Enas F.doc J Bagh College Dentistry Vol. 25(2), June 2013 The effect of different Orthodontics, Pedodontics and Preventive Dentistry143 The effect of different oral hygiene regimens on the quantity of cariogenic plaque on orthodontic bands with different attachments (A clinical photographic study) Enas J. Almusawi, B.D.S. (1) Hayder F. Saloom, B.D.S., M.Sc. (2) ABSTRACT Background: Fixed orthodontic appliances impede the maintenance of oral hygiene and result in plaque accumulation leads to enamel demineralization caused by acids produced by bacteria. Studies on plaque control strategies in orthodontic populations are limited. This might be caused by difficulties in the quantitative evaluation of dental plaque because the teeth have various levels of bracket coverage, and different tooth sizes and malocclusions, making the traditional categorical indices complex. The present study aims to evaluate the effect of different hygiene protocols on plaque quantity on bands with different attachments. Materials and method: Twenty patients had four bands within the orthodontic appliance. Then randomly divided into four groups of hygiene regimens where group A used chlorhexidine dentifrice, group B used fluoridated dentifrice, group C used chlorhexidine mouthwash along with chlorhexidine dentifrice and group D used chlorhexidine mouthwash in addition to the fluoride dentifrice. Bands were removed four weeks after the appliance been in place, cut out carefully into 2 pieces from the center of the mesial and distal contact areas, biochemical test (clinprocario L-pop) was applied then 80 digital photographs were obtained. Four areas of interest were estimated which are mesially and distally to each attachment (2 mm) in width each. Percentage of plaque in these areas was calculated and statistically analyzed. Results: Side difference revealed that the plaque accumulated on the right sided bands more than the left, however the difference was not significant. It was also found that the lower bands had insignificantly higher amount of plaque than the upper ones. Conclusions: The four groups of oral hygiene regimens have no significant different effects on the plaque amount. Moreover, the oral hygiene maintenance is more difficult in the right side than the left side but the difference was not significant. The lower arch accumulated insignificantly more plaque than the upper. Also, difference in attachments has no influence on plaque amount. Keywords: Cariogenic plaque, plaque quantity, clinprocario L-pop, orthodontic bands, oral hygiene. (J Bagh Coll Dentistry 2013; 25(2):143-148). INTRODUCTION Orthodontic treatment can improve the self- image of patients through the provision of better esthetics and a more attractive smile. In addition, orthodontics can in principle have long-term health advantages for patients, since crooked and crowded teeth are difficult to clean and maintain. Despite the post therapy health advantages of orthodontics, the treatment regimen itself creates obstacles for patients, because orthodontic brackets create plaque-retentive sites that impede tooth cleaning. Dental plaque is a causative factor for oral disease, and thus its removal and control are important aspects of oral health maintenance 1,2. This plaque can lead to enamel demineralization3 and gingivitis 4. Previous studies have shown that the rate of decalcification in orthodontic patients is higher than in patients without orthodontic treatment. White spots have been reported in as many as 50% of teeth treated with brackets and in up to 50% of orthodontic patients 5,6. (1)M.Sc. student. Department of Orthodontics. College of Dentistry. University of Baghdad. (2)Assistant professor. Department of Orthodontics. College of Dentistry. University of Baghdad. Although various studies have evaluated fluoride treatments for their effects in reducing white spot formation associated with orthodontic treatment7, surprisingly only a few studies have assessed plaque prevention by antimicrobials 4,8,9. Most of those studies that investigated plaque focused on hygiene aids 10-12. One reason for the limited number of studies of antimicrobial plaque control in orthodontic populations might be due to the lack of qualified, simple, and convenient measurement methods. Most traditional plaque scoring systems applied to unbracketed dentitions, such as the Löe and Silness index,13 the Turesky modification of the Quigley and Hein index14 or the Navy index 15 are difficult to use in orthodontic populations. This is because they are based on a nonlinear (categorical) scale focused on plaque along the gum line; even after modifications, they lack sensitivity when applied to orthodontic populations. Planimetry-based scales would probably be more appropriate for orthodontic patients, whose plaque accumulates in a variety of orientations driven by the presence of appliances. In recent years, several objective plaque evaluation methods with digital image analysis J Bagh College Dentistry Vol. 25(2), June 2013 The effect of different Orthodontics, Pedodontics and Preventive Dentistry144 have been developed 16-18. This study was performed to show the different effect of chemical plaque control agents (CHX, F) on plaque amount in orthodontic bands with different attachments. MATERIALS AND METHODS The sample Twenty patients were included in this study; from those who were attending the postgraduate clinic of Orthodontic Department in Collage of Dentistry/Baghdad University according to their fitness to the following criteria: 1) Patients age 18-25 included eleven females and nine males. 2) Good general physical health 3) The dental requirement for inclusion was a malocclusion in which orthodontic treatment without teeth extraction was needed. 4) No history of any systemic disease. 5) No history of any oral habit. 6) Good oral hygiene 7) The presence of well aligned adjacent teeth on both sides of the first permanent molar without spacing, caries or Cl II filling. 8) The patients had full set of upper and lower dentition excluding the third molars with no congenital missing or any abnormality in the form of dentition. 9) The patients should not take any antibiotic during the experimental study. 10) Posterior or anterior cross bite should not be included in the sample. 11) The participants should be well educated so they can be motivated. Materials and equipment 1) General dental materials and instruments 2) Orthodontic material and instruments 3) Orthodontic upper and lower 1st molar bands 4) Biochemical test kit ClinproCario L-Pop (CCLP) 5) Oral hygiene aids 6) The Digitizing and Storage Equipment and Programs Method Participants were examined clinically, standard orthodontic records were obtained and Oral hygiene status of the patients was determined. Tooth separation for proper seating of orthodontic bands by elastomeric separators was done, three days later fixed appliance was placed and the patients were randomly divided into four groups of hygiene regimens where group A used chlorhexidine dentifrice, group B used fluoridated dentifrice, group C used chlorhexidine mouthwash along with chlorhexidine dentifrice and group D used chlorhexidine mouthwash in addition to the floutride dentifrice. The patients received special oral hygiene instructions included a detailed brushing protocol with a demonstration of the Bass brushing technique. They were told to brush 3times a day for 2 minutes, using an amount of dentifrice that covers the entire head of the toothbrush; and to brush their teeth after snacks using the brush only. They were also asked not to use other oral hygiene products the next four weeks. The patients were checked two weeks later for their oral hygiene in terms of gingival index, and they were instructed to continue perform their hygiene regimens. After four weeks the experimental bands were removed and replaced by new ones. Immediately following careful removal from patients' mouths through grasping the band from the attachment by the band remover pliers, the bands were cut out from the middle of the mesial and distal contact areas with metal scissors into two pieces then each piece was flattened out by grasping it from the free ends using Adams pliers and pulled out, any contact with areas of interest were avoided. Furthermore, this procedure took place in an antiseptic environment. The two pieces of the band were placed in a petri dish. The biofilm was stained with a biochemical test for lactic acid (ClinproCario L-Pop; 3M ESPE, Seefeld, Germany) Figure 1. Using this method, the biofilm was identified according to bacteria that produce lactic acid as a key metabolic factor, these being bacteria with a highly cariogenic potential. The bands were positioned on a millimeter paper, waiting for two minutes and photographed. The four areas of interest, each 2 mm in width, were defined and digitally marked with the cursor on each band: the mesial and distal regions of the buccal and lingual attachment. The software calculated the surface area of each marked area. The stained biofilm area was then marked within the four areas using a cursor and the area covered, and calculated by the software again. A ratio was computed from the calculated results, which revealed the quantity of biofilm in the specific areas of interest. (figure2) RESULTS The mean values of plaque ratios and standard deviation with different attachments on orthodontic bands in patients following different oral hygiene regimens were estimated in (table 1). The differences among the four groups of oral hygiene were not significant. Side difference in J Bagh College Dentistry Vol. 25(2), June 2013 The effect of different Orthodontics, Pedodontics and Preventive Dentistry145 means of plaque amount on the upper bands from the buccal aspect revealed that the means on the right side were higher than those on the left side in all groups of oral hygiene regimens except for group D where the mean on the right side was lower than that on the left distal to the attachment , although the differences were not significant, lingually button and the cleat on the right and left bands respectively revealed insignificant difference in all groups of hygiene protocols. On the lower bands buccally, the difference between double tubes on the right and left sides was higher on the right side than the left side in all of four groups, it was significant in 100% of the sample in group A, while 50% of the sample was significant in group B. while plaque amount on the lingual button were insignificantly higher than the lingual cleat. Regarding arch differences on the right side, the plaque amount on the lower tripple tubes is insignificantly higher than that on the upper double tubes in all groups of hygiene regimens; this is also true for the lingual cleats. The double versus tripple tubes on the left side reveals insignificantly higher amount of plaque on the lower arch. In addition, lingual buttons also accumulated higher amount of plaque on the lower than the upper. DISCUSSION Studies on plaque control strategies in orthodontic populations are limited. This might be caused by difficulties in the quantitative evaluation of dental plaque because the teeth have various levels of bracket coverage, and different tooth sizes and malocclusions, making the traditional categorical indices complex. The other approach is measurement of the percentage area covered by plaque using digital image analysis of photographs19. Digital photographs of disclosed teeth greatly facilitate such analysis. Direct digital measurement of percentage plaque coverage is more complex but is likely to prove more valid and more reproducible than categorical indices. The advantages of a photograph are that it can be assessed at leisure, is a permanent record, and can be viewed on multiple occasions, enabling assessment of reproducibility, which was found to be excellent. It should be noted that area measurement is not completely immune from an element of subjective judgment and other potential sources of error. These potential errors are probably small in relation to those associated with visual estimation for a categorical index, but they are nevertheless a factor. In addition, Digital measurement requires longer time and greater technical complexity. The results of the present study revealed that all the chemical plaque control agents used were of no significant different effect. Furthermore, the use of CHX mouth wash as an adjunct to the CHX or fluoridated tooth pastes had no significant additive influence on the quantity of plaque. This is in agreement with other study which investigated the influence of 0.12% and 0.2% chlorhexidine gluconate on both dental plaque accumulation and salivary S. mutans and showed that there is no significant difference between them20. Previous study investigated the effect of 40% chlorhexidine varnish during a 30-month period. They also found that 40% chlorhexidine varnish did not decrease the number of cariogenic bacteria21. In contrast to this study, some previous studies suggested that higher concentrations of antimicrobial agents and multiple treatments extend the time of effectiveness against S mutans and dental plaque22. Investigation of varnishes with high concentrations of chlorhexidine (40% chlorhexidine) revealed a significantly stronger reduction of S. mutans in plaque and saliva compared to low-concentration varnish during a 2-week period which does not agree with this study 23. The germicidal effect of fluoride on cariogenic bacteria (such as S mutans and lactobacilli) is the inhibition of glycolysis. In addition, fluoride acidifies the interior of cells and inactivates some enzymatic metabolic processes 24. The use of fluoridated tooth paste in combination with CHX mouthwash in this study had no significant effect on the quantity of cariogenic plaque, this finding goes along with the result of other study25 which evaluated the effect of 0.3 % triclosan toothpaste with and without flouride on enamel demineralization and found that in combination with fluoride, triclosan has no additional protective effect against demineralization. Flouride did not increase the efficacy of the toothpastes, probably because a possible antimicrobial effect was not complementary or additive to the effect of other antimicrobial compounds of the toothpaste or mouth wash. Contrary to this study, AhumadoOstenga25showed that the effects of sodium fluoride (NaF) and chlorhexidine mouth rinse increase with different concentrations depending on the species of lactobacilli. Furthermore, Juric26 disagree with this study when J Bagh College Dentistry Vol. 25(2), June 2013 The effect of different Orthodontics, Pedodontics and Preventive Dentistry146 observed that professional tooth-cleaning and the usage of chewing gum with xylitol and fluoride on a daily basis could be helpful in reducing cariogenic bacteria. This finding is in contrast to the result of Gorelick4when the incidence of white spot formation was measured on banded or bonded teeth in a clinical setting. The lowest incidence was found to be in the lingual surfaces of lower canines, and the highest on labial areas of maxillary incisors. Moreover, this study showed that the right side has higher amount of plaque than the left side, although the difference is not significant. It appeared that the plaque accumulated on the right side more than the left side, which is not uncommon finding that the right side has a higher prevalence of white spot lesions following orthodontic treatment than the left as shown by Gorelick4. According to the results of the present study, the plaque amount was insignificantly higher on the lower arch. The presence of undercuts and tongue interference with performing proper cleansing in the lower arch may probably result in this difference. Also the lower teeth are more exposed to the salivary flow which contains calcium and other minerals and carry the biopolymers which are essential for early pellicle formation and food shedding during mastication, facilitating microbial attachment. This would also agree with other studies 27,28 that have found a higher amount of plaque on the right side of right-handed tooth brushers than on the left. The difficulty encountered during brushing on the right side may attribute to plaque accumulation on it. Most of the participants in this study were right handed. Consequently, it would be ideal to recommend chlorhexidine as a dentifrice, thus combining mechanical cleaning and antiplaque benefit with no added discomfort for patients. REFERENCES 1. Shibly O, Rifai S, Zambon JJ. Supragingival dental plaque in the etiology of oral diseases. Periodontol 2000 1995; 8: 42–59. 2. Fejerskov O, Kidd EAM. Dental caries: the disease and its clinical management. Oxford: Blackwell Munksgaard; 2003. 3. Ogaard B, Seppä L, Rölla G. Professional topical fluoride applications – clinical efficacy and mechanism of action. Advances in Dental Research 1994; 8: 190–201. 4. Ogaard B, Alm AA, Larsson E, Adolfsson U. A prospective, randomized clinical study on the effects of an amine fluoride/stannous fluoride toothpaste/mouthrinse on plaque, gingivitis and initial caries lesion development in orthodontic patients. Eur J Orthod 2006; 28(4): 8–12. 5. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod 1982; 81: 93–98. 6. Artun J, Brobakken BO. Prevalence of carious white spots after orthodontic treatment with multibanded appliances. Eur J Orthod 1989; 8: 229–234. 7. Benson PE, Parkin N, Millett DT, Dyer FE, Vine Sand Shah A. Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane Library 2005. 1–38. 8. Gehlen L, Netuschil R, Berg ER, Katsaros C. The influence of a 0.2% chlorhexidine mouth rinse on plaque re-growth in orthodontic patients. A randomized prospective study. Part I: clinical parameters. J Orofac Orthop 2000; 61: 54–62. 9. Tufekci E, Casagrande ZA, Lindauer SJ, Fowler CE, Williams KT. Effectiveness of an essential oil mouth rinse in improving oral health in orthodontic patients. Angle Orthod 2008; 78: 294–298. 10. Kossack C, Jost P, Brinkmann G. Plaque and gingivitis reduction in patients undergoing orthodontic treatment with fixed appliances—comparison of toothbrushes and interdental cleaning aids. A 6-month clinical single-blind trial. J Orofac Orthop 2006; 66: 20–38. 11. Costa MR, Silva VC, Miqui MN, Sakima T, Spolidorio DM, Cirelli JA. Efficacy of ultrasonic, electric and manual toothbrushes in patients with fixed orthodontic appliances. Angle Orthod 2007; 77: 361- 366. 12. Löe H, Silness J. Periodontal disease in pregnancy, prevalence and severity. Acta Odontol Scand 1963; 21: 532–551. 13. Sharma N, Lyle DM, Qaqish JG, Galustians J, Schuller R. Effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent patients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop 2008; 133: 565–5 14. Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc 1962; 65: 26–29. 15. Rustogi KN, Deasy MJ, Gattista G, Volpe AR. Antiplaque efficacy of a triclosan/copolymer prebrush rinse: a plaque prevention clinical study. Am J Dent 1992; 5: 91-4. 16. Sagel PA, Lapujade PG, Miller JM, RJ Sunberg. Objective quantification of plaque using digital image analysis. Monogr Oral Sci 2000; 17: 130–143. 17. Smith RN, Brook AH, Elcock C. The quantification of dental plaque using an image analysis system: reliability and validation. J Clin Periodontol 2001; 28: 1158–1162. 18. Carter K, Landini G, Walmsley AD. Automated quantification of dental plaque accumulation using digital imaging. J Dent 2004 32: 623–628. 19. Klukowska M, Bader A, Erbe C, Bellamy P, White DJ, Anastasia MK, Wehrbein H. Plaque levels of patients with fixed orthodontic appliances measured by digital plaque image analysis. Am J Orthod Dentofacial Orthop 2011; 139: 463–e470. 20. Zanella NL, Bijella MF, Rosa OP. The influence mouth rinses with microbial solutions on the inhibition of dental plaque and on the level of mutans streptococci in children. Pesqui Odontol Bras 2002; 16:101–106. J Bagh College Dentistry Vol. 25(2), June 2013 The effect of different Orthodontics, Pedodontics and Preventive Dentistry147 21. De Soet JJ, Gruythuysen RJ, Bosch JA, Van Amrogen WE. The effect of 6-monthly application of 40% chlorhexidine varnish on the microflora and dental caries incidence in a population of children in Surinam. Caries Res 2002; 36: 449–455. 22. Schaeken MJ, van der Hoeven JS, Hendriks JC. Effects of varnishes containing chlorhexidine on the human dental plaque flora. J Dent Res 1989; 68: 1786–1789. 23. Attin R, Tuna A, Attin T, Brunner E, Noack MJ. Efficacy of differently concentrated chlorhexidine varnishes in decreasing mutans streptococci and lactobacilli counts. Arch Oral Biol 2003; 48: 503–509. 24. Wahap FK, Shellis RP, Elderton RJ. Effect of low fluoride concentrations on formation of caries-like lesions on human enamel in a sequential-transfer bacterial system. Arch Oral Biol 1993; 38: 985–995. 25. Van Loveren C, Buijs JF, ten Cate JM. The effect of triclosan toothpaste on enamel demineralization in a bacterial demineralization model. J Antimicrob Chemother 2000; 45:153-158. 26. Ahumada Ostengo MC, Wiese B, Nadir-Macias ME. Inhibitory effect of sodium fluoride and chlorhexidine on the growth of oral lactobacilli. Can J Microbiol 2005; 51(2): 133–140. 27. Juric H, Dukic W, Jankovic B, Karlovic Z, Pavelic B. Suppression of salivary Streptococcus mutans and lactobacilli by topical caries preventive agents. Cent Eur J Public Health 2003; 11: 219–222. 28. Addy M, Griffiths G, Dummer P, Kingdom A, Shaw WC. The distribution of plaque and gingivitis and the influence of tooth brushing hand in a group of SouthWales 11–12-year-old children. J Clin Periodontol 1987; 14: 564–72. 29. Addy M, Dummer PM, Hunter ML, Kingdon A, Shaw WC. The effect of tooth brushing frequency, tooth brushing hand, sex and social class on the incidence of plaque, gingivitis and pocketing in adolescents: a longitudinal cohort study. Community Dent Health 1990; 7(3): 237–47. Table 1: Means, standard deviations and standard errors of the plaque amount ratio with different attachments in different oral hygiene groups. Groups Descriptive Statistics Group differences CHX dentifrice Fluoridated dentifrice CHX dentifrice+CHX mw Fluoridated dentifrice+ CHX mw Variables Mean S.D. S.E. Mean S.D. S.E. Mean S.D. S.E. Mean S.D. S.E. KKW p-value U pp er ri gh t B M 29.49 8.70 3.89 35.55 9.02 4.04 30.37 8.89 3.98 28.63 8.55 3.82 1.98 0.575 (NS) D 37.56 13.65 6.11 29.16 3.89 1.74 31.09 11.94 5.34 27.16 6.87 3.07 1.90 0.592 (NS) L M 28.46 9.60 4.29 24.97 3.49 1.56 24.51 7.02 3.14 26.44 7.39 3.30 0.60 0.894 (NS) D 30.99 10.02 4.48 35.10 9.87 4.41 34.56 15.77 7.05 27.22 11.84 5.30 1.69 0.638 (NS) U pp er le ft B M 28.05 0.85 0.38 25.87 5.80 2.59 25.48 6.34 2.84 25.73 5.64 2.52 2.06 0.559 (NS) D 20.67 4.31 1.93 22.70 7.47 3.34 29.15 3.39 1.52 28.47 6.66 2.98 7.06 0.070 (NS) L M 26.17 10.91 4.88 33.18 4.42 1.97 30.40 8.72 3.90 26.41 8.88 3.97 2.10 0.552 (NS) D 20.00 10.04 4.49 33.50 12.93 5.78 31.11 14.86 6.64 33.69 14.29 6.39 2.58 0.459 (NS) L ow er ri gh t B M 43.50 9.92 4.44 34.53 4.40 1.97 33.42 5.28 2.36 31.84 4.68 2.09 6.49 0.090 (NS) D 34.86 10.22 4.57 37.80 5.37 2.40 30.93 5.82 2.60 35.97 5.86 2.62 3.36 0.339 (NS) L M 30.94 5.57 2.49 31.87 5.70 2.55 31.82 6.85 3.06 33.34 6.97 3.12 0.78 0.854 (NS) D 36.48 12.30 5.50 36.96 4.33 1.94 31.43 4.93 2.21 36.42 4.71 2.11 3.22 0.358 (NS) L ow er le ft B M 38.39 11.21 5.01 24.51 8.82 3.94 27.61 3.22 1.44 29.07 9.10 4.07 5.72 0.126 (NS) D 30.63 7.88 3.53 25.75 8.44 3.77 28.70 8.22 3.68 30.92 6.21 2.78 1.74 0.627 (NS) L M 32.00 7.91 3.54 26.28 5.39 2.41 26.56 5.70 2.55 26.30 6.04 2.70 2.65 0.448 (NS) D 28.76 5.63 2.52 35.32 8.77 3.92 32.36 7.82 3.50 34.61 6.47 2.89 3.79 0.285 (NS) NS = P>0.05 Figure 2: orthodontic band with the four areas of interest (1) mesial of the attachment (2) distal of the attachment (3) mesial of the attachment (4) distal of the attachment Figure 1: Biochemical test kit ClinproCario L-Pop (CCLP) (1) CCLP swab containing sucrose (2) Color indicator (3) L-Pop blisters that contains lactate dehydrogenase enzyme (4)Control swabs. J Bagh College Dentistry Vol. 25(2), June 2013 The effect of different Orthodontics, Pedodontics and Preventive Dentistry148 Means of plaque amount (%) bands Figure 3: Plaque amount with different attachments in different oral hygiene groups.