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September 12, 2008

By Jaimee Morgan, DDS, and Stan Presley, DDS

When the smooth surfaces of teeth are interrupted by orthodontic brackets, maintaining plaque control can be a challenge for the clinician and the patient. The potential for gingival inflammation and enamel decalcification runs high among these patients as well. Changing wires and/or elastics in the presence of gingivitis can prove painful to patients and may decrease access and visibility to the clinician, thereby slowing down treatment. Evidence of decalcification at the completion of the orthodontic treatment is a lose-lose situation in that patients do not end up with the perfect smiles they were planning on, and the clinician's hard work is not showcased because of the distraction of the marred teeth. Inspiring orthodontic patients to invest in thorough oral hygiene measures may require not only a bigger effort in oral hygiene education, but also an element of creativity.

Of course there are the traditional home methods for keeping the teeth clean and healthy such as disclosing tablets, brushing, fluoride (rinses, pastes, gels, etc.), flossing, and oral irrigators (e.g., Waterpik). When patients come in for their orthodontic visits, an ultrasonic scaler (e.g., Cavitron, Dentsply International) can be invaluable in quickly removing debris from around the brackets. Applying fluoride varnish can also be instrumental in the fight against decalcification. However, with the implementation of longer lasting wires, it's not unusual for orthodontic patients to go eight or more weeks in between visits. Fewer visits mean fewer opportunities to provide in-office oral hygiene care and less time to reeducate and emphasize the importance of home care.

Motivational creativity may be the answer

Carbamide peroxide, hydrogen peroxide, and tray-delivered fluoride have been known to decrease plaque. With the decrease in plaque accumulation also comes a decrease in inflammation, decalcification, and the incidence of decay. Due to the common misconception that these materials must use custom delivery trays, orthodontic patients usually don't get to benefit from their use. Custom delivery trays used in an orthodontic patient could obstruct the planned movement of the teeth, or as the teeth moved, the trays would no longer fit. New delivery systems with prefilled, semi-custom, disposable trays address this problem.

Carbamide peroxide was introduced in the late 1960s as an oral antiseptic. It has been shown to be both safe and effective in reduction of plaque, inflammation, and decay.(1,2,3,4,5,6,7,8,9,10). Carbamide peroxide's whitening effects were discovered by accident in the late 1960s by an orthodontist (Klusmier) using removable appliances containing carbamide peroxide to improve the health of the gingival tissue. Its whitening effects were emphasized in an article in 1989 using a custom tray delivery system, and since then, carbamide peroxide's other benefits have been overshadowed.(11).

Fluoride inhibits the growth of bacteria and is credited with enhancing remineralization of enamel.(12). With fluoride present during the remineralization process, fluorapatite is formed, which is less pervious to acid than the original carbonated calcium hydroxyapatite. Fluoride also has long-term desensitizing effects. The desensitizing effects of fluoride come from its ability to block the tubules and slow the flow of fluid that causes sensitivity.(13). Potassium nitrate is also a desensitizing agent and has been used in toothpastes (e.g., Sensodyne, GlaxoSmithKline U.S.) for many years. Similar to hydrogen peroxide, potassium nitrate easily penetrates the tooth and has a direct effect on the nerve. It interrupts the pain cycle by preventing the nerve from repolarizing after it has depolarized. Potassium nitrate is used primarily for acute sensitivity. The recent addition of fluoride and potassium nitrate to hydrogen peroxide and carbamide peroxide bleaching agents has shown a decrease in the incidence of sensitivity from bleaching. Research reports this combination of potassium nitrate and fluoride also provides improvement in the microhardness of the enamel.(14,15,16,17).

With all the benefits that carbamide peroxide, hydrogen peroxide, fluoride, and potassium nitrate together have to offer, there's no better recipient than the orthodontic patient. The delivery systems that provide all these materials in one disposable tray are Treswhite Classic and Treswhite Ortho (Ultradent Products, S. Jordan, UT). The prefilled, adaptable, disposable trays have a 5% carbamide peroxide gingival barrier and a 9% hydrogen peroxide gel in the tray with potassium nitrate and fluoride. These trays easily adapt to and around the orthodontic appliance. The patient wears each tray only 30 to 60 minutes per day due to the high concentration of bleaching agent. Nine percent hydrogen peroxide is approximately equal to 30% carbamide peroxide. Although the patient will benefit from the whitening effects of this high-concentration bleaching agent, the other benefits may not be as apparent because of the limited contact time. In order to increase contact time, the percentage of hydrogen peroxide would need to be lowered.

Just like the adaptable, prefilled bleaching trays mentioned above, there are trays that are prefilled with fluoride and trays that are prefilled with a combination of fluoride and potassium nitrate without the bleaching agent. Have the patient add a 10%, 15%, or 20% carbamide peroxide gel containing additional potassium nitrate and fluoride (PF) to the trays prior to inserting them into the mouth. The whitening component provides the motivation for the patient, while the other ingredients have been shown to improve gingival health and increase the microhardness of the enamel as well as decrease potential for sensitivity during the bleaching treatment. The fluoride and fluoride/potassium nitrate combination gels that line the prefilled trays along with the added sustained release carbamide peroxide with PF (Opalescence PF bleaching gels, Ultradent Products, S. Jordan, UT) are active approximately eight to 10 hours. Have the patient increase the wearing time and reap the benefits of a prolonged exposure to all the ingredients.

Considering that the motivating factor behind most orthodontic treatment is the desire to have a more esthetic smile, that same objective can be used to help improve the oral hygiene of these patients. Scherer reported in his study that patients appeared to be motivated in their oral hygiene home care when bleaching.(18) Let your patients know that periodically you will be whitening their teeth during their orthodontic treatment. Suggesting bleaching during orthodontic treatment creates interest because most of them will want to know what will happen in the areas where the brackets are. Once it's explained to them that carbamide peroxide and hydrogen peroxide readily penetrate the teeth and that those molecules go in all directions — even under the brackets — that initial interest turns to motivation.

Case presentation one

In an effort to enhance the struggling oral hygiene efforts of a 23-year-old orthodontic patient, a combination treatment using potassium nitrate, fluoride, and carbamide peroxide was provided. The whitening effects held her interest, while the clinician was focused on the benefits to the gingival tissue and the health of the teeth. The regimen was easy enough for the patient in that all she had to do was remove the prefilled, adaptable potassium nitrate with fluoride tray from the package (UltraEze, Ultradent Products, S. Jordan, UT) and syringe a thin ribbon of the 10% carbamide peroxide with PF (Opalescence 10% PF, Ultradent Products, S. Jordan, UT) between the ribbons of PF that were already in the tray (Figure 1).

Figure 1

Once she placed the tray in her mouth, a simple swallowing action provided the initial adaptation of the tray to her teeth (Figures 2 and 3).

Figure 2

Figure 3

Removal of the colored outer tray was the next step, which left the remaining clear inner tray in place on the teeth and the orthodontic brackets (Figure 4).

Figure 4

Gentle pushing of the tray gingival to the brackets would add the final adaptation needed to keep it comfortably in place (Figure 5).

Figure 5

The patient was instructed to wear the tray as many hours as she could every day for the next 10 days to obtain the fastest whitening results.

Using in-office or power bleaching as a motivational tool can be effective too. Because of the short contact time, in-office bleaching may not provide all the benefits of the trays containing PF and carbamide peroxide and/or hydrogen peroxide. Nevertheless, it's still an excellent method of cleaning up around the brackets and whitening the patient's teeth during orthodontic treatment. The hydrogen peroxide will bleach under the brackets in the same way that the above mentioned trays do. Applying a prefilled tray of potassium nitrate and fluoride to the teeth after the in-office procedure is completed will decrease the potential for sensitivity and add some of the other benefits that PF provides. A side benefit of both in-office and home bleaching methods is that stain from around and on porcelain brackets is removed.

Case presentation two

A 9-year-old male patient had been in orthodontic treatment for several months when he started asking questions about whitening his teeth. There are no contraindications to whitening the teeth of young patients or even whitening patients with mixed dentition. Maturity and compliance are two factors to consider when choosing bleaching patients, and this patient exhibited both. With the patient fully reclined, the orthodontic wire was removed, lip moisturizer was applied to his lips, and cheek retractors were placed (KleerView Cheek Retractor, Ultradent Products, S. Jordan, UT) (Figure 6).

Figure 6

A combination bite block-tongue retractor was then placed (IsoBlock, Ultradent Products, S. Jordan, UT), and the patient was instructed to keep his tongue behind the tongue retractor during the procedure. The gingival tissue was then air-dried and a resin gingival barrier (OpalDam, Ultradent Products, S. Jordan, UT) was syringed onto the gingival margins of the teeth to be bleached overlapping approximately 1 mm onto the teeth. The barrier was also extended one tooth beyond where the bleach was to be placed. The resin barrier was then light cured. Once the teeth were isolated, the chemically activated 38% hydrogen peroxide bleaching agent (Opalescence Boost, Ultradent Products, S. Jordan, UT) was mixed using a syringe to syringe method. The bleach was only applied to the incisal half of the teeth to show how effectively the bleaching agent travels once it penetrates the teeth (Figure 7).

Figure 7

The gel remained on the teeth for 15 minutes, was removed, and reapplied for a total of two cycles. Normally, four 15-minute applications would have been used, but most likely due to the patient's young age, successful whitening results were accomplished in half the time. Surgical suction was used to remove the gel with no rinsing of the teeth between applications. After removal of the second application, the teeth were thoroughly rinsed. The OpalDam was easily removed by using an explorer to pull it away at the corners and peeling it from the tissues. The adverse effects of bleaching on bond strengths lasts approximately seven days and it is imperative to wait at least seven days after bleaching is completed before performing any bonding treatments including repositioning brackets.(19) The patient returned to the office three weeks after bleaching for evaluation. To show there was no dark or discolored area where the bracket had been, the bracket on Tooth No. 9 was removed. Comparing the maxillary bleached teeth with the mandibular unbleached teeth, it was apparent that significant whitening had been accomplished from incisal edge to gingival margin even in the areas of the tooth where no bleaching agent was applied (Figure 8).

Figure 8

Also, by bleaching the upper teeth first, the result was most dramatic because it allowed the patient to see how successful the treatment was when compared to the unbleached lower teeth.

Achieving and maintaining good oral health should always be at the top of the list of priorities. At the same time, the patients' esthetic needs should also rank high on the list. By bleaching with a potassium nitrate and fluoride containing formula, both oral health and esthetics can be improved. Whiter teeth with an increased microhardness of the enamel, reduced plaque formation, decreased inflammation, and decreased incidence of decay are benefits most any patient would want and your orthodontic patients especially need.

Jaimee Morgan, DDS, received her dental degree from the University of Texas Health Science Center at San Antonio. She divides her professional career between clinical practice and teaching. Her lectures have spanned the globe from the United States to Europe, South America, Australia, and Asia. She regularly contributes articles to dental periodicals and journals on cosmetic dental techniques for the general practice. She has served as a founding member of the South Texas Chapter of the American Academy of Cosmetic Dentistry, and has given numerous lectures at major national dental meetings. She is currently on the Board of Directors of the American Orthodontic Society. Salt Lake City, Utah, is the site of her dental practice where she provides both cosmetic restorative and orthodontic treatment with her husband, Dr. Stan Presley. She has earned the reputation of teaching cosmetic and orthodontic techniques using a practical approach that is both enjoyable and useful.

Stan Presley, DDS, received his doctorate degree from Baylor College of Dentistry in 1977. His training at the L.D. Pankey Institute and Dr. Bob Gerety's straight wire continuum has provided him with a sound cosmetic treatment philosophy. Dr. Presley was one of the founding members of the South Texas Chapter of the AACD where he served as secretary and vice president. In recognition of the need to provide an alternative to porcelain restorations in his practice, Dr. Presley focused his attention on conservative esthetic restoration combined with orthodontic treatment. He is co-developer of the Simplified Layering Technique for composites. Dr. Presley lectures internationally using both didactic and hands-on courses and has contributed numerous articles demonstrating realistic and learnable procedures for general practitioners. He currently practices orthodontics, cosmetic, and restorative dentistry with his wife, Dr. Jaimee Morgan, in Salt Lake City, Utah.

References

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