Don't Brush This Off
From the beginning of my career more than 40 years ago, preventive dental measures have fascinated me--perhaps because they seemed so reasonable and simple to implement. Most of these measures cost little: periodic dental prophylaxes, judicious dietary choices, and relatively inexpensive home oral-hygiene instrumentation. Organized dentistry has done much to help with its sponsorship of community fluoridation, its certification of commercial dental products, and its dissemination of public information. The combination of these collective dental efforts with the personal commitment of individual dentists, who daily instruct and encourage their patients in preventive care, has given this nation the best oral health on earth.
Over the past few years, my wife and I have had an opportunity to witness first-hand the dental conditions that prevail in countries all over the globe. I?ll never forget the comment of one Slovenian orthodontist, who told me, "There is nothing on earth like the smile of an American teen-age girl." I completely concur. Each journey we make reinforces the belief that American dental health is unsurpassed, and that dentists should feel good about the role they have played in this phenomenally successful saga.
Unfortunately, what is true in the aggregate doesn't always hold for individuals. In addition to our collective measures, we still need to devise helpful and specific remedies for people with various dental ailments. Preventive dental strategies, rather than remaining passive, must have a dynamic that blends the most current knowledge and technology to produce solutions for all our patients.
This issue of JCO carries a study I recently completed with some of my most at-risk patients. A new sonic toothbrush (Sonicare) had intrigued me, and I had purchased one for my personal use. Its cleansing power and gingival stimulation seemed phenomenal. Although there were ample studies showing its effectiveness in periodontal patients, no studies had been completed in orthodontic practices. I wondered if the Sonicare might prove useful for my patients with chronically poor oral hygiene.
From work I completed several years ago, I knew that these problem patients typically have low sensitivity thresholds and respond more strongly to actual or perceived discomfort.1 Measurements and simple observations both convinced me that they are masters of what behaviorists call avoidance techniques. For them, the touch of toothbrush bristles against the gingiva is terribly discomfiting, and they avoid this unpleasant sensation by not brushing at all, or by touching the gingiva only lightly.
Since the saliva cavitation of the Sonicare allows it to clean the teeth and reduce oral pathogens with minimal brush contact, I thought it might be especially beneficial to highly sensitive patients. My subsequent study showed that such patients who used the Sonicare had less plaque and inflammation than those who used an ordinary manual toothbrush.
Recent discoveries regarding oral pathogens bring a new urgency to our attempts to improve hygiene. Matasa has reported the ability of some oral bacteria to feed on the polymers used in bonding.2 These bacteria can destroy the adhesion between tooth and bracket and contribute to bond failures. Even more threatening to orthodontic patients is the increased pathogenicity of oral flora caused by tooth mobility.3 This poses a special challenge for orthodontists and their patients, because teeth must become mobile before they can be repositioned. It also may explain why some patients have so much trouble with chronic inflammation during treatment, and why the inflammation disappears so readily after the appliances are removed and the teeth lose their mobility, with little change in the patients' oral-hygiene habits.
Considering perils such as these, orthodontists can hardly afford to disregard poor oral hygiene during treatment. I believe high-risk patients benefit greatly from an aggressive soft-tissue therapy that includes thorough gingival scaling, chemotherapeutics such as chlorhexidine and antibiotics, and improved personal oral hygiene. Simple, routine brushing probably isn't enough to diminish the increased pathogenicity in oral flora that often accompanies orthodontic appliances or to reduce the concomitant inflammation. Although patients with good brushing habits will probably gain the most from the Sonicare--simply because brushing pressures from whatever source don't intimidate them--I have seen good evidence that the most problematic patients will also benefit.
I haven't detected any signs of gingival deterioration, tooth abrasion, or orthodontic appliance destruction from the Sonicare, either in personal use or in the study I conducted. However, the study was not designed specifically to look for such effects, so I cannot say with absolute certainty that they do not occur.
The one downside to the Sonicare appears to be its relatively high cost ($100-125). I alleviate this problem for my patients by providing the toothbrush to them at my discounted professional price of $80. To some families this remains a serious obstacle, but in a culture whose citizens seem to think nothing of spending $150 for a pair of tennis shoes, maybe I am a little too sensitive about such an expense.
Lest readers wonder if I have any kind of vested interest in this technology, Optiva Corp. is a privately held company with no shares available to the public. At present, neither I nor other dentists can participate in Sonicare's investment potential.
This sonic toothbrush will not satisfy every user--and nothing can be an oral-hygiene panacea--but it can help orthodontists and their patients overcome a problem that has become more significant than we believed even two years ago.