember to keep the products age-appropriate. Adult baby boomers
have a strong interest in gadgets and are comfortable with them.
Their Generation Y children, however, like color, movie and TV
logos, and are not influenced by brand name.
Dispensing products in the office is another viable way of
increasing patient compliance. Having products in office increases
the credibility of the recommendation and provides the potential tocapitalize on the patient's initial enthusiasm and motivation for the
suggested product. The dental professional is able to provide education
and training on the product thus helping ensure immediate product implementation by the patient. These efforts all add up to value-added
Introducing Innovative New Products from Waterpik Technologies SynchroSonic™ Plus Advanced Action Whitening Tips for the Sonic Plaque Removal System Waterpik® flosser
• Clinically proven better than manual at
• Ergonomic angled design allows better
Waterpik Wizard™ Cup & Brush Combination Disposable Prophy Angles
• Recharging base with power indicator light
• Soft prophy cup gently polishes teeth
• Two minute timer with 30 second pause signaling the
• Toothbrush-like bristles enhance stain
Helping Orthodontic Patients Achieve Optimum
dental professionals can help patients find products that will help
them have optimal oral health during orthodontic care and for the
convenience of obtaining the product in theoffice without additional travel or time neededfor a retail purchase.
The appropriate fee to charge a patient is a
question that many offices have regardingproduct dispensing. There are many viableoptions. Offices may provide the product complementary, some charge a fee commensurate with retail, while others incorporate the fee into the case presentation. Many orthodontic offices find including theproduct price in the initial case fee and introducing the device at the start of treatmentto be another beneficial aspect of achievingpatient compliance. See Table 3 for professionalpricing on some Waterpik products.
If dispensing or selling the products is not
an option. Waterpik® oral care products arewidely distributed in many mass merchandisers,drug chains, and Internet sites. Conclusion
Treating patients with orthodontic appli-
ances will be a continuing challenge for manyoral health practitioners. The careful evaluationof risk factors should not be overlooked. However, good oral health does not have to besacrificed during orthodontic care. With themyriad of power products available, most
1. Diamanti-Kipioti A. et al. Clinical and microbiological effects of
18. Jahn CA. Automated oral hygiene self-care devices: Making evi-
fixed orthodontic appliances. J Clin Periodontol 1987; 14:326-333.
dence-based choices to improve client outcomes. J Dent Hyg 2001;
2. Paolantonio M et al. Occurrence of Actinobacillus actinomycetem-comitans in patients wearing orthodontic appliances: A cross sec-
19. Bowen D. Evidence-based review of power toothbrushes. Compend
tional study. J Clin Periodontol 1996; 23:112-118. Contin Educ Oral Hyg 2000; 9(1):3-16.
3. Attarzadeh F. Water irrigating devices for the orthodontic patient. Int
20. Goldie MP. Power tooth brushing: An easy, effective way to improve
J Orthodon 1990; Spring/Summer: 17-22.
oral health. Cont Oral Hyg 2002; 2(4):28-33.
4. Atack NE, et al. Periodontal and microbiological changes associated
21. Anderson N et al. A clinical comparison of the efficacy of an
with the placement of orthodontic appliances: A review. J
electromechanical flossing device or manual floss in affecting inter-
proximal gingival bleeding and plaque accumulation. J Clin Dent
5. Boyd R et al. Periodontal implications of orthodontic treatment in
adults with reduced or normal periodontal tissues versus those of
22. Shibly O et al. Clinical evaluation of an automated flossing device
adolescents. Am J Orthod Dentofac Orthop 1989; 96: 191-199.
versus manual flossing. J Clin Dent 2001; 12:63-66.
6. Polson AM et al. Long-term periodontal status after orthodontic
23. Al-Mubarak S et al. Comparative evaluation of adjunctive oral irri-
treatment. Am J Orthod Dentofac Orthop 1988; 93:51-58.
gation in diabetics. J Clin Periodontol 2002; 29:295-300.
7. Genco RJ. Current view of risk factors for periodontal diseases. J
24. Cutler CW et al. Clinical benefits of oral irrigation for periodontitis
Periodontol 1996; 67:1041-1049.
are related to reduction of pro-inflammatory cytokine levels and
8. Grossi S et al. Assessment of risk for periodontal disease. I. Risk
plaque. J Clin Periodontol 2000;27:134-143.
indicators for attachment loss. J Periodontol 1994; 65: 260-267.
25. Chaves ES et al. Mechanism of irrigation effects on gingivitis. J
9. American Lung Association® Fact Sheet on Teenage Tobacco Use;
Periodontol 1994; 65: 1016-1021.
American Lung Association® www.lungusa.com/tobacco Accessed:
26. Newman MG et al. Effectiveness of adjunctive irrigation in early
periodontitis: Multi-center evaluation. J Periodontol 1994; 65:224-
10. Basic Diabetes Information. American Diabetes Association;
27. Flemmig TF et al. Adjunctive supragingival irrigation with acetylsal-
11. Mealey B et al. Position paper: Diabetes and periodontal diseases. J
icylic acid in periodontal supportive therapy. J Clin PeriodontolPeriodontol 2000; 71(4): 664-678.
12. Perno M. Estrogen and its effect on the oral cavity. Access 2000;
28. Flemmig TF et al. Supragingival irrigation with 0.06% chlorhexi-
dine in naturally occurring gingivitis I: 6-month clinical observa-
13. Reinhardt RA et al. Influence of estrogen and osteopenia/osteoporo-
tions. J Periodontol 1990; 61:112-117.
sis on clinical periodontitis in postmenopausal woman. J
29. Lobene RR. The effect of a pulsed water pressure cleansing device
Periodontol 1999; 70(8):823-828.
on oral health. J Periodontol 1969; 40:51-54.
14. Spolarich AE. The top 20 most commonly used prescription medica-
30. Burch et al. A two-month study of the effects of oral irrigation and
tion for 2000. Access 2001; 15(8):54-57.
automatic toothbrush use in an adult orthodontic population with
15. Lang NP, Joss A, Osanic T, Gusberti FA, Siegrist BE. Bleeding on
fixed appliances. Am J Orthod Dentofac Orthop 1994;106:121-126.
probing: A predictor for the progression of periodontal disease? J
31. Warren et al. A practice-based study of a power toothbrush:
Clin Periodontol 1986; 13:590-596.
Assessment of effectiveness and acceptance. J Am Dent Assoc 2000;
16. Joss A, Adler R, Lang NP. Bleeding on probing. A parameter for
monitoring periodontal conditions in clinical practice. J Clin
32. Marconi J. Future marketing: Targeting Seniors, Boomers, andPeriodontol 1994; 21: 402-408. Generations X and Y. 2001. Chicago: NTC Business Books.
17. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on prob-
33. Kirk J. The power of tweens. Forget the 18-24 year-olds; advertisers
ing. An indictor of periodontal stability. J Clin Periodontol 1990;
and manufacturers are now swooning over the 8-12 set. ChicagoTribune. September 4, 2002. www.chicagotribune.com
1730 E. Prospect Rd. Fort Collins, CO 80553-0001(800) 525-2020
Academic Position: Clinical Practice: 7501 NW 4th Street, Suite 215 Plantation, Florida 33317 Specializing in Stress, Trauma & Addiction Work Phone: Email Address: Florida License: Connecticut License : Education 2000-2003 Doctor of Philosophy in Clinical Psychology Nova Southeastern University, Center for Psychological Studies Master of Science
AmeriChoice Pharmacy & Therapeutics Committee Minutes June 17, 2009 Meeting Date: June 17, 2009 Location: Via conference call D. Morgan, J. Bellicini, R. Brekosky, J.Weiss, R. Justman, S. Nichols, C. Freed, M. Mahler, S. Stein, E. Francis, B. Selius, A. Burkins, M. Reich, J. Carlson, V. Members in Attendance: Members Absent: J. Hancovsky, S. Bush, G. Fleszar, D. Rose, K. Top