Orthodontic first aid for general dental practitioners

Fixed appliance (Figure 2)

Removable appliance (Figure 3)

Toolkit (Figure 4)

The management of the majority of orthodontic emergencies can be performed using equipment readily available to GDPs:

Discomfort

Patients undergoing orthodontic treatment may commonly experience discomfort for a few days after the appliance is fitted or adjusted. This is a result of the physiological changes occurring within the periodontal ligament (PDL). As forces are applied to the teeth during orthodontic treatment, the PDL is compressed and stretched. These changes cause the cells within the PDL to release chemical messengers that initiate an inflammatory cascade to cause the pattern of bone resorption and deposition required for tooth movement.³ Unfortunately, these chemical messengers, coupled with the reduced blood flow due to compression of the PDL, stimulates pain.

Anti-inflammatory analgesics, such as Ibuprofen, have been proven to be effective at reducing pain.^4,5 However, as many of these medications work by inhibiting chemical messengers involved in the inflammatory response that causes pain, they have the potential to affect the inflammatory process required for tooth movement. Fortunately, this is not seen when such analgesics are used in low doses and for short durations, as is usually the case when managing orthodontic related pain.³ Therefore anti-inflammatories, such as Ibuprofen 400 mg taken three time daily, are still the most commonly used and recommended method of orthodontic-related pain relief;^3,4,5 this should be supported with reassurance that discomfort is very common and usually self-limiting, as well as advice to adopt a soft diet and use warm salt water mouthrinses.^6,7

Research has been carried out into other non-pharmacological pain management solutions, including low level laser therapy (LLLT),⁸ acupuncture/acupressure,⁹ the use of bite wafers or sugar-free chewing gum^3,10,11 and psychological intervention, where patients are called during treatment and offered reassurance and advice;¹¹ however, further, well constructed trials are required to validate the efficacy of any of these methods.

Mouth ulcers

The use of orthodontic appliances is associated with oral lesions, such as erosions and ulcers. The irritation from the appliance can either precipitate or exacerbate such lesions.^{12,13,14,15,16} The presentation of these ulcers can be quite varied in terms of size and appearance and they can arise on any mucosal surface, including the lips, cheeks or tongue.¹² Patients can experience severe discomfort as a result of such lesions but, fortunately, prompt relief is achievable with the use of topical anaesthetic directly applied to the site with a microbrush. The patient can then be advised to re-apply topical anaesthetic to the lesion as required.^6,7

Antiseptic mouthwashes, such as chlorhexidine, may be a useful aid in managing ulcerations. A study found that the daily use of 0.2% chlorhexidine mouthwash in patients with orthodontic appliances reduced the incidence, duration and pain associated with mouth ulcers.¹⁶ Chlorhexidine mouthwash has also been shown to be effective at managing aphthous ulcerations, which may be exacerbated by orthodontic appliances.¹⁷ Interestingly, a study found that 0.15% Benzydamine hydrochloride had no effect on the incidence, duration or pain associated with mouth ulcers in patients with orthodontic appliances.¹⁵

Patients can also be given and instructed on the use of orthodontic relief wax to help prevent ulcers emerging or being exacerbated.

Orthodontic relief wax (Figure 5)

Orthodontic relief wax is a pliable material that can be used to cover prominent components of the orthodontic appliance to prevent it from irritating the soft tissues. When using orthodontic relief wax the area should be isolated with cotton rolls and a saliva ejector and a 3-in-1 can be used to dry the surface to be treated. A small piece of wax is rolled into a ball and flattened on the targeted area (eg in this case a molar band tube and hook). Patients can be advised that it will cause no harm if the wax is accidentally ingested.^6,7

Trapped food

This is not considered an emergency but patients may present to their dentist because of food debris in the appliance because it can be uncomfortable and unsightly. This is easily treated using dental floss or an interdental brush to gently remove the food from between the tooth and the appliance.^6,7 Compliance to the use of oral hygiene instructions should also be stressed to the patient.

Swollen/bleeding gums (Figure 6)

Swollen and/or bleeding gums are quite common in patients with orthodontic appliances but they can be quite alarming to patients. This is usually due to poor oral hygiene and can be managed simply with oral hygiene instructions and a dental polish. Patients should be made aware that orthodontic therapy requires consistently high levels of oral hygiene to ensure healthy gums and to prevent dental decay.^6,7

Irritated lips or cheeks

Patients may report that their braces are irritating the lips/cheeks; this often occurs soon after the appliance is initially fitted and is usually more pronounced when the patient is eating. Treatment involves placing non-medicated relief wax over the area causing irritation using the technique described above.^6,7

Loose ligatures

Ligatures are the small wires or elastic bands that hold the archwire to the bracket. When an elastic ligature becomes loose it can be repositioned using tweezers. If a wire ligature becomes loose, do not attempt to replace it. If it can be easily removed, this should be done using tweezers and a piece of gauze to protect the airway. If it cannot be easily removed and/or is causing irritation to the lip, then it should be covered with orthodontic relief wax and a follow-up appointment made with the orthodontist.^6,7

Lost ligature

If a ligature is lost then the archwire is not secured within the bracket and may result in a reduction in the effectiveness of the appliance on the tooth. Therefore, the orthodontist should be notified so that he/she can advise when the patient should arrange for it to be replaced.^6,7

Loose removable appliance

Removable appliances can easily be adjusted to increase their retention if they become loose. If the appliance is amenable to adjustment, the Adam's cribs/retentive component should be tightened using wire benders until the appliance is retentive. This can be done by bending the wire at either the bridge of the clasp, to adjust the height of the crib, or the arrowhead, to alter the tightness of the crib, for the closer the crib is to the tooth the more retentive it will be (Figure 7).

If this is unsuccessful or not possible then the orthodontist should be contacted to advise when the patient should next be seen.

Lost separator/spacer

Separators/spacers are fairly rigid elastic rings that sit inter-proximally between the teeth to open up the contact point prior to placing metal bands. Arrangements are usually in place for the patients to be seen by the orthodontist to fit the metal bands quite soon after the separators have been placed. However, if a patient presents to the GDP because a separator is lost before this appointment, then the orthodontist should be notified promptly so that he/she can advise when the patient should next be seen.

Protruding archwire (Figure 8)

Sometimes the end of the archwire protruding distal to the last bracket/band can start to irritate the patient's mouth. The wire should be bent so that it is flat against the tooth and not protruding into the soft tissues. This can be done with wire benders or a flat plastic. If this is not possible, then the end of the wire can be covered in relief wax and the orthodontist should be informed. In situations where the protruding wire is causing significant discomfort and the patient will not be able to see his/her orthodontist urgently, then the wire can be clipped using sharp wire cutters or distal-end cutters. Alternatively, the whole wire can be removed by first removing the ligatures then removing the wire, however, this should be a very last resort. It is important to avoid inhalation or ingestion of the small piece of wire after it has been cut. This can be achieved by using gauze around the area and/or distal end-cutters which grip the snipped piece of wire after it has been cut.^6,7

De-bonded bracket (Figure 9)

If a bracket de-bonds from the tooth, the orthodontist should be informed as soon as possible so that appropriate action can be taken. This may range from simple reassurance and waiting for the next scheduled appointment, to arranging an emergency appointment for further management. To prevent irritation to the lip or cheek in the short term, the de-bonded bracket can be removed from the archwire by first removing the ligature holding it in place, whilst protecting the airway. The bracket should then be given to the patient to take to the orthodontist. Alternatively, the bracket can be moved along the wire and temporarily secured to the adjacent bracket with orthodontic relief wax to prevent irritation of the lip or cheek.^6,7

Fractured removable appliance

Occasionally, removable appliances break. If this happens, the orthodontist should be informed as soon as possible and will then take the appropriate action. The patient should be advised to stop using the appliance if the damage renders the appliance a potential airway risk or will cause marked trauma.

Loose or fractured fixed appliance (wire/band)

Components, such as a palatal/lingual arch or a molar band, can fracture or become loose causing irritation or trauma to the patient. If the component is not mobile, it should be covered with orthodontic relief wax and a review appointment arranged with the orthodontist. However, if the component is very mobile or loose, it can carefully be removed with tweezers whilst protecting the airway to prevent inhalation.^6,7

Lost or damaged retainers

Orthodontic retainers are either fixed or removable and their purpose is to hold the teeth in their new position after active treatment is complete. It is now widely accepted that patients should wear their retainers long term to prevent relapse, which can be for many decades. However, patients are usually discharged from their orthodontist 12 months after the active treatment has been completed. Therefore, patients may present to their GDP if they have lost or broken their retainer.

Removable retainers can easily be repaired if the damage is minor. An accurate impression of the arch should be taken and sent to the laboratory with the broken appliance. However, if the damage is more extensive, or the appliance is lost, a new retainer will need to be made. To do this, an accurate impression of the arch is required and the type and design of the retainer should be clearly stated on the laboratory ticket. Retainer designs and further information can be found in the Dental Update article ‘First Aid for Orthodontic Retainers’.¹⁸

Fixed retainers are bonded to the palatal/lingual surface of teeth and are used where even minimal amounts of tooth movement are deemed unacceptable by the patient. Patients often receive a removable retainer as well as the fixed retainer, so they have something to use in the short term if the fixed retainer breaks.¹⁸ If a fixed retainer de-bonds from a tooth but is securely attached to adjacent teeth and lies passively on the tooth in question, it can be re-bonded. This is done by carefully removing any residual composite, preparing the tooth surface with acid etch and bond and replacing the composite to secure the wire without distorting it. A more detailed description can be found in the Dental Update article ‘First Aid for Orthodontic Retainers’.¹⁸ If the fixed retainer is broken, lost or not amenable to simply re-bonding it to the tooth, it will need to be replaced. The patient should be referred to an orthodontist but an impression can be taken for a removable retainer to be used in the interim.

Allergic/hypersensitivity reaction

There are some patients who may develop an allergy to a component of an orthodontic appliance. The most common allergy in orthodontics is to nickel which is found in many components, such as nickel-titanium (NiTi) archwires and stainless steel brackets.^19,20 Owing to the popularity of nickel-containing jewellery and body piercings, many patients have been exposed to nickel before undergoing orthodontic treatment and may be sensitized to the metal. This can precipitate a Type IV delayed hypersensitivity immune response when they are re-exposed to nickel in orthodontic appliances. This association is supported by estimations of higher nickel allergy in adolescents with pierced ears (31%) than those without pierced ears (2%).²¹

This type of immune response is not usually immediate but develops after a few days or weeks so that patients may present to a GDP first. The intra-oral clinical signs and symptoms can be quite varied but may include gingivitis not caused by plaque, gingival hyperplasia, labial desquamation, burning sensation, metallic taste, angular cheilitis, numbness/altered sensation, labial swelling or soreness of the tongue.²⁰ In such cases, the orthodontist should be informed immediately so that he/she can arrange to review the patient and may use nickel-free components.

Fortunately, the majority of patients who are sensitized to nickel can still wear nickel-containing orthodontic appliances without eliciting a response, as it is thought that a much higher concentration of nickel is needed to produce a response in the oral mucosa than is required on the skin.²⁰

Another possible allergy that patients may develop is to unpolymerized monomer in the acrylic of removable appliances. Although this is very rare, it can produce similar signs and symptoms seen with a nickel allergy and should be managed the same way, by informing the orthodontist to arrange a review.²²

The British Orthodontic Society recognizes that patients can develop allergies to appliances and have produced an advice sheet on ‘Nickel Allergy in Orthodontics’. They also monitor adverse incidents in orthodontics so that any adverse reaction should be reported on the BOS website under ‘Adverse Incident Reporting’ (www.bos.org.uk/Professionals-Members/Adverse-Incident-Reporting).²⁰

Airway obstruction

A true emergency arises when a loose component or small removable appliance obstructs the airway. If the object is still visible in the mouth, attempts should be made to remove it with the patient reclined, otherwise the patient should be encouraged to cough the object out. If this is not successful immediately, call for help and call an ambulance.²³ The immediate management should follow the guidelines for ‘Choking/Aspiration’ detailed in the ‘Medical Emergencies and Resuscitation’ document provided by the Resuscitation Council UK (Figure 10).²⁴

Ingested or aspirated component

Ingestion of an orthodontic component or appliance is not uncommon, and is usually asymptomatic and causes no injury to the patient, therefore requiring no treatment besides monitoring the stool to check that the component has passed naturally. However, if the component becomes lodged in the oesophagus or oropharynx, the patient may experience pain or vomiting. In such situations, the patient should immediately be sent to hospital for advice and management, ideally with an example of the component that has been ingested. If the component has not yet reached the stomach it can be removed via fibre-optic endoscopy.²³

Regardless of the symptoms, a patient should always be referred to the Accident and Emergency (A+E) department at a local hospital when the ingested component is more than 5 cm long as there is a higher risk of obstruction and perforation of the gastrointestinal tract, so removal may be advised instead of allowing the component to pass naturally. It is important when a patient is sent to the hospital that the referral letter includes information about the component, such as its size, shape, flexibility and radio-opacity, as well as information about the incident, such as when the object was swallowed. This will help in locating the component and predicting the outcome.²³

Aspiration of an orthodontic component that has not been removed by the management of an airway obstruction as described above should be managed by immediate referral to A+E for plain radiographs, such as a chest radiograph, and removal of the component. The referral letter must again include information about the component, including its size, shape and if it is radio-opaque.^23,24

Further information can be found on the BOS advice sheet entitled ‘Guidelines for the Management of Inhaled or Ingested Foreign Bodies’,²³ and the recommended radiographs that should be taken can be found on The Royal College of Radiologist Guidelines.²⁵

The orthodontist should also be informed if a component has been ingested or inhaled so that he/she is aware of the situation and can arrange a review at an appropriate time. The incident should also be reported on the BOS website under ‘Adverse Incident Reporting’.