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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 53  |  Issue : 1  |  Page : 43-48

A Comparative assessment of the effect of professional oral hygiene measures on the periodontal health of patients undergoing fixed orthodontic appliance therapy


1 Principal, Prof. and Head, Department of Orthodontics and Dentofacial Orthopedics, MES Dental College, Perinthalmanna, Kerala, India
2 Additional Prof., Department of Orthodontics and Dentofacial Orthopedics, Government Dental College, Thrissur, Kerala, India
3 Prof., Department of Orthodontics and Dentofacial Orthopedics, MES Dental College, Perinthalmanna, Kerala, India
4 Formerly Reader, Department of Periodontics, MES Dental College, Perinthalmanna, Kerala, India
5 Formerly Reader, Department of Orthodontics and Dentofacial Orthopedics, MES Dental College, Perinthalmanna, Kerala, India
6 Formerly Senior Lecturer, Department of Orthodontics and Dentofacial Orthopedics, MES Dental College, Perinthalmanna, Kerala, India

Date of Submission14-Feb-2018
Date of Acceptance05-Aug-2018
Date of Web Publication5-Feb-2019

Correspondence Address:
Dr. Prathapan Parayaruthottam
209 C, Hilite Residency, Hilite City, Kozhikode - 673 014, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jios.jios_21_18

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  Abstract 


Objective: Maintaining good oral hygiene during fixed orthodontic treatment will help keep good periodontal health, which will reflect in the final outcome of orthodontic treatment. Hence, we undertook this study to find out whether doing professional prophylaxis midway during fixed orthodontic treatment will reduce adverse changes on the gingival and periodontal apparatus due to poor oral hygiene maintenance when compared to homecare measures only. Materials and Methods: This prospective study involved twenty patients who underwent fixed orthodontic therapy, in the Orthodontics Department of a teaching institution. The effect of regular home care measures only as compared to professional prophylaxis midway during orthodontic treatment in addition to regular home care on the periodontal health was evaluated on two separate visits over a 9-month period. Results: The clinical parameters indicating periodontal conditions during fixed orthodontic treatment, such as plaque, gingival, bonded bracket plaque indices and probing depth, were evaluated. The results revealed that an oral prophylaxis done in the 5th month during a 9-month study drastically improved the gingival and periodontal health of patients. Conclusions: The present study was done to understand the importance of professional prophylaxis and proper instructions in oral hygiene maintenance during orthodontic treatment in our target population. Results showed a significant improvement of gingival and periodontal health in the present study, with an improvement in plaque control with professional prophylaxis which was in accordance with most of the previous studies. Hence, it can be concluded that plaque control with professional prophylaxis in orthodontic patients is a very important adjunct in the maintenance of proper periodontal health and prevention of periodontal disease.

Keywords: Bonded Bracket Plaque Index, gingival index, oral hygiene measures, periodontal health, plaque index


How to cite this article:
Francis P G, Parayaruthottam P, Antony V, Ummar F, Shaloob K M, Hassan K J. A Comparative assessment of the effect of professional oral hygiene measures on the periodontal health of patients undergoing fixed orthodontic appliance therapy. J Indian Orthod Soc 2019;53:43-8

How to cite this URL:
Francis P G, Parayaruthottam P, Antony V, Ummar F, Shaloob K M, Hassan K J. A Comparative assessment of the effect of professional oral hygiene measures on the periodontal health of patients undergoing fixed orthodontic appliance therapy. J Indian Orthod Soc [serial online] 2019 [cited 2019 Feb 21];53:43-8. Available from: http://www.jios.in/text.asp?2019/53/1/43/251546




  Introduction Top


Malocclusion is shown to be having an association with increased plaque accumulation due to the difficulty of following proper brushing techniques. When a fixed orthodontic appliance is strapped up to correct these malocclusions, most patients develop generalized gingivitis due to difficulty in following proper brushing techniques. Increase in probing depth during orthodontic treatment could also be due to an enlargement of gingiva after orthodontic bracket placement. Hence, importance of oral hygiene is always stressed to orthodontic patients to prevent periodontal disease. Plaque is seen to accumulate on orthodontic appliances when proper oral hygiene is not maintained, which in turn leads to the destruction of periodontal tissues.[1] Maintaining good oral hygiene during fixed orthodontic treatment will help keep good periodontal health. This will have a positive effect in the final treatment outcome. The study was thereby undertaking to test the hypothesis that doing professioal prophylaxis midway during fixed orthodontic treatment will produce a statistically significant reduction in adverse changes on gingival and periodontal apparatus due to poor oral hygiene maintenance during fixed appliance therapy as compared to homecare measures only.

Aims and objectives

This study was done with the aim of finding out:

  1. If doing professional prophylaxis midway during fixed orthodontic treatment will reduce adverse changes on gingival and periodontal apparatus due to poor oral hygiene maintenance during fixed appliance therapy as compared to homecare measures only
  2. If there is a need to highlight the importance of professional prophylaxis midway during orthodontic treatment in addition to regular home care as compared to proper personal plaque control for maintaining proper oral hygiene.


The period selected to evaluate oral hygiene maintenance on the gingival and periodontal health in orthodontic patients was on two separate visits (T0 and T1) over a 9-month study period.

The objectives of the study included

  1. To evaluate and quantify plaque using the Plaque Index by Silness and Lōe
  2. To assess the gingival health using the Gingival Index described by Lōe and Silness[2],[3]
  3. To assess plaque accumulation on bonded brackets using the Bonded Bracket Plaque Index (BBPI) advocated by Kilicoglu et al.[4]
  4. To assess the periodontal probing depth which signifies periodontal disease.



  Materials and Methods Top


The present study was a prospective study and approval for the study was obtained on March 24, 2015, as per the Institutional Ethical Committee No: 16. Twenty patients (five males, fifteen females; mean age, 16.7 ± 2.3 years) were selected to undergo fixed orthodontic treatment in the Department of Orthodontics of a teaching institution. Statistical evaluation indicated that a minimum of six patients per group should be studied to eliminate α-error at 0.05. All participants were informed about the study, and they provided written, informed consent. Patients were given standardized toothbrush, toothpaste, and mouthwash and were instructed not to use any other oral hygiene aids during the period. Following the extraction of four first premolars, all patients were treated with the pre-adjusted Edgewise (PEA) (MBT-0.022” slot, Ormco).

Inclusion criteria were as follows:

  1. Patients with full complement of teeth except third molars:
  2. The subjects were aged 15–20 years
  3. Patients with Angle's Class I bimaxillary dentoalveolar protrusion malocclusion with no habits (mouth breathing, tongue thrusting) indicated for fixed appliance therapy (Pre-adjusted Edgewise Appliance 0.022” MBT Prescription) with extraction of all four first premolars.


Exclusion criteria were as follows:

  1. Those who have used either systemic or subgingival antibiotics in a period of 3 months before initial examination
  2. Those using systemic drugs for chronic illnesses
  3. Those who had any periodontal treatment within a 3 months' period of initial examination
  4. Smokers, mouth breathers, pregnant women, or lactating mothers
  5. Those with any systemic diseases which could affect periodontal health
  6. Patients with missing teeth, crowded dentition, or those needing combined surgical and orthodontic treatment.


Methodology

The 20 patients were divided into two clinical groups by random selection:

  1. Control Group (Group 1) – Ten patients with Angle's Class I bimaxillary dentoalveolar protrusion who underwent all four first premolar extraction followed by fixed appliance therapy. Oral hygiene measures included regular home care with orthodontic toothbrush. Regular home care measures include using orthodontic toothbrush, interproximal brushes, and the same brand of toothpaste and mouthwash for all the patients in both groups
  2. Experimental Group (Group 2) – Ten patients with Angle's Class I bimaxillary dentoalveolar protrusion who underwent all four first premolar extraction followed by fixed appliance therapy. Oral hygiene measures included professional scaling in the 5th month of orthodontic treatment along with regular home care measures.


Teeth selected for periodontal health indexing were 16, 25, 36, 45, and 41. Clinical parameters were recorded on these teeth.

Periodontal health was assessed by:

  1. Plaque Index (William's modification)
  2. Gingival Index[2],[3]
  3. BBPI[4]
  4. Pocket depth measured with a Williams periodontal probe.


The periodontal assessment was done by the same examiner at T0 and T1 in both groups to avoid any interexaminer error.

At the beginning of treatment, the subjects received oral prophylaxis and oral hygiene instructions as per the modified Bass technique. The patients in Groups 1 and 2 were then sent for therapeutic extraction of all four first premolars. Following this, fixed appliance therapy was started.

After 1 month (T0), Plaque Index, Gingival Index, BBPI, and probing depth were measured and recorded for the participants in both the groups.

In the 5th month, professional prophylaxis was given for the patients in Group 2.

At the end of the 9th month (T1), Plaque Index, Gingival Index, BBPI, and probing depth were again measured and recorded for the subjects in both the groups.


  Results Top


All the statistical analyses were done using the SPSS statistical package (Version 16-SPSS Statistics for Windows, IBM Corp., Armonk, NY, USA). P < 0.05 was considered statistically significant. The Mann–Whitney U-test was done to understand any significant differences between these groups at a time interval of 9 months, by taking the differences between the two groups for the Plaque Index, Gingival Index, BBPI, and probing depth. The comparison of gingival and periodontal parameters between the two time periods was done with the Wilcoxon signed-rank test.

[Table 1] reveals the values of Plaque Index, Gingival Index, BBPI, and probing depth in the Control Group at two time periods.
Table 1: Plaque Index, Gingival Index, bonded bracket plaque index, and probing depth in the Control Group at two time periods

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[Table 2] reveals the values of Plaque Index, Gingival Index, BBPI, and probing depth in the Experimental Group at two time periods.
Table 2: Plaque Index, Gingival Index, bonded bracket plaque index, and probing depth in the Experimental Group at two time periods

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[Table 3] shows the statistical comparison of periodontal measurements between groups.
Table 3: Statistical comparison of periodontal measurements between groups

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The results were suggestive of a significant correlation between fixed orthodontic treatment and periodontal disease progression.


  Discussion Top


Most patients undergoing fixed orthodontic therapy have been seen to develop gingival pathology at some point of time during its course.[5] Bonded orthodontic appliances have reported to cause less gingivitis than banded appliances.[6] Orthodontic treatment with fixed appliances has been listed as a risk factor for plaque accumulation. Assessment of dental plaque is therefore essential in the evaluation of the oral hygiene of individual patients undergoing fixed appliance treatment and in clinical studies measuring plaque. Dental plaque should be assessed both before and after placing the appliance. If patients are motivated during treatment, the Gingival Index of the patient can be prevented from rising.[7]

In this study, the periodontal status was evaluated in 20 patients for whom fixed orthodontic treatment was started. The study was conducted to evaluate the periodontal status clinically around the brackets/bands placed on the teeth specified for taking the index, during orthodontic treatment. The study was conducted for 9 months which usually is midway of the duration of orthodontic treatment. Fifth month during treatment was selected as the time at which professional prophylaxis was done as it signified the time at which alignment phase was completed, and retraction was started. The study was conducted to find out if professional prophylaxis carried out at a fixed time (5th month in this study) during the course of orthodontic treatment would enable better periodontal health.

There is no definite protocol in our scenario as of now regarding professional prophylaxis as part of oral hygiene maintenance during the course of fixed orthodontic treatment and we wanted to create a protocol for our institution. The initial phase of orthodontic treatment holds importance in that it is during this phase that the patient is getting used to the appliance and alignment is being done, especially in patients with crowding, where oral hygiene maintenance is difficult. Furthermore, in the final phase of treatment, when the patient is accustomed to fixed appliances, the results of any improvement achieved in oral hygiene maintenance during the initial alignment phase may not be that visible or significant than during the initial phase. After this initial study, we aim to find out in our ongoing study if further professional prophylaxis is needed at any other time during the full duration of orthodontic treatment.

The baseline values were found to have no significant differences in both groups which showed that the pretreatment oral hygiene of patients in both groups was comparable. Hence, the study is highly significant with respect to the results obtained after professional prophylaxis is done in between treatment for the Experimental Group.

The results of the study showed significant change (P = 0.05) in periodontal status and thus supports our hypothesis. There was a marked increase in the Plaque Index, Gingival Index, BBPI, and probing depth at the completion of the study period in the Control Group. Naranjo et al. reported similar findings in that there was accumulation of biofilm following bracket placement at the retentive sites.[8] According to Ristic and coworkers, clinical and microbiological parameters showed a marked elevation 3 months after fixed appliance treatment was started, followed by a decrease in the values after another 6 months.[9]

Both the anterior as well as the posterior indexed teeth showed change in the periodontal health parameters (P < 0.05). Therefore, it was found that the brackets, as well as the bands, influence the periodontal health which was in agreement with other similar studies.[10],[11],[12],[13]

Plaque accumulation is also indicated as a factor which increases the clinical parameters such as bleeding on probing and pocket depth. A large number of patients reporting for orthodontic treatment are young patients, of whom the majority has gingivitis related to plaque accumulation. Adolescents are shown to have more gingivitis than adults during the course of orthodontic treatment.[14] Therefore, maintaining stable periodontal health should be the primary aim before any orthodontic intervention.[15] Maintaining stable periodontal health during orthodontic treatment would deliver accurate treatment results. Regular motivation and practice of oral hygiene measures in young age groups will definitely enhance the oral hygiene standards.[16],[17]

In the present study, Plaque index in the Control Group showed a definite increase in values between the two time periods and was statistically significant (P = 0.005); whereas in the Experimental Group, an oral prophylaxis intervention in the 5th month definitely reduced the values of the Plaque Index at the 9th month (P = 0.008) as revealed in [Graph 1]. This could be due to the fact that the oral prophylaxis in the 5th month had physically reduced the plaque level and thus improved oral hygiene.



A definite reduction in Plaque Index and bleeding on probing was seen in the Experimental Group at the end of the study period. It can therefore be inferred that proper plaque control measures helps in reducing gingivitis. This is very important considering that maintaining good gingival and periodontal health during treatment would actually contribute to better retention of the changes obtained during treatment.

Similarly, analysis of the values of the Gingival Index in the Control Group revealed a definite increase in the index (P = 0.008). Group 2 on the other hand revealed a decrease in values (P = 0.012) which can be attributed to the oral prophylaxis in the 5th month as seen in [Graph 2]. The result is significant at P < 0.05.



The BBPI, as seen in [Graph 3], revealed an increase in the Control Group (P = 0.005) in contrast to the Experimental Group which showed a decrease in values (P = 0.005).



Probing depth showed no significant differences between the two groups at the two time periods at the completion of the study period with both groups showing a very slight increase in the probing depth (P = 0.032). This may be due to the fact the periodontal disease has not advanced much in both the groups, with some patients even showing a decrease in values. We may have got more conclusive results of the same if we had evaluated the patients for their full orthodontic treatment period.

This study gives us the inference that oral prophylaxis done in the 5th month during a 9-month study drastically improved the periodontal health of patients. Further studies are to be done with patients being included for the full duration of their treatment including the retention period. We will also have to evaluate the best time to do oral prophylaxis in between treatment.


  Conclusions Top


The present study was done to understand the importance of professional prophylaxis and proper instructions in oral hygiene maintenance during orthodontic treatment in our target population. Results showed significant improvement of gingival and periodontal health in the present study with an improvement in plaque control with professional prophylaxis which was in accordance with most of the previous studies. Hence, it can be concluded that plaque control with professional prophylaxis after initial alignment is of utmost importance in the maintenance of periodontal health as well as the prevention of periodontal disease during orthodontic treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sallum EJ, Nouer DF, Klein MI, Gonçalves RB, Machion L, Wilson Sallum A, et al. Clinical and microbiologic changes after removal of orthodontic appliances. Am J Orthod Dentofacial Orthop 2004;126:363-6.  Back to cited text no. 1
    
2.
Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35.  Back to cited text no. 2
    
3.
Loe H, Silness J. Periodontal disease in pregnancy. I. prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 3
    
4.
Al-Anezi SA, Harradine NW. Quantifying plaque during orthodontic treatment. Angle Orthod 2012;82:748-53.  Back to cited text no. 4
    
5.
Boyd RL, Baumrind S. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissue versus those of adolescents. Angle Orthod 1992;62:117-26.  Back to cited text no. 5
    
6.
Zachrisson S, Zachrisson BU. Gingival conditions associated with orthodontic treatment. Angle Orthod 1972;42:26-34.  Back to cited text no. 6
    
7.
Boyd RL. Enhancing the value of orthodontic treatment: Incorporating effective preventive dentistry into treatment. Am J Orthod Dentofacial Orthop 2000;117:601-3.  Back to cited text no. 7
    
8.
Naranjo AA, Triviño ML, Jaramillo A, Betancourth M, Botero JE. Changes in the subgingival microbiota and periodontal parameters before and 3 months after bracket placement. Am J Orthod Dentofacial Orthop 2006;130:275.e17-22.  Back to cited text no. 8
    
9.
Ristic M, Vlahovic Svabic M, Sasic M, Zelic O. Clinical and microbiological effects of fixed orthodontic appliances on periodontal tissues in adolescents. Orthod Craniofac Res 2007;10:187-95.  Back to cited text no. 9
    
10.
Ristic M, Vlahovic Svabic M, Sasic M, Zelic O. Effects of fixed orthodontic appliances on subgingival microflora. Int J Dent Hyg 2008;6:129-36.  Back to cited text no. 10
    
11.
Huser MC, Baehni PC, Lang R. Effects of orthodontic bands on microbiologic and clinical parameters. Am J Orthod Dentofacial Orthop 1990;97:213-8.  Back to cited text no. 11
    
12.
Paolantonio M, di Girolamo G, Pedrazzoli V, di Murro C, Picciani C, Catamo G, et al. Occurrence of actinobacillus actinomycetemcomitans in patients wearing orthodontic appliances. A cross-sectional study. J Clin Periodontol 1996;23:112-8.  Back to cited text no. 12
    
13.
Alexander SA. Effects of orthodontic attachments on the gingival health of permanent second molars. Am J Orthod Dentofacial Orthop 1991;100:337-40.  Back to cited text no. 13
    
14.
Hamp SE, Lundström F, Nyman S. Periodontal conditions in adolescents subjected to multiband orthodontic treatment with controlled oral hygiene. Eur J Orthod 1982;4:77-86.  Back to cited text no. 14
    
15.
Boyd RL, Murray P, Robertson PB. Effect of rotary electric toothbrush versus manual toothbrush on periodontal status during orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:342-7.  Back to cited text no. 15
    
16.
Polson AM, Subtelny JD, Meitner SW, Polson AP, Sommers EW, Iker HP, et al. Long-term periodontal status after orthodontic treatment. Am J Orthod Dentofacial Orthop 1988;93:51-8.  Back to cited text no. 16
    
17.
Eliasson LA, Hugoson A, Kurol J, Siwe H. The effects of orthodontic treatment on periodontal tissues in patients with reduced periodontal support. Eur J Orthod 1982;4:1-9.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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