Early orthodontic intervention: enhancing oral hygiene compliance in the transitional dentition

Dr. Christina Carter points out the importance of oral hygiene education for early orthodontic patients

Introduction: framing the hygiene challenge in mixed dentition

The mixed dentition stage represents a critical window of opportunity in a child’s oral development. Between the ages of 6 and 12, the eruption of permanent teeth alongside retained primary teeth creates a complex oral environment prone to plaque retention, gingival inflammation, and early signs of periodontal stress.¹ At the same time, children in this stage often lack the dexterity, motivation, and maturity to maintain adequate oral hygiene independently. These compounding factors set the stage for increased risk of caries, demineralization, and compromised outcomes from both restorative and orthodontic care.

Traditionally, orthodontic treatment has been reserved for adolescence, but clinical evidence increasingly supports the benefits of early interceptive treatment — not only for skeletal and dental correction but also for behavioral shaping and hygiene compliance.² Early orthodontic intervention provides a platform for education, habit formation, and caregiver engagement that can dramatically influence long-term oral health outcomes.

Clinical evidence: hygiene risk in the transitional dentition

Oral hygiene in children undergoing orthodontic treatment presents a unique clinical challenge. The presence of orthodontic appliances, combined with the eruptive pattern of the mixed dentition stage, often results in increased areas for plaque retention and difficulty with access during brushing. Crowded arches, exfoliating primary teeth, and partially erupted molars can hinder effective hygiene even before brackets are placed. In many cases, this age group tends to show inconsistent brushing habits, and their oral hygiene tends to require more caregiver involvement than that of older adolescents. When orthodontic appliances are introduced in this already vulnerable stage, plaque accumulation becomes more likely without active prevention and support strategies.

These patterns emphasize the need for early, targeted hygiene instruction tailored to this developmental window. Clinical teams should not assume that the absence of obvious gingival inflammation or caries in early appointments equates to effective hygiene. Preventive protocols — especially in the context of interceptive treatment — must begin with behavioral engagement and education at the first signs of eruptive transition.

Developmental barriers: why hygiene habits fail in younger patients

It is critical to recognize the unique developmental stage of early mixed dentition patients. At this age, many children are still developing the cognitive and motor skills necessary for consistent hygiene.³ They may struggle with toothbrush angulation, flossing technique, and time perception.

Furthermore, emotional and behavioral factors often play a role. Younger patients are more prone to oppositional behavior, have less intrinsic motivation for hygiene, and often rely heavily on caregivers to enforce routines. Without consistent reinforcement, oral hygiene becomes inconsistent at best, and neglectful at worst.

Clinical success in early treatment depends not just on tooth movement, but on fostering compliance through age-appropriate tools, visual feedback, and parental guidance. Without this foundation, long-term orthodontic results are at risk.

A picture is worth a thousand words and shows real repercussions that cannot be repaired. When trying to convey to patients the risk of white-spot lesions, I show a clinical photograph of a patient’s teeth after debond with unattractive white-spot lesions and decalcification. We also keep this picture in all the operatories so it stays fresh in the patient’s mind, and also we include a picture in our take-home care material. Parents have found that placing this picture on the bathroom mirror as a reminder is helpful. As we explain this picture, our patients are empowered with the knowledge that they have complete control over what their teeth will look like after we remove braces if they follow our protocol. We recommend brushing above, below, and between the braces using a prescription toothpaste such as Elevate Fluorimax^® 5000, Just Right 5000^® (Elevate Oral Care^®), or PreviDent^® 5000 Plus (Colgate).

We advocate checking to “shine your smile and see your shape” as a visual target to guide their efforts.  We recommend flossers that fit under the wire for easy use such as Plackers Orthopick^® Flossers and Gum^® Proxabrushes^® for in between difficult spots.

The role of early orthodontic intervention in hygiene shaping

Early orthodontic treatment presents a unique opportunity: the ability to use appliance therapy as a catalyst for hygiene improvement. Designer braces in this stage can be leveraged to minimize plaque traps, facilitate easier brushing markers, and engage patients with visual cues that reinforce hygiene behavior. The AAO website notes, “Children can make their orthodontic journey fun with designer braces that feature brackets in various shapes like stars, hearts, and even sports-themed designs. These braces are equally effective and safe as their conventional counterparts.”⁴

An example of designer braces is WildSmiles whose shaped brackets come in various shapes, college logos, and Disney designs.⁵ These fun shapes of WildSmiles brackets have a broader base that sits on the tooth and extends beyond the tie wing, which protects more of the tooth from risk of decalcification. This fun shape is part of a child’s “signature smile,” and brushing to see the shape helps provide a visual target and achievable goal that is more tangible than “go brush your teeth.” Guiding a child to their brushing goal eliminates the struggle between parents and children. With the proper and fun direction, they will not need to re-brush because they were not effective the first time.

Early treatment protocols also encourage more frequent visits or remote monitoring scans, which create additional opportunities for clinicians to reinforce brushing technique, monitor oral health, and educate caregivers. In these regular intervals, oral hygiene is repositioned from an abstract instruction into a visible, trackable goal. For patients who are not yet ready for independent hygiene, these visits or scans can serve as anchor points for accountability and encouragement.

This proactive strategy reframes interceptive orthodontics not as an isolated biomechanical phase, but as a developmental milestone where habits and healthcare literacy are actively shaped.

Compliance tools and strategies: from chairside to homecare

1. Behavioral reinforcement: Positive reinforcement strategies — such as sticker charts, progress photos, and digital rewards — have shown effectiveness in improving pediatric compliance.
2. Visual tracking tools: Tools that allow children to see plaque accumulation, such as disclosing tablets or color-coded brackets, enhance awareness and ownership.
3. Parental coaching: Chairside modeling, instructional videos, and take-home materials empower parents to serve as hygiene coaches.
4. Technological aids: Smartphone apps with reminders, timers, and gamified elements encourage consistency and make brushing feel like a routine rather than a chore.
5. In-office protocols: Every visit can include a hygiene check-in, verbal praise or correction, and visual tracking of progress.
6. Brushing cues for younger patients: Simple strategies such as encouraging patients to “brush to see the shape” of their appliance or teeth have proven effective. By prompting children to reveal the clean contours of designer brackets, clinicians can guide attention to thorough brushing without complex instructions. This method promotes ownership and an easily understood visual goal for the young patient and caregiver.

Integrating these strategies into interceptive treatment fosters a stronger clinician-patient-parent partnership and reinforces the value of early compliance.

Appliance considerations: supporting hygiene through design

Fixed and removable appliances used in early treatment should prioritize hygienic access and minimize plaque-retentive areas. For example:

• Bands versus bonds: Where clinically appropriate, bonded molar tubes may provide easier access for brushing compared to full bands.
• Archwire simplicity: Reducing the number of auxiliaries or unnecessary archwire accessories can limit areas prone to plaque accumulation.⁶
• Customized designs: Incorporating appliance features that are visually engaging for children — such as personalized color choices and themed shapes — can make oral hygiene more goal-oriented and fun. Customized options allow patients to take ownership of their appliance design and help clinicians tailor appliance selection to each patient’s motivational profile.

Clinicians should assess appliance options not only by mechanical function but also by their potential to increase brushing and engagement consistency in young patients.

Case example: a compliance-centered interceptive case

A 9-year-old female presented with moderate crowding, anterior crossbite, and poor hygiene scores despite parental supervision. Treatment was initiated using a limited fixed-appliance approach with bonded tubes and esthetic bracket designs chosen by the patient. Brushing instruction and a hygiene chart were provided at each visit.

What made the brushing instruction effective was the integration of visual, child-led feedback tools. The patient was taught to use disclosing tablets before brushing at home and to “brush to see the shape” of her appliance — a cue that helped her recognize missed plaque in a nonjudgmental way. In-office praise for visible improvements and monthly plaque tracking built intrinsic motivation. The chart used a simple weekly reward system that both patient and caregiver could monitor. (Figures 1-3)

By the third month, plaque scores had improved by 32%, and the patient reported brushing twice daily with caregiver oversight. At 6 months, the anterior crossbite was resolved, and hygiene scores remained in the optimal range. The patient was retained with a removable appliance and transitioned to monitoring until phase II.

This case illustrates the compounding success that occurs when early treatment goals include both biomechanical correction and behavioral hygiene shaping.

Conclusion: hygiene as a clinical priority in early orthodontics

For orthodontists and pediatric dentists, the mixed dentition stage represents more than a biomechanical phase — it is a formative window for habit shaping, behavior reinforcement, and preventive care. Oral hygiene compliance is not a secondary outcome but a foundational one.

By embracing early treatment as an opportunity to influence behavior, reinforce family education, and integrate hygiene into appliance design, clinicians can improve both immediate outcomes and lifelong oral health trajectories. The intentional alignment of treatment goals, communication strategies, and compliance tools transforms interceptive treatment into a comprehensive care experience.

Author’s note: This article was developed with the assistance of AI-based writing tools under the direction of the author. The author takes full responsibility for the accuracy, clinical integrity, and originality of the final manuscript.