J Bagh College Dentistry Vol. 29(1), March 2017 Gingival health condition Pedodontics, Orthodontics and Preventive Dentistry 132 Gingival health condition and salivary physical properties among a group of patients with intermaxillary fixation in tow times intervals (Follow up study) Entiqal N. Jasim Al-Wazni, B.D S., H.D., M.Sc.(1) Nadia A. Al- Rawi, B.D.S., M.Sc., Ph.D.(2) ABSTRACT Background: One of the methods used in the treatment of maxillofacial fracture is intermaxillary fixation(IMF), the most common type is the Erich arch bar with interdental wiring. This study was conducted to investigate the impact of intermaxillary fixation on gingival health condition among a group of patients with facial fracture in relation to salivary physical properties. Materials and methods: Thirty patients with an age range of (17-37) years old with facial fractures and indicated for IMF. Plaque index and gingival index (Loe, 1967) were used to assess both of them before application and after removal of IMF. Unstimulated saliva sample collection was carried out under standardized conditions according to Navazesh and Kumer (2008) before IMF application and after removal to measure salivary flow rate and viscosity. Analysis of data was carried out using SPSS (version 18). Results: A higher mean values of plaque and gingival index were recorded after IMF removal than that before IMF application, with highly significant changes (p<0.01). In regarding to salivary physical properties, salivary flow rate mean values was lower after IMF removal than before IMF application with statistically highly significant changes ( p<0.01). Concerning salivary viscosity, it has been found that a higher mean values after IMF removal than before IMF application with highly significant changes (p<0.01). Conclusion: The results of current investigation revealed that intermaxillary fixation (Arch bar) have a significant effects on gingival health in addition to disturb normal level of certain salivary physical properties. Key words: Intermaxillary fixation, facial fracture, gingival health condition, salivary physical properties. (J Bagh Coll Dentistry 2017; 29(1):132-138) INTRODUCTION Intermaxillary fixation is a technique used to stabilize a fractured jaw involving maxilla, mandibular complex both for closed reduction and adjuvant to open reduction (1). Various types of tooth mounted devices like arch bar, dental and interdental wiring, metallic and non metallic splints are used to achieve intermaxillary fixation (2). The time of intermaxillary fixation which may last for 6 weeks, may be associated with general and oral problems like: weight loss, intense emotional stress, poor oral hygiene, periodontal health problem, loss of tooth vitality, extrusion of teeth, in addition to traumatic ulcer of buccal mucosa ( 3, 4, 5). Saliva is the principal defense mechanism and maintaining the health of the oral tissue. Adequate salivary physical properties are critical to the maintenance of the health of the oral tissues (6). Flow rate play very important function in flushing, dilute substance and neutralizing effect which referred as salivary clearance so higher flow rate faster clearance (7). )1( M.Sc. student Department of Pedodonticsand Preventive Dentistry, University of Baghdad. )2( Assistant Professor, Department of Pedodonticsand Preventive Dentistry, University of Baghdad. Measuring salivary viscosity is of paramount important since an elevated salivary viscosity was found to be associated with an increased occurrence of oral disease (8). There are no Iraqi studies relating salivary composition with oral problems among patients with IMF so this study was conducted to investigate the correlation of certain salivary variables among IMF patients with oral hygiene condition. MATERIALS AND METHODS The study sample included 30 patients , with an age range of 17- 37years, they were all with confirmed diagnosis of facial fracture and indicated for IMF application, the sample was divided according to the age into three age groups: (17-23) years, (24-30) years and (31-37) years. They were examined at the Imam Al- Hussein Medical Hospital in Karbala City, department of maxillofacial surgery for their treatment. Oral examination was done at the day of IMF application. Unstimulated salivary samples were collected for assessment of physical properties (flow rate and viscosity). Dental plaque and gingival inflammation were assessed at the time of IMF application by using Loe index (9).The collection of unstimulated saliva sample was performed following the instruction cited by Navazsh and Kumer (10) . Measurement of salivary viscosity by Ostwald J Bagh College Dentistry Vol. 29(1), March 2017 Gingival health condition Pedodontics, Orthodontics and Preventive Dentistry 133 viscometer (11). After six weeks of IMF application, and at day of IMF removal oral examination and unstimulated salivary sample collection were repeated for study sample. Analysis of data was carried out using SPSS (version 18), and the statistical tests that were used in this study, paired t-test and pearson correlation. RESULTS Result revealed that a high percentage of patients with facial fracture recorded among (17- 23) years age group compared to the other two groups as seen in Table (1). Table (2) represents a higher mean values of plaque index and gingival index among a group of patients with facial fracture after IMF removal than before IMF application with highly significant changes (p< 0.01). Figure (1) illustrates the nominal scales of plaque index among the patients with facial fracture before IMF application and after removal. This study revealed that, the higher percentage was cited under the fair plaque scale followed by good plaque scale and poor plaque scale. Figure (2) illustrates the nominal scales of gingival index among the patients with facial fracture before IMF application and after removal. This study revealed that, the higher percentage was cited under the moderate gingivitis scale followed by mild and sever gingivitis. Table (3) presents rates of secretion of unstimulated saliva and viscosity among patients with facial fracture. Lower mean values of salivary flow rate after IMF removal than before application with highly significant changes (p<0.01). Regarding salivary viscosity, higher mean values of salivary viscosity after IMF removal than before application with highly significant changes (p<0.01). Table (4) referred to the correlation coefficient of plaque index with gingival index in the patients with facial fracture before IMF application and after removal. A strong and positive statistically highly significant correlation were existed between plaque index with gingival index in the both times, before IMF application and after removal. Regarding correlation between dental plaque index with salivary physical properties Table (5) illustrates the correlation coefficient between plaque index with salivary flow rate (SFR) and viscosity among patient with facial fracture before IMF application and after removal. In general a week negative significant correlation were recorded between salivary flow rate and dental plaque before application and after IMF removal. Regarding salivary viscosity a positive significant correlation recorded with dental plaque before application of IMF and after removal. Table (6) demonstrates the correlation coefficient between gingival index with salivary physical properties. The statistical results revealed that there is a negative significant relation between salivary flow rate and gingival inflammation. Also there is a negative non significant relation between salivary viscosity and gingival inflammation before IMF application and a positive non significant relation after IMF removal. Table (1): Distribution of patients with facial fracture by age Table (2): Plaque and gingival index (Mean and Standard Deviation) for total sample Age (Year) No. % 17-23 11 36.666 24-30 9 30.000 31-37 10 33.333 Variable Before IMF application After IMF removal Statistical test Mean±SD Mean±SD t-value df p-value (PlI) 1.22±0.41 1.72±0.48 -7.483 29 0.000** GI 1.24±0.37 1.78±0.33 -11.071 29 0.000** J Bagh College Dentistry Vol. 29(1), March 2017 Gingival health condition Pedodontics, Orthodontics and Preventive Dentistry 134 Figure (1): Plaque severity among patients with facial fracture before application of IMF and after removal. * Time 1: Before application of IMF, Time 2: After removal of IMF Figure (2): Gingival severity among patient with facial fracture before IMF application and after removal. Table (3): Salivary flow rate and viscosity (Mean and Standard Deviation) for total sample Variables Before IMF application After IMF removal Statistical test Mean±SD Mean±SD t-value Df P-value Salivary flow rate (ml/min) 0.41±0.21 0.32±0.12 3.436 29 0.001** Salivary viscosity (poise) 0.04±0.2 0.06±0.02 -11.35 29 0.001** J Bagh College Dentistry Vol. 29(1), March 2017 Gingival health condition Pedodontics, Orthodontics and Preventive Dentistry 135 Table (4): Correlation coefficient between plaque index with gingival index for total sample Table (5): Correlation coefficient between plaque index with salivary flow rate and viscosity for total sample Table (6): Correlation coefficient between gingival index with salivary flow rate and viscosity for total sample IMF application and removal Variable Salivary flow rate Salivary viscosity r P-value r P-value Before IMF application GI -0.375 0.040* -0.066 0.729 After IMF removal GI -0.112 0.555 0.121 0.523 DISCUSSION Various methods have been used for IMF in management of mandibular fracture, one of the most common method in treatment of mandibular fracture is the application of Erich arch bar for IMF with circumdental wiring, Erich arch bars have been used in management of maxilla mandibular fracture since World War 1 (2). However this type of management has been linked with increased risk for oral diseases. The present study (follow up study) was conduct to evaluate the effect of intermaxillary fixation (Erich arch bar) on gingival health condition in relation to salivary physical properties. The patient's selected age were between (17- 37) years old, because most of the patients with motor-vehicle accident with facial fracture with an average age of 20-35 years old (4), in addition to that the most patients were attending to hospital with facial fractures and treating with IMF (Erich arch bar) with these range. In order to provide evidence between the amount of plaque accumulation and gingival inflammation, gingival index (9), was used to assess gingival health condition, with plaque index (9), these are widely used in epidemiological studies due to their ease, feasibility and validity, in addition to allow the assessment of the state by severity (12). In present study, the higher mean values of gingival index after IMF removal may be attributed to the higher mean values of plaque index, with highly significant changes compared to the same group of patients before IMF application, these finding was in agreement with other study that increased gingivitis in patients with IMF after removal (13). Also high significant correlation between plaque index and gingival index among a group of patients with facial fracture before Application of IMF and after removal, this result was agreed with that record by Lone et al (13), Reddy (14). Unfortunately, there are no previous Iraqi studies concerning effect of IMF application on gingival health condition to compare with it. However; the present follow up study revealed that higher PlI and GI among patients after IMF removal than in patients before IMF application, IMF application and removal Variable GI r P Before IMF application PlI 0.730 0.000** After IMF removal PlI 0.761 0.000** IMF application and removal Variable Salivary flow rate Salivary viscosity r P-value r P-value Before IMF application PlI -0.468 0.009** 0.414 0.023* After IMF removal PlI -0.261 0.164# 0.454 0.012* J Bagh College Dentistry Vol. 29(1), March 2017 Gingival health condition Pedodontics, Orthodontics and Preventive Dentistry 136 one of explanation may be due to Erich arch bar that used for treatment of facial fractures with circumdental wiring, the wire pass below the gingival margin and has disadvantages: injury to gingival tissues, compromised the health of periodontium, rounded wire edges collect food debris cause gingival inflammation and difficulty in maintaining oral hygiene (2). Another explanation, patients with facial fracture under emotional stress, which effects on gingival inflammation either by direct influence of stress on immune system (biologic model), through release of stress hormones or by an influence of increase plaque accumulation during stressful experiences period leading to gingival inflammation, as the plaque is the causative factor of gingival inflammation (behavioral model), through the change in life-style such as ignoring self-oral health measures and impropriate cariogenic diet, both models resulting in increasing susceptibility to periodontal diseases (15, 16). In the present study increase gingivitis in addition to plaque accumulation may be due to trauma from wiring which may lead to increase in gingival inflammation, this factor demonstrate the direct impact of IMF on gingival condition (17). Stooky in 2008 reported that saliva through its flow rate and constituents may play an essential role in maintaining the integrity of the hard and soft oral tissues, and reflecting a physiological status of the oral cavity (18). This study revealed that patients with IMF after removal, had a lower mean value of salivary flow rate compare to the same patients before application of IMF, these finding may be attributed to several cause, one of them is that salivary flow rate affect by several factor (medication, position of individual, hydration, nutrition) (5, 19). Patients with facial fracture usually under analgesic to relief the pain, so these medication play a role in decreasing the flow rate of saliva. Also patients with facial trauma most of time with laying position and salivary flow rate is more in standing position than in under laying position (6, 19). Patients with trauma had a difficulty in drinking and improper eating this will lead to dehydration, the degree of individual hydration is the most important factor that affect salivary secretion. When the body water content is reduced by 8%, salivary flow rate virtually diminishes to zero, whereas hyper hydration causes an increase in salivary flow rate (19). During dehydration salivary gland cease secretion to conserve water. Additionally, other explanation for these findings, patients with facial fracture treated with IMF under emotional disturbances (anxiety, stress, and depression) this condition produce transient reduction in salivary flow and change in salivary components (20). Another explanation for decrease of salivary flow rate in patients with facial fracture treated with Erich arch bar after IMF removal is that application of arch bar, patients can not open the mouth this condition resemble to the patients when sleeping so no secretion of saliva and lead to decrease in saliva flow rate (21). Lower salivary flow rate among a group of patients after IMF removal with highly significant, the result can be explained by that the flow rate of saliva may play important role in relation to plaque accumulation, so decrease in flow rate of saliva lead to decrease of washing action of saliva which lead to oral dryness as well as decrease of protective constituents (21). Salivary flow rate in this study was negatively correlated with dental plaque and gingival indices. This result was in agreement with Iraqi studies found an inverse relation between salivary flow rate and gingival index (22- 24), this could be attributed to the fact that saliva exerts a major influence on plaque initiation and maturation (25). Salivary viscosity is a quality or state of being viscous, relates to the glycoprotein content of saliva (26, 27). Viscoelastic properties are essential for humidification and lubrication which providing mucosal integrity (28). An increased salivary viscosity increased oral health problem (8, 29). In the present, investigation salivary viscosity is higher after IMF removal compare with the mean values before IMF application, an explanation of increase in salivary viscosity in addition to the factor related with decrease salivary flow rate, is that patients with facial fracture suffer from emotional disturbance (anxiety, stress) so, sympathetic stimulation produces little saliva but of high protein concentration (30-32). However, this elevation in the total protein could be attributed to sympathetic activation during stress as the sympathetic innervations of the salivary glands controls protein secretion (33, 34). However no significant correlation has been recorded between salivary viscosity ad gingival inflammation. This result in agreement with Al-Awadi and Yas (23,35). Data of present study show a positive correlation between plaque index and salivary viscosity. J Bagh College Dentistry Vol. 29(1), March 2017 Gingival health condition Pedodontics, Orthodontics and Preventive Dentistry 137 REFERENCES 1. Coletti D, Salama A, Caccamese J. Application of intermaxillary fixation screws in maxillofacial trauma. J Oral Maxillofac Surg 2007; 56(9): 1746 -1750. 2. Chandan S, Ramanojam S, Comparative evaluation of the resin bonded arch bar versus conventional Erich arch bar for intermaxillary fixation. J Maxillofac Oral Surg 2010; 9: 231 - 5. 3. Booth P, Schendel S, Hausamen J. 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J Bagh College Dentistry Vol. 29(1), March 2017 Gingival health condition Pedodontics, Orthodontics and Preventive Dentistry 138 الخالصة االسالك بين االسنانمع اريك قوسشريط واالنواع االكثر شيوعا هي .الفكينلعالج كسور الوجه والفكين هي تثبيت التي تستعمل واحدة من االساليب المقدمة: . فيما يتعلق بالخصائص.يعانون كسر في الوجه لمرضى بين مجموعة من ا الفكين على الحالة الصحية لللثة تهدف الدراسة إلى بيان تأثير تثبيت أهداف الدراسة: اللعابية. الفيزيائية الفك السفلي والفكين, تم عالجهم عن طريق تثبيت سنة, يعانون من كسور في الوجه 71-71العينة ثالثون مريض للفئة العمرية المواد وطرق العمل: تتضمن ظل ( قبل التثبيت وبعد رفع التثبيت. تم جمع عينات اللعاب غير المحفز فيLoe, 1967بالفك العلوي. تم قياس الصفيحة الجرثومية والتهاب اللثة باستخدام ) اجري تحليل البيانات اللعاب واللزوجة.قياس معدل تدفق لتثبيت, تم( قبل التثبيت وبعد رفع ا (Navazesh and Kumer, 2008ظروف موحدة وطريقة .71االصدار SPSSنظام باستخدام مع تغيرات معنوية منه قبل وضع التثبيت التثبيتى بعد إزالة اظهرت نتائج الدراسة الحالية ان متوسط قيمة الصفيحة الجرثومية كان اعلى بين المرض النتائج: . P<0.01)معنوية عالية ) مع تغيرات تثبيتمنه قبل وضع ال التثبيتبعد إزالة . متوسط قيمة التهاب اللثة كان اعلى بين المرضىP<0.01)عالية ) , اظهرت الدراسة عدم وجود اي ارتباط بين P<0.01)مع تغيرات معنوية عالية )التثبيت قبل وضع منه لتثبيتا معدل تدفق اللعاب غير المحفز كان اقل بعد ازالة بالنسبة للعالقة بين التهاب اللثة و معدل تدفق اللعاب لتثبيت . مع وجود عالقة سلبية عالية قبل وضع اتثبيت الصفيحة الجرثومية ومعدل تدفق اللعاب بعد إزالة ال ربط وبعده.هناك ارتباط سلبي قبل وضع ال أظهرت الدراسة وجود عالقة بين لزوجة اللعاب و .P<0.01)مع تغيرات معنوية عالية ) منه قبل وضع التثبيت تثبيتمعدل اللزوجة كان أعلى بعد إزالة ال بعد رفعه.و التهاب اللثة قبل التثبيت لعاب ومع عدم وجود عالقة بين لزوجة الوبعد رفعه تثبيت ة الجرثومية قبل الالصفيح .ائيةباالضافه إلى اإلخالل بالمستوى الطبيعي لمكونات اللعاب الفيزي اثار جانبية على صحة اللثةبحث الحالي إن لتثبيت الفكين االستنتاجات: أثبتت نتيجة ال