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upfront Opinion Ian McConnachie DDS MS Orthodontic-Related Decalcifications and Caries: It’s Time for a Shift in OutcomesW e all have patients who pleted. Reports indicate that decalci- at-home use, with the support of the complete a comprehensive fication can start within the first orthodontic office. The communica- course of orthodontic care month after bracketing;1 on facial sur- tion must be ongoing and three-way.and look forward to enjoying the faces, it mostly occurs around and Preventive strategies depend onpleasure of a beautiful new smile. It gingival to the brackets.2 The devel- level of risk and fall into two generalis deeply disturbing when our patient opment of decalcification and decay categories: diagnostic techniques andinstead faces unsightly decalcifica- with these patients is a failure equally therapeutic interventions. All ortho-tions and decay. One such case is one of the orthodontic team, the primary dontic patients should have a com-too many. A leading orthodontic care team, and the family. Solutions prehensive oral examination,speaker, Dr. Gerry Samson, suggests to this problem equally lie with this including bitewing radiographs, com-the desired orthodontic outcome is same triad. pleted pre-treatment. During activegood function, esthetics and stability. When orthodontic treatment is treatment with fixed appliances, up-When there is decalcification and scheduled to start, the primary care dated bitewings must be scheduled atdecay, this is a failure to achieve the dental office and the orthodontic of- appropriate intervals; this may neces-esthetic outcome. This situation is to- fice should begin a collaboration and sitate co-ordination of visits such thattally preventable and I believe it is communication triad with the patient the orthodontist removes the wires sotime to make the necessary adjust- to achieve the desired outcomes. bitewings can be taken then replacesments in care to achieve that. Gone are the days when adolescent the wires after. A very interesting and Decay risk exists for all patients to patients received essentially the same promising complementary diagnosticvarying degrees in occlusal pits and treatment and preventive measures in technique is the use of the Canaryfissures, interproximal surfaces and fa- the dental office. We know now that System, a laser-based device thatcial surfaces. Orthodontic treatment these interventions should be the re- quantifies levels of decalcification onincreases the risk of decay for a vari- sult of a thorough risk assessment. all tooth surfaces, including inter-ety of reasons. Oral hygiene is more That risk assessment should be docu- proximal. Frequencies of diagnosisdifficult; wires are in place for two to mented and shared with the patient should depend on the level of risk.three years or longer with little op- and the orthodontic office. If the or- Determining this risk requires ongo-portunity to obtain bitewing radi- thodontic office is unaware of the pa- ing monitoring of hygiene levels andographs; excess resin around brackets tient’s risk level, it should either do its for evidence of decalcification at theacts as a plaque trap; patients some- own risk assessment or request one orthodontic office and, possibly, attimes believe that because they are from the general dentist. Once risk the primary care provider as well,being seen regularly at the orthodon- level is established, the general den- with corresponding communication.tic office, they don’t need to visit their tist must create a comprehensive pre- Therapeutic interventions again be-regular dentist until treatment is com- ventive protocol for in-office and long with all three parts of the triad.14 Ontario Dentist • May 2012

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OpinionThe home care program with measures such as high fluo-ride toothpaste or oral rinses, flossing and proxy-brushesmust be reinforced by the parents. The primary care officemust schedule appropriate office visits for fluoride varnish,oral hygiene reinforcement and, in the high-risk situation,consider using anti-microbials such as povidone iodinetopically together with the fluoride varnish to dramatically Photo courtesy of Reliance Orthodonticslower Strep mutans counts.3 The orthodontic office shouldconsider fully sealing the entire facial enamel surface, notjust the surface under the bracket, at the time of bracketplacement. This should be done with a specially designedfluoride-releasing sealant material such as Reliance’s ProSeal and Opal Orthodontic’s Opalseal. The retention statusof these materials should be monitored and the sealant re-applied as necessary. What is briefly described here is a strategy to preventwhat is now a serious problem. For its success, the strategy Enamel decalcification in a teen-aged orthodontic patient.depends on commitment to current evidence-based diag-nosis and treatment planning and effective three-way com-munication and collaboration. If the primary care providerand the orthodontic provider are unsure that this can beachieved and maintained, then there needs to be serious Referencesdiscussion as to whether or not the orthodontic treatment 1. Ogaard B. et al.Orthodontic appliances and enamel dem-should even be started. We all are seeking successful out- ineralization Part 1: Lesion development, AJODO 1988 Aug;comes of function, esthetics and stability for our patients. 94(2) 113-128Twenty-first century oral health care demands no less. 2. Robertson M.A. et al .MI Paste Plus to prevent demineraliza- tion in orthodontic patients: A prospective randomized controlled trial AJODO 2011 140(5): 660-668Dr. Ian McConnachie is an ODA Past-President and a member 3. Milgrom P., Tut O.K., Mancl L.A. Topical Iodine and Fluorideof the Ontario Dentist Editorial Board. He is a pediatric Varnish Effectiveness in the Primary Dentition: A Quasi-dentist based in Ottawa. Dr. McConnachie may be contacted at Experimental Study. J Dent Child (Dec 2011)ian.mcconnachie@bellnet.ca. May 2012 • Ontario Dentist 15