Fall 2002 New and Young Member Committee:

Oral Hygiene – Take it Seriously

by Dr. Andrea Laidlaw

In our attempt to turn out exceptional functional and esthetic occlusions, it can sometimes be easy to lose the forest for the trees.

Have you ever been so focused on a particular aspect of a patient’s treatment that months can go by and you may fail to notice that other aspects of his or her treatment may be less than ideal?

This has happened to me in the area of oral hygiene a few times.

How often have you uttered the words “I need you to do a better job on your brushing and flossing,” only to then move quickly on to giving your assistant instructions for completing the patient’s appointment?

We need to remember that it isn’t enough for most kids that we quickly mention it in passing. Most patients need a little more structure.

If we as doctors don’t place adequate focus on the area of oral hygiene, how can we expect our patients to?

We have the daunting task of creating beautiful smiles using complicated mechanics for a patient pool that for the most part can be fairly non-compliant when it comes to oral hygiene. When braces come off and problems exist with either decalcification or caries, patients and parents often feel it is our fault or the fault of our appliances.

If you don’t already have a hygiene protocol in place in your office, I suggest you start one. Get all of your staff on the same page, and start educating your patients about the in office consequences of poor hygiene. Dealing with this problem early in treatment is the only time to do it.

I suggest instituting a system of positive and negative reinforcements. This can be tailored in a variety of ways to suit your individual practice style, but regardless of the specifics, the system should be followed routinely to help train patients regarding your expectations of their commitment to their own treatment.

First, patients need to be educated. In our office this is done on the banding day.

Each staff member knows our basic “script” and discusses home care, brushing, flossing, daily fluoride rinse, eating restrictions and consequences of poor home care.

I suggest writing out a basic outline of areas you want staff to discuss at this appointment. It is important that all patients get the same information delivered in a non-threatening, yet no-nonsense fashion.

Patients and parents should be privy to this information. Let the parent be with the child while your staff goes over this information, and provide a written version of all the information including your office policy on home care for the patient to take home after their banding day.

If you have a website, post it there as well, so that patients can be directed to it.

The following hygiene policy is given as an example to build from:

Set the stage – stay positive

We inform patients and parents that dental and periodontal health will be checked at each appointment by both the staff and the doctor.

When brushing and flossing are good, the patient receives a raffle ticket for our monthly drawing. A raffle or similar incentive builder can help motivate patients to try a little harder than they otherwise may have at home. We have found that our monthly gift certificate raffles have been a big success.

On the other hand, when OH doesn’t meet our standard there are a series of steps we take to ensure improvement.

First visit

When we see poor oral hygiene at the first visit we tell the patient that there is a problem and instruct on how to improve the situation. We inform the parent that we have discussed the problem with their son or daughter.

This is always done in a positive way with the message being one of concern, never criticism. Remember, this is a first offense.

A note is made in the chart that step #1 has been taken and OH should be checked first thing next visit. If improvement is not seen to a satisfactory level then we move to step #2.

Feedback

The second phase of our OH policy calls for a frontal intraoral digital image to be taken of the patient after chewing a disclosing tablet. This image serves as a concrete visual confirmation of the problem.

The patient/parent is given a copy of the image to take home along with a copy of a stock letter informing them that their son or daughter has shown unacceptable levels of home care for two consecutive appointments and if things don’t improve by the next visit we will need to remove wires and stop tooth movement until dental and periodontal health return to acceptable levels.

A copy of this picture and letter are also sent to the patient’s general dentist. We want the dentist to know that we are aware of the problem, and hold the patient’s overall dental heath as our primary concern.

We also ask the dentist to help us in this matter by checking OH, especially in those areas that show in the image as “missed spots,” at the patient’s next regular dental visit. Notes about this step and plans for the next visit are written in the chart.

Facing up – treatment comes to a standstill

Removing a patient’s wires as discussed above is step #3. It is important that adolescent patients understand that when wires are removed, teeth stop moving and in most cases, corrections regress, thus extending treatment times.

When patients understand that they in fact can have positive and negative control over how quickly their treatment progresses they usually seem to be more cooperative. Again, this is not a punitive step, but caring concern.

Tough love

The final step in this oral hygiene protocol would be removal of appliances to ensure no further damage to teeth or supporting structures due to poor hygiene. While this step is a last resort, do not be afraid to use it when it is in the best interest of the patient.

Before treatment starts, be sure to explain to parents and patients that this could happen, and what the financial ramifications would be.

When treatment is complete and braces are removed, even a “Board perfect” case looks unacceptable if there are rampant decalcifications and caries in the mouth. Neither the patient nor the doctor benefit with this scenario. Don’t let it get this far.

Each practitioner might set a different time line for the various steps in our hygiene protocols based on his or her own specific comfort levels. One doctor may move from step one to step two in fewer appointments, while another doctor may chose to give patients two to three months to show improvement. The key is consistency. Patients must first be educated as to what we expect from them during treatment and why it is important for their long-term dental health. They need to know that if they don’t live up to their end of the bargain there will be consequences both in the quality of the result and the health of the teeth and gums. A well-defined oral hygiene protocol will help you finish patients with the beautiful smiles you both desire.

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