Oral hygiene condition in orthodontic patients treated with fixed appliance

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INTRODUCTION
Oral hygiene of utmost importance in maintaining good oral health, particularly in individuals with fixed orthodontic appliances.These appliances can pose challenges for regular oral care practices [1,2,3] as shown a notable decline in oral hygiene shortly after the initial bonding of these appliances, followed by gradual improvement by the fifth month of treatment [4].However, some studies have indicated that oral hygiene problems are highest towards the end of orthodontic treatment [5].
These appliances like brackets, tubes, band material, ligating materials and arch-wires are liable for microbial adhesion and create new retentive areas for dental biofilm (plaque) and debris [6] leading to elevate the presence of cariogenic bacteria like Streptococcus mutans that result in acid production causing tooth demineralization [7], and increase the incidence of gingivitis [8,9,10].Because of these adverse effects, 5-10% of patients might discontinue or even termination of treatment [11,12,13].
Therefore, orthodontic patients should pay attention to their diet, avoiding sugary and sticky foods that can lead to dental problems.In addition, routine dental check-ups and professional cleanings are vital for monitoring and maintaining oral health throughout the treatment period [14].
The objective of this study was to evaluate oral hygiene and gingival health in patients undergoing fixed orthodontic treatment at four different time points, with repeated oral hygiene instructions provided during each visit.

MATERIALS AND METHOD a) Subjects and settings
This longitudinal prospective study was conducted in Orthodontic Clinic at Al-Shamyia Specialized Center in Thiqar.Participants for this study included patients with fixed orthodontic appliance according to the following criteria.
Inclusion criteria: I. Patients with age between 18 and 22 years who received their orthodontic appliances with the starting of the study and patients that had passed 5th month of orthodontic treatment.II.All anterior teeth are present without missing any tooth such as lateral incisor missing cases.III.Subjects should talk and read Arabic language.
Exclusion Criteria: I. Patients with mental and physical disability or craniofacial disorders.II.Patients with enamel or dentin dysplasia.III.Patients that taking medications affecting plaque accumulation such as antibiotics or antibacterial mouth rinses.IV.Patients with periodontal disease.V. Patients with first premolar extraction cases.
b) Sample size The sample size was taken according to Farhadifard et al. [15] results.Using the mean values of the two groups with their standard deviations, a total of a minimum 14 patients were needed per group to yield an Alfa value of 0.05 with a study power of 80%.In this study a total of 41 patients were distributed into two groups.

c) Treatment protocol
The sample was divided into two groups, one group (21 person) was starting orthodontic treatment with the starting of the study (called New), and the other (20 person) was at 5th month from the starting of the orthodontic treatment (called Old).Only New group participant were recalled after one week after insertion the appliances for recording the scores to give time for plaque formation and gingival irritation [16].All groups received oral hygiene instructions, toothpaste (SENSODYNE), oral hygiene kit at the baseline (T0) with repeated the instructions at each visit.
• The oral hygiene instructions that recommended by the British Orthodontic Society were the times of brushing a day that recommended at least to brush twice a day, using the dental floss at least once a day, using fluoridated tooth paste (SENSODYNE) and avoid sticky and sugary foods [17].The method of brushing was the Charter's technique (small, circular shaking motions, with the brush is held at a 45 degree angle to the tooth long axis) that is specifically indicated for patients with orthodontic and prosthodontic appliances [18].
• The study outcomes are the amount of plaque and the total number of gingival bleeding sites in the incisors, canines and first premolars of the maxilla and mandible as dental lesions affect anterior teeth especially lateral incisors more than posterior teeth [19].
• Al-Anezi and Harradine plaque index (a modification to Silness and loe plaque Index) was used since most orthodontic trials employed the original Silness and Loe Plaque Index because of its simplicity.The limitation of the original index was it follows the usual pattern of plaque collection and development in the absence of orthodontic bracket.The buccal surfaces of these teeth were sectioned into four areas (mesial, distal, gingival and incisal) depending on the orthodontic bracket for plaque measurements.Each of the four buccal tooth sites were received a score between 0 and 3 (TABLE 1) [20].Denoting the absence of visible dental plaque but the accumulation of soft deposits on a probe used to clean the surface.

2
Denoting a modest buildup of soft deposits visible to the bare eye on the tooth.

3
Denoting a plenty of soft deposits visible on the tooth.
While the gingival bleeding will be assessed by using the Marginal Bleeding Index by angling a probe toward the tooth's longitudinal axis by roughly 60 degrees as moving along the marginal gingiva.When there was bleeding, a score of (1) was assigned; otherwise, a score of (0) was assigned.The buccal aspects were evaluated at the mesio-buccal, buccal, and disto-buccal locations.Marginal probing provided a more accurate assessment of a healthy gingival condition in contrast to the probing the button of the pocket with its false positive outcomes [21].

d) Statistical analysis
The statistical package for social sciences software (SPSS Inc., version 26, Chicago, Illinois, USA) was used to carry out the statistical procedures.Data were analyzed through parametric tests including: 1. Descriptive statistics: • Mean • Standard deviation (SD).
• Tables and figures.2. Inferential statistics: • Paired sample t-test.In the statistical evaluation, the following levels of significance were used according to probability value (p-value): P ˃ 0.05 Non-significant (NS) 0.05 ≥ p ˃ 0.01 * Significant 0.01 p ˃ 0.001 ** highly significant

Gender
Regarding gender distribution, it was found that more females were participated in the study than males (FIGURE 1).

FOLLOW UP OF PLAQUE INDEX 3.2.1 NEW GROUP
The comparison of the mean plaque index of the New control group at baseline, after 4, 8 and 12 weeks of treatment showed no significant increase in the mean plaque index throughout the study period (TABLE 2).

OLD GROUP
Also in this group, the mean plaque index after 8 and 12 weeks of orthodontic treatment was not significantly reduced from that at baseline (TABLE 3).

FOLLOW UP OF GINGIVAL BLEEDING INDEX 3.3.1 NEW GROUP
In this group, the mean bleeding index significantly increased after 4 weeks compared to that at baseline (P= 0.010).No difference was detected after 8 and 12 weeks of treatment (TABLE 4).

OLD GROUP
In this group, the mean bleeding index was not significantly different after 4, 8 and 12 weeks than that at baseline (TABLE 5).

GENDER
In terms of gender distribution in this study, the number of females was more than males participated, this could be explained that more females search for orthodontic care in all age groups excluding 40 and older [22].

PLAQUE SCORES
In the present study, the mean plaque values of New group showed slight increase over time without significant differences, as it was found at evidence-based studies that an initial period of one month following braces installment is a challenging period for patients [23,24].In addition, these results are similar to a recent study that found that there was on significant increase in plaque index after 3 months of orthodontic treatment compared to that before treatment [25].
While the Old group showed a reduce in plaque means again without significant differences that was consistent with a study shown a decline in plaque values by the fifth month of orthodontic treatment [12].In contrast to Migliorati et al. [26] who revealed that plaque accumulation and its consequence to gingival inflammation rises during active stage of orthodontic treatment demonstrating the increased complexity of the therapy.

BLEEDING SCORES
The New group showed a significant increase of the bleeding values after 4 weeks (p= 0.010).This result is in agreement with a study found that patients with fixed orthodontic appliances had significant increase in the mean value of bleeding on probing scores after 4 weeks [27], while other study showed this parameter increased at the initial stage of treatment (first month) but without statistically significant difference from baseline [28].
While for the other (Old) group, they showed no statistical difference in bleeding mean scores that is covenant with Eppright et al. [29] who found no statistical differences within the control group while the text message group as a reminder for oral care, there was significant change in bleeding and plaque indices over time.

LIMITATION OF THE STUDY
• Limited age range that was available in the research center.
• The study was not multicenter as it conducted only at Al-Shamyia Specialized Center in Thi-qar.
• The complexity of the orthodontic treatment was not taken into account.

CONCLUSION
In conclusion, the relying solely on oral hygiene instruction may not be sufficient to improve oral hygiene, indicating the need for additional methods or approaches to achieve better results in maintaining oral health such as smartphone reminders.