Brackets, Aligners, and Oral Health: Tools That Support Treatment Success

Alison Werner (00:04)
Hello and welcome to the Orthodontic Products Podcast. I’m your host, Alison Werner In this episode sponsored by Proctor and Gamble, we’re diving into a challenge every orthodontic practice knows well, keeping patients oral health on track throughout treatment. Whether they’re in brackets or aligners, lapses in hygiene can lead to demineralization, inflammation, and avoidable delays. Problems that can affect not only clinical outcomes, but also patient satisfaction and practice efficiency. To help us unpack the risks, the science, and the tools that can make a measurable difference, we’re joined by Dr. Stephanie Gans, senior scientist

and professional and scientific relations manager for Crest + Oral-B. With a decade in clinical dentistry and more than seven years working on oral care innovation and education, Dr. Gans brings a practical evidence-based perspective on the power of advanced status fluoride formulations, oscillating rotating brushes and behavior driven tools like the Ortho Essentials program to support healthier, more predictable orthodontic treatment. Here’s our conversation.

Alison Werner (01:00)
Dr. Gans thank you so much for joining me. I really appreciate it.

Stephanie Gans, DDS (01:03)
Thank you so much for having me.

Alison Werner (01:05)
Well, okay, so let’s get started with the basics. When a patient begins orthodontic treatment, whether with brackets or aligners, what are some of the most common oral health challenges that can arise?

Stephanie Gans, DDS (01:15)
Sure, when we have orthodontic patients, about 96 % of them are going to develop some type of oral disease. Usually it’s in the family of gingivitis or decay or white spot lesions, which is just basically the decay starting to begin. So we want to make sure that before patients start any orthodontic treatment, that we give them the proper home care tools to help prevent any of these issues from occurring.

Alison Werner (01:42)
Okay, so let’s start with bracket patients specifically. What types of risks can occur if they don’t maintain good brushing and flossing habits throughout treatment?

Stephanie Gans, DDS (01:52)
For brackets patients, as you know, they have so many pieces of metal in their mouth. So what we’re seeing is that metal is leading to a lot more plaque retention, a lot more places for that plaque to hide. It’s difficult to clean. And so we’re seeing a real increase in intraoral bacteria. ⁓ So for these patients, we’re seeing, like we talked about, we see a lot of the gingivitis. We’re starting to see white spot lesions, especially where those brackets are placed, cause it can be difficult to clean around them. And of course the wires,

Alison Werner (02:19)
Yeah.

Stephanie Gans, DDS (02:21)
can

make it difficult to clean and embrasure spaces and floss properly. So for those patients, we’re seeing a lot of different issues and a lot of different decay.

Alison Werner (02:32)
Okay. And then for aligner patients, know, people often think that they have it easier, but they’re not risk-free either, from what I understand. So what are some of the unique oral health issues that could develop with aligner therapy if patients aren’t diligent with their hygiene?

Stephanie Gans, DDS (02:46)
Aligners are a tricky one because I think naturally people think that aligners are, they’re easier. And in a sense they are in terms of home care. When you’re brushing your teeth, you can take them out. You can brush as you normally would. You can floss and rinse as you normally would without them. But aligners add a certain challenge and it’s completely different than for brackets because if we wear aligners properly, they’re supposed to be on our teeth up to 22 hours a day.

Alison Werner (02:52)
Mm-hmm. Yeah.

Mm-hmm.

Okay.

Stephanie Gans, DDS (03:15)
they’re covering the entire surface of the tooth. And the issue with that being is our natural cleansing defenses and our natural remineralization that we have from our saliva cannot help your teeth. So normally our saliva, they’re helping to clean the teeth. They’re helping to remineralize the teeth. ⁓ And none of that can happen when the tooth is completely covered. So that leaves these patients really susceptible to decay and erosion, which once that tooth structure is gone,

Alison Werner (03:28)
Mm-hmm.

Stephanie Gans, DDS (03:45)
It is gone. So what we’re seeing specifically with white spot lesions is that patients are getting white spot lesions that are shallower, but they have a larger surface area. And that makes sense, right? Because when the tooth is covered 22 hours a day, that entire tooth surface cannot remineralize. It cannot be cleansed and our saliva can’t buffer any acids that are present. And yeah, and diet can be an issue too. So when you have aligners in, you can only

Alison Werner (03:55)
Mm.

Yeah.

Okay.

Stephanie Gans, DDS (04:15)
really, you’re really just supposed to drink water. I did aligners for a little bit and it is challenging. I’m usually a pretty disciplined person, but they can be difficult to wear. You can’t eat or drink anything with them in and, or you can drink water. ⁓ And then after you eat or drink anything with the aligners out, you really have to brush your teeth before you put them in.

Alison Werner (04:17)
Mm-hmm.

Mm.

Thanks

Stephanie Gans, DDS (04:35)
And for a lot of patients, they might not be a hundred percent compliant. So they could be putting these aligners in while there’s plaque on the teeth, sugar on the teeth. They might be drinking acidic beverages with them in that’s going to fuel the fire of poor outcomes for these patients.

Alison Werner (04:53)
Okay, all right. So then from a clinical standpoint, how do poor oral hygiene habits during orthodontic treatment impact treatment outcomes and what kind of costs or setbacks can that create for both patients and the practice?

Stephanie Gans, DDS (05:07)
Sure, well let’s start with.

the biggest issue would, which would be patient satisfaction. So imagine you had a patient that just finished, you know, two years of treatment, the brackets come off or the aligners, you know, you’re done with, and all of a sudden there’s all of this decay under the brackets. This is not going to be a patient that’s going to be satisfied, which of course can impact potential referrals and all of that for the practice. But in addition, we’re seeing that patients that don’t have proper home care during treatment, their treatment is going to be longer

So on average, if a patient has three poor oral care entries into their chart, on average treatment is extended by about 2.2 months. So as we know, when you have brackets, you don’t want to wear them for two months longer than you have to. And of course, when it comes to the practice is what we’re finding is that every time that patient has to come back in, whether something breaks, falls off, they need to extend treatment for the average $7,000

Alison Werner (05:44)
Mm-hmm.

okay.

Mm-hmm.

Stephanie Gans, DDS (06:08)
treatment plan that’s about two years, it’s going to cost that office $260 in lost profit. So imagine if you have one patient each day that should be done with treatment, how much over time that is costing the office.

Alison Werner (06:10)
Mm-hmm.

Okay.

Mm-hmm.

Okay. All right. So then let’s talk about prevention tools and let’s start with toothbrushes. So the newer toothbrushes are, you know, have these oscillating rotating electric brushes. So compare that to manual or even sonic brushes when it comes to improving oral health outcomes for orthodontic patients.

Stephanie Gans, DDS (06:42)
Sure, so when it comes to toothbrushes, just like your cell phone has improved over time, our toothbrushes have improved over time. And they have a lot of great features and benefits for our patients. So first is the type of toothbrush. So there’s several different types of toothbrushes. When it comes to electric toothbrushes, there’s two main categories, which would be oscillation, rotation, and sonic. And of course, when it comes to… ⁓

Alison Werner (06:49)
Mm-hmm.

Okay.

Stephanie Gans, DDS (07:08)
not electric, there’s manual toothbrushes. So when we compare oscillation rotation versus sonic, there’s lots of benefits for oscillation rotation. So an oscillation rotation brush is a round brush head that goes so many degrees clockwise and then so many degrees counterclockwise over a hundred times per second. And when it comes to cleaning plaque biofilm off of your teeth, you need to create what’s known as sheer force. And that’s what’s really going to help get that biofilm off of your teeth. It gives you that nice slick smooth feeling of your

Alison Werner (07:10)
Yeah.

Mm-hmm.

Stephanie Gans, DDS (07:38)
teeth just because they’re so nice and clean. So shear force is created when the bristles change direction. And with an oscillation rotation brush such as the Oral-B IO, you can see when you turn it on, it moves very quickly and that shear force is going to help get your teeth nice and clean.

Alison Werner (07:41)
Mm-hmm.

Mm-hmm.

Stephanie Gans, DDS (07:57)
When you compare it to a sonic brush, a sonic brush is similar to a manual brush in shape and size. So it doesn’t adapt to the natural anatomy that we would see with an oscillation rotation toothbrush. In addition, it’s not creating that sheer force as effectively. So it’s not getting your teeth as clean. So when we get into some of the clinical results, I can show you some of the differences. Specifically, one great study to take a look at is a 2023 meta analysis that took a look at the Oral-B IO.

Alison Werner (08:06)
Mm-hmm. Okay.

Mm-hmm.

Mm-hmm.

Stephanie Gans, DDS (08:26)
compared it to previous iterations of oscillation rotation brushes, sonic brushes, and manual. And when it came to looking at plaque and gingivitis endpoints, the Oral-B IO was the winner. We consider a patient to have healthy gingival tissue with a patient that has gingivitis.

so someone has considered they have gingivitis if they have between 10 and 30 % bleeding sites in the mouth. If they have greater than 30 % bleeding sites in the mouth, they have what’s considered generalized gingivitis. So in our studies, we can track the progression between gingivitis and health, how many people transition to a healthy gingival state post baseline. So in this study, we found that

Alison Werner (08:46)
fine.

Stephanie Gans, DDS (09:09)
88 % of patients that had gingivitis transitioned to a state of gingival health just by switching to an IO toothbrush. We can compare that to previous iterations of brushes, which had about 65 % of patients transition to health, which shows you how the technology has improved over time. Just like your iPhone from 10 years ago isn’t the same iPhone that you have now. And also compare that to a sonic toothbrush. When we take a look at a sonic toothbrush post-baseline, only about 54 % of patients transitioned to

Alison Werner (09:16)
Okay.

Stephanie Gans, DDS (09:39)
gingival health versus 88 % with the Oral-B IO. So showing what kind of outcomes we can have just by switching our toothbrush type. And of course, if we look at manual, only 27%, oh, excuse me, 21 % of patients using the manual toothbrush transition to health over time. So compare 21 % to 88%. We’re getting a lot more patients healthy. And in addition to the most amount of patients healthy,

Alison Werner (09:43)
Okay.

Stephanie Gans, DDS (10:07)
people using the Oral-B IO are guiding to health faster. So we find is actually, we look at oscillation rotation as a general category, patients are transitioning to health 33 % faster than a sonic toothbrush and 50 % faster than a manual toothbrush. So if you remember, if you remember anything, the main take home point is that the Oral-B IO is getting more patients healthy and oscillation rotation as a general category is getting them there faster. So healthier patients and getting

Alison Werner (10:23)
Okay.

Mm-hmm.

Okay.

Stephanie Gans, DDS (10:37)
them there faster.

Alison Werner (10:38)
Okay.

Can you talk specifically about the features within the Oral-B IO and the brush heads that are available with it?

Stephanie Gans, DDS (10:46)
Sure. So with the Oral-B IO, there’s so many great features to help patients brush better. So some of the common barriers that we see is that one, patients aren’t brushing longer enough. They are not brushing with the right amount of pressure and they are not replacing their brush heads as frequently as they need to be. When it comes to brush heads, they wear out over time, just like your tennis shoes will wear out over time. Your windshield wiper blades will wear out over time and needs to be replaced to have the same efficacy. So if we take a look at the Oral-B IO,

Alison Werner (11:08)
Mm-hmm.

Okay.

Stephanie Gans, DDS (11:16)
if we take a look at how longer patients are brushing. So do you know how longer on average patients brush?

Alison Werner (11:22)
I know it’s probably under the two minutes that’s recommended.

Stephanie Gans, DDS (11:25)
Exactly. So patients on average

are brushing for 46 seconds. So we want to make sure that patients are brushing for two minutes. And it’s not just, it’s not only for plaque removal. You need two minutes to have the fluoride uptake in the mouth to be efficient as well. So.

Alison Werner (11:29)
⁓ okay.

⁓ okay.

Stephanie Gans, DDS (11:43)
It might be hard to see for those just listening, but right on our screen, you can see a timer right on there. Every 30 seconds, it’ll buzz so that patients are brushing for the full two minutes. And it’s really guiding people to brush with that right amount of time. In addition, we’re seeing a lot of patients that aren’t brushing hard enough or they’re brushing too hard, which is causing other issues such as recession and abrasion. So you can think of it like Goldilocks. People brush too hard, not hard enough, and we want them to brush

Alison Werner (11:45)
Uh-huh.

Mm-hmm.

Yeah.

Hmm.

Okay.

Mm.

Mm-hmm. ⁓

Stephanie Gans, DDS (12:13)
just right. And

there is a smart pressure sensor right on the brush head, right on this ring that’ll turn red if you’re brushing too hard, white or the color of your choice, if you’re not brushing hard enough or green, if you’re brushing with the right amount of pressure. And even as a dentist, I didn’t appreciate times when I was brushing too hard. We think of it when it comes to cleaning teeth, a lot of us sort of equate it to like scrubbing a floor. Like people think of it as like the harder, the better, right? But our teeth aren’t really like that. It’s more like polishing porcelain.

Alison Werner (12:18)
Mm-hmm.

⁓ okay.

Mm. Mm-hmm.

Stephanie Gans, DDS (12:42)
because what happens is, is that if you start brushing too hard, you’re smushing those bristles, those bristles that are supposed to create that shear force, you’re smushing them. So the bristles can’t do what they need to do and they can’t move effectively. So what’s interesting is that when you start brushing too hard, you’re actually starting to remove less plaque. So if we look at it live, this is our Oral-B IO. If you’re brushing too hard, it’ll turn red. If you’re brushing just right, it’ll turn green.

Alison Werner (12:55)
Mm-hmm.

Uh-huh.

Mm-hmm.

Stephanie Gans, DDS (13:12)
not hard enough, it’ll be white or the color of your choice. So it’s really guiding people to brush with the right amount of time, for the right amount of pressure, and of course you will get a refill replacement reminder when it is time to replace the refill brush head.

Alison Werner (13:15)
Okay.

⁓ Okay,

okay. So let’s talk about toothpaste now. So stannous fluoride formulations for toothpaste have really evolved over the years. Can you explain the difference between a stannous fluoride and a sodium fluoride and how Crest stannous fluoride technology stands out from other formulations?

Stephanie Gans, DDS (13:43)
Sure, and this is something that I truly didn’t understand when I was practicing. It wasn’t something that I understood until I was really with P&G So for toothpaste, there’s lots of different ways to get fluoride in the mouth. So for sodium fluoride, the fluoride is really the only active portion of the molecule. The fluoride is going to remineralize our teeth. It’s gonna help prevent demineralization to help prevent cavities, which is excellent. That’s a miracle in itself. But the stannous fluoride, it’s…

Alison Werner (13:48)
Mm-hmm.

Mm-hmm.

Mm-hmm.

Yeah.

Stephanie Gans, DDS (14:13)
stannous with two fluoride molecules on it. The stannous is active as well and can have a lot of other benefits for our patients. So the stannous portion of the molecule is going to help prevent and treat gingivitis. It’s going to help ⁓

treat sensitivity and it’s also going to help prevent erosion. Erosion is an interesting one because erosion occurs when we have really strong acids overwhelm our pellicle and it’s causing the enamel, the tops of the enamel rods to actually wear down over time and it cannot be remineralized. It’s different than how we start to get demineralization in the enamel rods for decay. It’s those tops of those enamel rods that are wearing down over time and once that enamel is gone, it is gone. So really

Alison Werner (14:32)
Mm-hmm.

Mm-hmm.

okay.

Okay.

Stephanie Gans, DDS (14:58)
the only thing you can do is help prevent it. And the best way to prevent it is by brushing with a stannous fluoride paste. The stannous will create almost like a sacrificial barrier on the tooth surface so that when you’re having something acidic, like I’m a fan of Diet Coke, I know I shouldn’t be, but…

Alison Werner (15:01)
Mm.

Stephanie Gans, DDS (15:16)
⁓ Diet Coke coffee, orange juice, anything acidic is going to help prevent that erosion from occurring, which is something that we can’t see from a sodium fluoride paste. And of course, if you do have gingivitis, stannous is going to help, ⁓ prevent that gingivitis from occurring and treat it. And what it does is it interrupts the inflammatory cascade, ⁓ which would be a story for another time of how stannous works and how it helps to prevent and treat gingivitis.

Alison Werner (15:41)
Yeah.

Okay. Well for now, can you kind of talk about what specific toothpaste products you recommend that have this stannous fluoride?

Stephanie Gans, DDS (15:52)
Sure, Crest Gum Detoxify or Crest Pro Health, Crest Pro Health Advanced, those are all gonna have stannous fluoride formulations. And one thing to keep in mind is that not all stannous is the same. ⁓ Other competitor paste, the formulation can be different, leading to less bioavailable stannous to do the work. And the reason that is, is stannous is a very tricky molecule to work with. The way like to think about it and explain to people is that stannous has two hands, one fluoride in each hand.

Alison Werner (16:04)
Okay.

Mm-hmm.

Stephanie Gans, DDS (16:22)
Unfortunately,

stannous is a very friendly molecule and likes to shake hands with everybody. Unfortunately, if it’s interacting with different molecules, it may not be available, bioavailable, to do the work that we want it to in the mouth. And by do the work that we want it to, it’ll be preventing and treating gingivitis, preventing erosion, and treating sensitivity. And of course, the fluoride should be helping to remineralize. So long story short, just because a toothpaste has .454 %

stannous fluoride in the formulation does not mean you’re getting the same amount of stannous to do the work in the mouth. I always think of it as ⁓ one time I went to the dermatologist and he told me to specifically get Cordaid brand hydrocortisone cream. And now I’m cheap so I would normally go to a retailer and buy the private label, the generic whatever’s cheapest. I would look at the label and say you know it’s 1 % hydrocortisone cream it’s all the same.

Alison Werner (17:08)
Okay.

Right. Uh-huh.

Right.

Stephanie Gans, DDS (17:19)
But based on what that dermatologist told me, there are certain inactive ingredients and certain formulations that make the active ingredient more efficacious. So for Crest Gum Detoxify or for Crest Pro Health or Pro Health Advanced, you’re really getting a very large amount of bioavailable stannous fluoride. And you can see that in some of the clinical studies that have been run showing how our pace versus a competitor, how it’ll help to ⁓ decrease bleeding sites over time.

Alison Werner (17:29)
Okay.

Stephanie Gans, DDS (17:49)
You’re really getting the most benefit out of your toothpaste.

Alison Werner (17:50)
Okay.

Okay, so we’ve talked about brushing and we’ve talked about toothpaste but and fluoride so but we know those are alone aren’t enough for oral health during orthodontic treatment. So how does the Ortho Essentials program bring these different elements together? So the pace the power brush the rinse the floss brings them together in a way that helps patient for patients form lasting habits and maintain oral health throughout treatment.

Stephanie Gans, DDS (18:16)
Sure. The Ortho Essentials system is excellent because it has all the pieces of the puzzle to have excellent oral health at home during treatment. So it’s going to include the Oral-B IO. It’s going to have a stannous fluoride paste. It’s going to have a rinse that has CPC and fluoride to help remineralize and help kill all the germs, as well as super floss. So it’s helpful for brushing around or for flossing around brackets. ⁓ In addition, the Ortho Essentials system contains the targeted

clean brush head. So the targeted clean brush head for those of you who can see is a really unique brush head because it has one center tuft with three tufts.

surrounding it. So what it’s really great for is it’s great for getting around brackets, under wires, under anatomical irregularities to help you get the best possible clean. Because as we were saying, the wires can make it really difficult to clean around those areas effectively, and that’s where plaque likes to hide. So the targeted clean is really the only power brush head on the market that can help you clean in those areas.

Alison Werner (19:02)
Mm.

Okay.

Okay.

Stephanie Gans, DDS (19:20)
In addition to just the products that we have, there’s also great communication tools ⁓ to help patients ⁓ if it’s a child, their parents during orthodontic treatment. So for example, we have a nice chair side laminate that helps to score patients on where they are in terms of their oral health. And we see this a lot where I think a lot of patients don’t understand what health looks like or feels like. I feel like…

Alison Werner (19:44)
Mm-hmm.

Stephanie Gans, DDS (19:46)
bleeding or pink in the sink when you spit has become almost normalized. But if you brush your hands and they were bleeding, that would be pretty startling, right? And that’s sort of the same response we should have with oral care in the mouth. ⁓ We’ve also had patients come in with calculus bridges and they’ll come in saying they chipped a tooth and really they just chipped off a chunk of that calculus. So patients don’t understand what health should look like and feel like. So in terms of patient communication, we have chair-side laminates and guides and videos available.

Alison Werner (19:50)
Yeah, right.

⁓

Stephanie Gans, DDS (20:16)
to show patients not just how to take care of their teeth when they have orthodontic treatment, but what health looks like and feels like to set them up for lifetime of healthy smiles.

Alison Werner (20:25)
Okay, so last question. From your experience working with dental professionals, what communication or education strategies have you seen work best when helping patients build and stick with healthy oral care habits during orthodontic treatment? You talked a little bit about those educational materials, but what else have you seen?

Stephanie Gans, DDS (20:45)
I think what really helps is that for the specific, ⁓ chief complaint, so to speak, that a patient has is really tying that specific feature and benefit of the brush or the paste back to that. So for orthodontic patients specifically, I mean, really their goal is to have, ⁓ a healthy smile, a beautiful smile and straighter teeth. And we want to help patients get to that. So it’s by tying back. So for the Oral-B IO, ⁓ with the power brush, we don’t want patients to have white

Alison Werner (21:05)
Right.

Stephanie Gans, DDS (21:15)
lesions, decay, gingivitis. So we want to make sure that they have those proper tools at home. So one, think it’s about as soon as the patient has committed to treatment, getting them started on the right oral care routine. Because once those teeth are sore, it’s going to be a lot harder to get them started on a power brush, a targeted clean brush head, ⁓ and switching up their routine at home. So getting that habit started, I would also encourage patients and their parents to download the Oral-B app.

Alison Werner (21:32)
All

Stephanie Gans, DDS (21:42)
So what’s really great about the Oral-B IO is it has what’s called position detection technology. So it can actually track in real time where you’re brushing. So if there’s a specific area or quadrant that the patient tends to miss, it’ll help guide them to have the right amount or to brush all the areas of their mouth. It’s like having a dentist or a hygienist like right on your shoulder watching you to making sure that they’re brushing. So I think with communication, it’s making it clear that

Alison Werner (22:02)
Mm-hmm.

Stephanie Gans, DDS (22:09)
it’s going to be harder to take care of your teeth during this time. These are the tools that I want you to be using and that you need to be using during treatment. And I think it’s reiterating it every appointment of taking that chair side laminate saying here’s where you are, here’s where I need you to be, and this is how I’m going to help you get there. Because for… ⁓

All the products in the Ortho Essentials system, we really have a synergistic effect of using multiple items from our portfolio. So if you remember earlier, I was talking about just how using the Oral-B IO was getting 88 % of patients to health. If you use the Oral-B IO with a CPC rinse or stannous fluoride Paste and floss, we can actually get a hundred percent of patients to health. This was a 12 week study for patients that used all of the items in the portfolio versus a manual toothbrush and a

Alison Werner (22:40)
Mm-hmm.

Stephanie Gans, DDS (22:57)
sodium fluoride paste. Patients that used the entire system, kind of the Rolls Royce of oral care, 100 % of them went from a state of gingivitis to a state of health versus just 7 % of manual brush users using a sodium fluoride paste. So it just shows you ⁓ how we can get so many more patients healthy if they have the proper tools at home.

Alison Werner (23:17)
Mm-hmm.

Well, Dr. Gans thank you so much for explaining this all to us. I really appreciate it.

Stephanie Gans, DDS (23:24)
Thank you so much for having me.