J Bagh College Dentistry Vol. 32(2), June 2020 Effect of Different 1 Effect of different bracket types on streptococcus mutans count in orthodontic patients using fluoridated toothpaste (3)Maha A. Mahmood (2) Dabagh-Dhiaa J. N. Al (1) Hala M. Jasim https://doi.org/10.26477/jbcd.v32i2.2886 Article DOI: ABSTRACT Background: Plaque retention during fixed orthodontic therapy is an important cause of developing enamel demineralization. The purpose of this study was to evaluate the effect of different brackets types on the count of Streptococcus Mutans in orthodontic patients using conventional fluoridated toothpaste. Materials and Methods: Plaque samples were collected from maxillary 1st premolar teeth of twenty right handed patients (using split mouth technique) before bonding, after 48 hrs of bonding using tooth brush only, and after 2 weeks of using fluoridated toothpaste. Stainless steel bracket was bonded on right first premolar while the left one was bonded with sapphire bracket. The calculation of the Streptococcus Mutans count was done using the plate counting method utilizing colony counter. The differences between the two types of brackets were determined using the Wilcoxon signed ranks test. Results: The median bacterial count on the right side was insignificantly higher than the left side; streptococcus mutans in the plaque sample around the sapphire brackets showed insignificantly less counts than around the stainless steel one, when the patients used tooth brush only or fluoridated toothpastes. Fluoridated toothpastes reduced streptococcus mutans insignificantly around both types of brackets. Conclusion: Fluoridated toothpaste acts effectively in reducing streptococcus mutans colony counts around sapphire and stainless steel brackets. Keywords: Streptococcus mutans, Stainless steel brackets, Sapphire brackets. (Received: 10/10/2019; Accepted: 6/11/2019) INTRODUCTION White spot lesion formation following enamel demineralization is the most popular complication associated with fixed orthodontic appliance therapy. (1) It resulted from increased numbers of cariogenic microorganisms in dental biofilm, compromised oral hygiene and decreased pH. (2) Although white spot lesion occurs irrespective of orthodontic therapy, patients undergoing orthodontic treatment have oral ecological alterations in which the numbers of cariogenic bacteria, especially Mutans streptococci are significantly increased and returned to the ordinary level after the removal of the orthodontic appliance. (3) Streptococcus Mutans is a potent initiator of enamel demineralization because there are many virulence factors unique to it and play important role in caries initiation. (4) First, S. Mutans is an anaerobic microorganism which produces lactic acid during its metabolism. Second, it has the ability to bind tooth surfaces in the existence of sucrose via the formation of glucans which are a polysaccharide that helps binding the microorganism to the tooth surface. (1) Master student, Department of Orthodontics, College of Dentistry, University of Baghdad. (2) Professor, Department of Orthodontics, College of Dentistry, University of Baghdad. (3) Professor, Department of Basic Sciences, College of Dentistry, University of Baghdad. Corresponding author, adelmaha70@yahoo.com The most important virulence factor of S. Mutans is the acidophilicity. In contrast to the majority of oral bacteria, S. Mutans thrives under acidic environment and becomes the dominant microorganism in cultures with reduced pH. (5) Although brushing teeth twice daily is considered effective in bacterial count reduction, the high prevalence of gingival inflammation in orthodontic patients often suggests improper oral hygiene procedures in most patients. (6) There is an important difference in biofilm formation and adhesion of bacteria among orthodontic brackets made from various materials. (7,8) The primary affinity of bacteria to surfaces is mostly due to hydrophobic and electrostatic interactions. Surfaces with high surface free energy (SFE) attract bacteria such as S. Mutans more easily. (9) A study conducted by López et al. (10) showed a statistically non-significant difference in the S. Mutans adhesion to stainless steel, plastic or ceramic brackets. Chemical plaque control procedures are used sometimes for more effective plaque removal (8). Dean et al. (11) reported that fluoride concentration in biofilms increased significantly after brushing with toothpaste containing fluoride and the primary cariostatic effect of fluoridated toothpastes is the remaining fluoride in the dental biofilm that was not eliminated by tooth brushing. The objectives of the present study were to determine the levels of S. Mutans on sapphire and stainless steel orthodontic brackets in patients undergoing fixed orthodontic therapy brushing their teeth with fluoridated toothpaste. https://doi.org/10.26477/jbcd.v32i2.2886 J Bagh College Dentistry Vol. 32(2), June 2020 Effect of Different 2 MATERIALS AND METHODS Twenty patients accepted to participate in this study. After signing a written consent form, a baseline record of bacterial count was taken from the right and left maxillary 1st premolars, then bonding of the maxillary teeth was performed with stainless steel brackets (Pinnacle, Orthotechnology, USA) except the left maxillary 1st premolar that was bonded with sapphire bracket (Pure, Orthotechnology, USA) using Resilience bracket adhesive (Orthotechnology, USA) and Light Cure Unit (Woodpecker, China) as shown in Figure 1. The patients were instructed to brush their teeth with toothbrush only and come in a recall visit after 48 hr. to take another sample from the same teeth. After that, the patients were instructed to brush their teeth with fluoridated toothpaste (Sensodyne toothpaste, GlaxoSmithKline, USA) twice daily and come again for a recall visit after 2 weeks to take further sample. The samples taken were pooled plaque collected from the buccal surface of both teeth using a sterilized dental probe (after drying) utilizing the four-pass sampling technique in which a standardized, sterilized instrument's tip is moved circumferentially around the bracket. Data were analyzed using SPSS program version 25. The descriptive statistics included medians, means, standard deviations, minimum and maximum values, while the inferential statistics included Wilcoxon signed ranks test to detect the side difference and Friedman test to study the effect of time on bacterial count. Probability value was set at 0.05. Figure 1: A; Stainless steel bracket bonded on tooth number 14, B; Sapphire bracket bonded on tooth number 24. RESULTS Table 1 shows the descriptive statistics and side difference of the bacterial count in three periods. Statistically, the bacterial count in the right side was insignificantly higher than the left one in all periods (p>0.05). Friedman test was used to test the effect of time on S. Mutans count. In both sides, bacterial count was decreased insignificantly after using fluoridated toothpastes (Table 1 and 2). Table 1: Descriptive statistics and side difference of bacterial count before bonding, after 48 hrs of using tooth brush only, and after 2 weeks of using conventional fluoridated toothpastes. Duration Side Descriptive statistics Side difference Median × 103 Mean × 103 S.D. × 103 Min. × 103 Max. × 103 Wilcoxon Signed Ranks Test p-value Before bonding Right 135 279.5 331.2 3 20 840 -0.663 0.508 (NS) Left 107.5 175.5 173.6 4 15 575 After 48 hrs (Brushing only without toothpaste) Right (SS) 227.5 314.3 319.5 0 8 900 -0.178 0.859 (NS) Left (Sapph.) 132.5 258.5 305.3 9 5 950 After 2 weeks (Brushing with fluoridated toothpastes) Right (SS) 75 159.5 178.0 2 4 500 -0.357 0.721 (NS) Left (Sapph.) 25 251.3 5 514.4 9 3 1600 SS: Stainless steel, Sapph: Sapphire bracket, NS: non-significant A B J Bagh College Dentistry Vol. 32(2), June 2020 Effect of Different 3 Table 2: Effect of time on the bacterial count for both sides. Side Right side Left side Friedman test 3.2 2.6 d.f. 2 2 p-value 0.202 (NS) 0.273 (NS) DISCUSSION The market contains various bracket types made of different biomaterials. The adherence of plaque to the fixed appliance is highly contributed by the type of bracket material as it plays a role in the amount of plaque accumulation and bacterial adhesion as well as in the risk of white spot lesion development. (8) Brackets surface characteristics are shown to affect bacterial adhesion especially surface free energy (also called wettability) and surface roughness. Variations in surface characteristics can explain the differences in the adhesion of Streptococcus Mutans to different biomaterials. (9) In the present study, the median bacterial count in the right side was higher than the left side although non-significant but the difference is clear. This can be attributed to the use of right side hand in brushing that cleans the teeth of the left side better than the right one. (13) After 48hr of bonding and brushing with tooth brush only, bacterial count is increased on both sides with a non-significant difference being higher in right side also. This could be due to the fact that the Monocrystalline sapphire bracket (on left side) has a surface roughness less than that of the stainless steel bracket (on the right side). (7,14,15) Moreover; Eliades et al. (16) found that stainless steel offered the highest critical surface tension and total work of adhesion, demonstrating an amplified potential for microorganism attachment on metallic brackets. In contrast, Fournier et al. (17) investigated the affinity of S. Mutans to different bracket types and found that S. Mutans demonstrated weaker adherence to the metal brackets than to plastic or ceramic brackets. After 2 weeks of using fluoridated toothpastes, the bacterial count decreased markedly with a non- significant side difference. This could be due to anti-caries effect of the fluoride containing toothpaste which results from the formation of calcium fluoride (CaF2) in dental plaque and on the enamel surface. (18,19) The effect of time on Streptococci Mutans adhesion was examined using Friedman test. By comparing the medians of both sides before bonding and after 48hr, the adhesion of Streptococcus Mutans increased with increasing time but there was no statistically significant difference. This elevation in count could be due to the fact that orthodontic brackets are covered instantly by the salivary pellicle in the oral cavity; therefore, the adhesion of oral microorganisms to the bracket surfaces is governed to a large extent by the properties of the adsorbed salivary protein layer. The salivary pellicle as a binding receptor can promote the adhesion of S. Mutans. (7,20) CONCLUSION Fluoridated toothpaste is clinically efficient in reducing S. Mutans colony counts around sapphire and stainless steel orthodontic brackets. Conflict of interest: None. REFERENCES 1. Chambers C, Stewart S, Su B, Sandy J, Ireland A. Prevention and treatment of demineralization during fixed appliance therapy: a review of current methods and future applications. Br Dent J. 2013; 215: 505-11. 2. Korbmacher HM, Huck L, Kahl-Nieke B. Fluoride- releasing adhesive and antimicrobial self-etching primer effects on shear bond strength of orthodontic brackets. Angle Orthod. 2006; 76: 845-50. 3. Fournier A, Payant L, Bouclin R. Adherence of Streptococcus mutans to orthodontic brackets. Am J Orthod Dentofacial Orthop.1998;7: 114- 414. 4. Samaranayake LP, Jones BM, Swlly C. Essential microbiology for dentistry. 2nd ed. Edinburgh: Churchill Livingstone; 2002. 5. Bagg J, Macfarlane TW, Poxton IR, Smith A. Essential of microbiology for dental students. Delhi: Oxford University press; 2006. 6. Jurela A, Repic D, Pejda S, Juric H, Vidakovic R, Matic I. The effect of two different bracket types on the salivary levels of S. mutans and S. sobrinus in the early phase of orthodontic treatment. Angle Orthod. 2013; 83: 140-5. 7. Ahn SJ, Kho HS, Lee SW, Nahm DS. Roles of salivary proteins in the adherence of oral streptococci to various orthodontic brackets. J Dent Res. 2002; 81: 411–5. 8. Papaioannou W, Gizani S, Nassika M, Kontou E, Nakou M. Adhesion of Streptococcus Mutans to different types of brackets. Angle Orthod. 2007; 77: 1090-5. 9. Lee SP, Lee SJ, Lim BS, Ahn SJ. Surface characteristics of orthodontic materials and their effects on adhesion of Mutans streptococci. Angle Orthod. 2009; 79: 353-60. 10. López JDT, Sánchez Meraz W, Mariel Cárdenas J, González Amaro AM, Gutiérrez Cantú FJ, Mariel Murga H. Bacterial load assessment in metallic versus esthetic brackets. Revista Mexicana de Ortodoncia. 2015; 3: 228-32. J Bagh College Dentistry Vol. 32(2), June 2020 Effect of Different 4 11. Dean JA, Avery DR, McDonald RE. Dentistry for the child and adolescent. 9th ed. C.V. Missouri: Mosby- Elsevier; 2011. 12. George J, Hegde S, Rajesh KS, Kumar A. The efficacy of a herbal-based toothpaste in the control of plaque and gingivitis: a clinico-biochemical study. Indian J Dent Res. 2009; 20: 480-90. 13. Kadkhodazadeh H, Khodadustan A, Amid R, Darabi A. Plaque removal ability in left and right handed patients in different parts of the oral cavity. J Periodontol Implant Dent. 2012; 4: 24-28. 14. Anhoury P, Nathanson D, Hughes CV, Socransky S, Feres M, Chou LL. Microbial profile on metallic and ceramic bracket materials. Angle Orthod. 2002; 72: 338-43. 15. Kassis A, Sarkis D, Adaimé A. Quantitative evaluation of adhesion of Streptococcus Mutans to three orthodontic adhesives: An in vitro study. IAJD 2011; 2: 13-8. 16. Eliades T, Eliades G, Brantley W. Microbial attachment on orthodontic appliances: Wettability and early pellicle formation on bracket materials. Am J Orthod Dentofacial Orthop. 1995; 108: 351–60. 17. Fournier A, Payant L, Bouclin R. Adherence of Streptococcus Mutans to orthodontic brackets. Am J Orthod Dentofacial Orthop. 1998; 114: 414–7. 18. Ghazi SM. Comparative study of in vitro antibacterial activity of miswak extracts and different toothpastes. Am J Agricultural Biol Sci. 2013; 8: 82-8. 19. Sharma A, Kumar RR, Mathew S. The effect of miswak and fluoride toothpastes on dental plaque- a comparative clinical and microbiological study. J Dent Med Sci. 2017; 16: 74-7. 20. Ahn S, Lim B, Lee S. Surface characteristics of orthodontic adhesives and effects on streptococcal adhesion. Am J Orthod Dentofacial Orthop. 2010; 137: 489-95. الخالصة : ان تجمع الطبقة الجرثومية خالل ارتداء جهاز التقويم الثابت يعد سبب مهم في فقدان معادن االسنان. الغرض من هذه الدراسة الخلفية هي فحص تاثير االنواع المختلفة من حاصرات التقويم على اعداد البكتريا المسببة للتسوس في مرضى تقويم االسنان الثابت الذين سنان حاوي على الفلورايد.يستعملون معجون ا : تم جمع عينات الطبقة الجرثومية من االسنان الطاحنة لمرضى يرتدون التقويم , الحاصرات المعدنية تم تثبيتها على المواد و الطرق ساعه 48عد و تم جمع العينات قبل تثبيت التقويم وب 24الحاصرات المصنوعه من السيراميك تم تثبيتها على الطاحن رقم 14الطاحن رقم وبعد اسبوعين وخالل االسبوعين استعمل المرضى معجون اسنان حاوي على الفلورايد. تم تقييم االختالف بين المثبتات باستخدام اختبار ولكسون. موجودة في : اظهرت النتائج ان تعداد البكتريا في الجهة اليمنى اكثر من الجهة اليسرى وبدون فوارق معنوية. كانت البكتريا الالنتائج الصفيحة الجرثومية حول الحاصرات المصنوعه من السيراميك اقل من تلك حول الحاصرات المعدنية. قللت معاجين االسنان الحاوية على الفلورايد من اعداد البكتريا حول الحاصرات المعدنية و الحاصرات المصنوعة من السيراميك. الفلورايد فعاله في تقليل اعداد البكتريا حول الحاصرات المعدنية و الحاصرات المصنوعة ان معاجين االسنان الحاوية على االستنتاجات: من السيراميك.