Article ID: WMC004782 ISSN 2046-1690

Periodontal and hard tissue maintenance in fixed

orthodontic treatment: A review
Peer review status:
No

Corresponding Author:
Dr. Silvia Del Prete,
DDS, Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6 - Italy

Submitting Author:
Dr. Silvia Del Prete,
DDS, Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6 - Italy

Other Authors:
Dr. Emanuela Coppotelli,
DDS, Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, italy - Italy
Dr. Anna D'Urso,
DDS, Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy - Italy
Dr. Doria Tolevski Meshkova,
DDS, Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy - Italy

Article ID: WMC004782

Article Type: Review articles
Submitted on:11-Dec-2014, 10:10:14 PM GMT Published on: 12-Dec-2014, 09:46:39 AM GMT
Article URL: http://www.webmedcentral.com/article_view/4782
Subject Categories:ORTHODONTICS
Keywords:Oral health promotion, fixed orthodontics appliances, plaque index
How to cite the article:Coppotelli E, Del Prete S, D'Urso A, Tolevski Meshkova D. Periodontal and hard tissue
maintenance in fixed orthodontic treatment: A review. WebmedCentral ORTHODONTICS
2014;5(12):WMC004782
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution
License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Source(s) of Funding:
None

Competing Interests:
None

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Periodontal and hard tissue maintenance in fixed
orthodontic treatment: A review
Author(s): Coppotelli E, Del Prete S, D'Urso A, Tolevski Meshkova D
Abstract
The orthodontic appliances increase the degree of
difficulty in maintaining a proper oral hygiene, resulting
in higher plaque accumulation around the brackets,
arches and the gingival margin, predisposing the
development of a chronic gingivitis and enamel
demineralization, known as white spot. Several studies
have analysed the correlation between the degree of
oral hygiene and orthodontic appliances and is still a
topic of great interest for many authors. In the
literature, there were no significant differences
regarding the degree of adhesion of the bacteria in the
use of orthodontic brackets of different materials (steel
and ceramic brackets). The purpose of this article is to
conduct a literature review to assess the problems
encountered in periodontal tissue and tooth structure
associated with and/or caused by fixed orthodontic
treatment.
Introduction
The delicate balance of bacteria in the oral cavity is
related to the presence of niches where bacteria can
grow without response from the host's immune system.
In sites where the equilibrium state is altered occurs
uncontrolled colonization of bacteria that promotes the
development of pathological conditions (1, 2).
The fixed orthodontic treatment may be the cause of
the deterioration of the oral ecosystem due to the
application of orthodontic forces, to the presence of
arches, brackets and orthodontic bands that increase
the accumulation of plaque and to the stress of the
periodontal ligament, which can lead to loss of clinical
attachment.
The presence and the increase of the plaque, during
the orthodontic treatment, is an important side effect
that should not be overlooked, because it can
compromise the outcome of the treatment.
Factors that favor the accumulation of plaque during
multi-brackets orthodontic treatment are:
1. The poor ability of the patient to maintain adequate
oral hygiene
2. The ease of creating niches for bacteria retention
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around the brackets
3. Change in the microbial flora
By analysing the three factors independently it can be
said that the presence of fixed orthodontic appliances
undoubtedly contributes to a worsening of the plaque,
complicating the daily hygiene operations which aim
its removal.
Often the orthodontist finds a chronic hyperplastic
gingivitis after a short period of time from the
placement of an orthodontic appliance. The etiology of
chronic hyperplastic gingivitis is not yet fully
understood, although it is certain that the plaque is the
most important causal factor. In some individuals were
also identified co-factors: genetic and/or environmental
conditions; these include polymorphism of the gene for
interleukin-1 (IL-1), cigarette smoking, diabetes, and
leukopenia. In these situations, the hyperplastic
gingivitis leads to periodontitis and the loss of clinical
attachment over time.
The business of professional mechanical cleaning, so
the hygienist is a valuable aid to the patient, has the
function of balancing the oral bacterial ecosystem and
to motivate/encourage patients to improve their oral
health management at home.
The figure of the 'dental hygienist has a vital role as
through its intervention should lead to a reduction in
the problems associated with orthodontic treatment.
As regards the ease of creating niches for bacteria
retention around the brackets, a number of studies (3, 4)
have analyzed the association between the fixed
orthodontic appliance and the unwanted accumulation
of plaque bacteria around the brackets, which can be
further complicated by the formation of tartar around
the components.
Last but not least is the change in the composition of
the bacterial flora (5). The variation of the quantity and
the metabolic activity of the pathogenic microflora of
the oral gingival hyperplasia can lead to a pathological
condition generalized, to a bleeding on probing (BOP)
and a periodontal inflammation with consequent
worsening gingival index (GI) and the probing pocket
depth (PPD).
Often periodontal problems associated with fixed
orthodontic treatment are transient, as opposed to the
"white spots" that can sometimes be in an advanced
stage to be recovered (6).
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The bacterial flora changes dramatically following the
placement of a multi-brackets appliance; several
studies have shown, in fact, the presence of a greater
number of anaerobic bacteria such as T. forsythia, C.
rectus and P. Nigrescens, (4) (7) which are the cause of
gingival and periodontal problems.
here are clear changes in the sub-gingival flora where
the predominant species are: Tennerella Forsythia, P.
Gengivalis and Treponema Denticola.
The orthodontic appliances are responsible for the
transition from gingivitis to perodontitis (8); plaque can
build up inside the brackets and / or between the band
and the gingival margin (9) , the process can be
exacerbated when the bands are positioned under the
gum.
Although this is a risk that involves all patients treated
with fixed orthodontic appliance, attachment loss is
more significant in patients with a before treatment
attachment loss, and these subjects are more
sensitive to the worsening of the disease process. It is
strongly evident even in patients with hormonal
changes due to puberty, pregnancy, menopause,
using oral contraceptives, and those with poor manual
dexterity to clean teeth. Particular attention should be
given to patients who smoke because smoking not
only promotes the development of gingivitis and
periodontitis, but results in a slowing of cellular
turnover(10). It is very important that smoking patients
give up the habit before starting treatment.
The incidence of caries and demineralization, as
reported in literature (11), increases during orthodontic
treatment. In the process of demineralization, the tooth
(enamel and dentin) has lost calcium and phosphate,
which can be precipitated together somewhere else in
the tooth or be lost in the mouth by saliva and plaque.
The demineralization is defined as a complication of
considerable interest in orthodontic treatment, in
addition to determining irreversible changes to allow
for the continuation alter the orthodontic treatment
from aesthetic point of view.
During orthodontic treatment is needed to stop the
progression of white spot, whose incidence ranges
from 2% to 97% (12) (13).
Preventive procedures that avoid undesired
accumulations of plaque reduce the damage to the
soft and hard dental tissues are:
Professional Cleaning
Use of topical fluoride (gel-paint)
Plaque detectors
Motivation of the patient
Rinsing with chlorhexidine
Laser therapy
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The association of various preventive procedures have
better results compared to a procedure applied alone.
Reiew
In a literature review of 218 studies, Grey and
McIntyre (14) found that in a short period of time, when
it was adopted a protocol for the prevention of oral
health in patients with fixed orthodontic appliance, will
have significant reductions in levels of plaque. Denes
and Gabries (11) comparing the indices of plaque of the
two groups of patients have observed that the group
treated with amine fluoride showed better oral hygiene
compared to the second group that had been
subjected only to oral hygiene. They concluded their
study by stating that the use of fluoride gel has a
beneficial effect in reducing plaque.
Boyd et al. (15) (16) (17) studied the accumulation of plaque
and decalcification of dental hard tissue during
orthodontic treatment. They claim that the use of an
electric toothbrush, of a manual toothbrush, and the
application of the gel to 0.4 stannous fluoride are
associated with low values of the plaque index and the
gingival index, but also to a less hard tissue
decalcification.
Boyd (18) observing orthodontic patients for ten months
has highlighted the need to strengthen education on
hygiene procedures every 4-7 weeks to keep plaque
under control.
Holder-Olsen et al. (19) compared a group of patients
with a comprehensive preventive approach with a
control group that received no treatment specific quote.
From this study, there were no differences on the rise
in the number of caries between the two groups, but a
statistically significant difference has been described
for the increase of white spots.
Holderlin Olsen et al.(19) (20) established a protocol of
oral hygiene consisting of: brushing teeth 3 times a
day after main three meals, the use of dental floss
although complicated by the presence of the device
multi-brackets and the use of fluoride rinse . In
addition, patients were instructed to avoid especially if
sugary sweets, fizzy drinks and acidic fruit juices.
Buck et al. (20) and Dalessandri et al.(21) showed a
reduction in plaque using a bonding indirect than a
direct one.
Giannini et al. (22) in the surgical-orthodontic have
suggested a plaque control program that is
represented by hygiene, fluoridation local, and in the
chlorhexidine mouthwash.
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Indices of plaque
Plaque index was introduced by Silness and Loe, and
it is widely used in dentistry for its simplicity.
It is constituted by four codes as follows:
1. Code 0: no plaque
2. Code 1: This plaque in the gingival third of the tooth
3. Code 2: visible plaque
4. Code 3: accumulation of plaque visible
Williams et al. (23) changed the original classification of
Silness and Loe on the evaluation of tooth surfaces
affected by plaque. In the new classification of
Williams et al. the tooth was divided into 4 regions
based on the bracket:
incisal
gingival
mesial
distal
The quantity of plaque is then reported on the basis of
4 codes the index of Silness and Loe, finally, the
values are summed to obtain a total score that can
vary from 0 to 16 for each tooth. This index was also
used by Clerehugh et al. (24) and shows higher reliability
than the index of Silness and Loe. To quantify the
degree of gingival inflammation based on the surface
of another index of particular importance evaluates
revealed the plaque on the buccal and lingual surfaces
of the non-restored teeth on scales from 0 to 5,
defined by Quigley and Hein in 1962 and modified by
Turesky and Gilmore. All teeth except the third molars
are assessed.
An index for the entire mouth is determined by dividing
the total score by the number of surfaces examined.
Quigley-Hain plaque index:
No plaque
1.Isolated flecks of plaque at the gingival margin
2.A continuous band of plaque up to 1 mm at the
gingival margin
3.Plaque greater than 1 mm in width and covering up
to one third of the tooth surface
4.Plaque covering from one thirds to two thirds of the
tooth surface
5. Plaque covering blackberries than two thirds of the
tooth surface
This index is of particular importance to quantify the
WebmedCentral > Review articles
degree of gingival inflammation according to the tooth
surface covered by plaque.
Plaque in brackets and
bindings
Ira and Dewi Lindel et al. (25) in their study stated that
the stainless steel and ceramic brackets show no
significant differences in the type of plaque biofilm.
The study by Lindel showed that the amount is
significantly higher than of stainless steel brackets on
ceramic brackets. Most of plaque feedback on the
mesial and distal surfaces for stainless steel bracket
surfaces and gum for ceramic brackets.
Forsberg et al. (26) through their work have shown that
incisor bound with an elastic ligature are associated
with a greater amount of plaque than the incisor bound
with a steel ligature.
In a more recent study (6) it has been demonstrated
that the two methods of bindings of the arcs show no
difference with regard to the accumulation of plaque.
Saud and Al-Anezi (27) has shown that, in the first three
months of fixed orthodontic treatment, BOP (the
Bleeding On Probing index) involving lateral incisors,
which were applied elastic ligatures, underwent a
significant increase; but the most surprising is that the
bleeding index declined for the incisors which have not
been applied elastic ligatures, the patients who were
treated with self-ligating brackets.
There were no statistically significant changes in index
of probing depth and gingival inflammation.
The same study confirmed that there is no difference
in plaque accumulation between self-ligating brackets
and elastomeric devices, although there is a significant
change in the microbial flora of three months of
treatment.
Turkkohramom et al. (28) comparing the steel ligatures
and elastomeric devices, found that there is no
difference in plaque index (PI) in probing depth (PPD)
and gingival index (GI).
The elastomeric ligatures are associated with an
increased bleeding on probing that is why the authors
have not recommended to use this kind of ties in
patients with poor oral hygiene motivation.
In a recent systematic review (29): it is argued that there
is no evidence, in terms of retention of plaque and
periodontal health for preferring self-ligating brackets
to conventional brackets and vice versa.
Conclusions
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Each time a patient takes a fixed orthodontic treatment,
it is necessary to plan and carry out a protocol for the
prevention of oral health, to avoid complications that
are difficult to manage and can affect the outcome of
orthodontic treatment. An increase in the plaque, as
well as producing a chronic hyperplastic gingivitis can
cause permanent damage to the hard tissues of the
tooth (30). A single preventive method in many cases is
not sufficient to avoid complications.
Every patient should receive counseling by a dental
hygienist, supported by written documents and, if
possible, by video evidence. The method of video
gives significant advantages in terms of dissemination
of information and are more effective in positively
influencing the behavior of the patient, the
disadvantage is the high cost of video production. The
verbal advice of a professional associated with a
program of detection of plaque has been shown to be
greater than the simple consultation with an oral
hygienist.
The response of a patient to a protocol of maintaining
oral health during orthodontic treatment is, however,
variable from subject to subject. All patients who
present loss of attachment prior the orthodontic
treatment, who are predisposed to the development of
attachment loss, or who experience systemic
problems (immunocompromised, diabetes, pregnancy,
menopause, puberty, smoking) should receive regular
preventive oral maneuvers by the hygienist.
References
1. Zarco M.F., Vess T.J., and Ginsburg G.S. The
oralmicrobiome in health and disease and the potential
impact on personalized dental medicine. Oral
Diseases 2012; 18(2):109-120.
2. Suzuki N., Yoshida A., and Nakano Y.
Quantitative analysis of multi-species oral biofilms by
TaqMan Real-Time PCR. Clinical Medicine &
Research 2005; 3(3):176-185.
3. Neves S. and Cruz R.A. Aplicao de mtodo de
higiene bucal em pacientes portadores de aparelho
ortodntico. Revista Brasileira de Odontologia 1987;
44:2-8.
4. Balenseifen J.W. and Madonia J.V. Study of
dental plaque in orthodontic patients. Journal of Dental
Research, 1970; 49:320-324.
5. Pender N. Aspects of oral health in orthodontic
patients. British Journal of Orthodontics 1986;
13:95-103.
WebmedCentral > Review articles
6. Lindel I.D., Elter C., Heuer W. et al. Comparative
analysis of long-term biofilm formation on metal and
ceramic brackets. The Angle Orthodontist 2011; 81(5).
7. Icaza J.E. et al. Avaliao comparativa do controle
de placa bacteriana e da gengivite em paziente sob
tratamento ortodntico com mtodos de higiene
supervisionados e de controle profissional. Ortodontia
1998; 22:29-39.
8. Ciancio D.G., Cunat J.J. et al. A comparison of
plaque accumulation in bonded versus banded teeth.
Journal of Dental Research; 1985; 64:325.
9. Anhoury P., Nathanson D. et al. Microbial profile
on mettalic and ceramic bracket materials. Angle
Orthd; 2002; 72:338-43.
10. Chang YC, Huang FM, Tai KW, Yang LC et al.
Mechanisms of cytotoxicity of nicotine in human
periodontal ligament fibroblast cultures in vitro. J
Periodontal Res 2002; 37:279-85.
11. Dnes, J. and Gbris K. Results of a 3-year oral
hygiene programme,including amine fluoride products,
in patients treated with fixed orthodontic appliances.
European Journal of Orthodontics 1991; 13:129-133.
12. Geiger A.M., Gorelick, L., Gwinnett A.J. and
Griswold P.G. The effect of a fluoride program on
white spot formation during orthodontic treatment.
American Journal of and Dentofacial Orthopedic,
1988;93:29-37.
13. Larsson, E., Henriksson, T., Birkhed, D. and
Bishara, S.E. Effects of combined application of
antimicrobial and fluoride varnishes in orthodontic
patients. American Journal of Orthodontics and
Dentofacial Orthopedics, 2001;120:28-30.
14. Grey D., Mclntyre G. Does oral health promotion
influence the oral hygiene and gingival health of
patients undergoing fixed appliance orthodontic
treatment? A systematic literature review. Journal of
Orthod.2008,35:262-69.
15. Boyd R.L. and Rose C.M, Effect of rotaty electric
toothbrush versus manual toothbrush onn
decalcification during orthodontic treatment. AJO
Dentofacial Orthopedics 1994;105;450-456.
16. Boyd, R.L. et al. Eighteen-month evaluation of the
effects of a 0.4% stannous fluoride gel on gingivitis in
orthodontic patients. Its Constituent Societies, and the
American Board of Orthodontics,1994:105; 35-41.
17. Jiang, H., Hua F. et al. Effect of 1.23% acidulated
phosphate fluoride foam on white spot lesions in
orthodontic patients: a randomized trial. Pediatric
Dentistry,2013:35; 275-278.
18. Boyd R.L. Longitudinal evaluation of a system for
Page 5 of 6
WMC004782 Downloaded from http://www.webmedcentral.com on 12-Dec-2014, 09:46:40 AM

self-monitoring plaque control effectiveness in 29. Fleming PS, Johal A. Self-ligating Brackets in
orthodontic patients. Journal of Clinical Orthodontics. Angle Orthod. 2010; 80:575-84.
Periodontology, 1983:10; 380-388. 30. Kay E, Locker D. A systematic review of the
19. Hadler-Olsen S. et al. The incidence of caries effectiveness of health promotion aimed at improving
and white spot lesions in orthodontically treated oral health. Community Dent Health 1998; 15:132-44.
adolescents with a comprehensive caries prophylactic 31. Burden D, Mullally B, Sandler J. Orthodontic
regimen-a prospective study. European Journal of treatment of patients with medical disorders. Eur J
Orthodontics 2012:34, 633-639. Orthod. 2001; 23:363-72.
20. Buck, T., Pellegrini et al. Elastomeric-ligated vs
self-ligating appliances: a pilot study examining
microbial colonization and white spot lesion formation
after 1 year of orthodontic treatment. Orthodontics:
The Art and Practice of Dentofacial Enhancement.
2011,12;108-121.
21. Dalessandri, D., Dalessandri, M., Bonetti, S.,
Visconti, L. and Paganelli, C. Effectiveness of an
indirect bonding technique in reducing plaque
accumulation around braces. The Angle Orthodontist,
2012; 82, 313-318.
22. Giannini, L., Folegatti, C., Siviero, P., Galbiati,
G. and Maspero, C. Prevenzione e igiene orale in
pazienti in terapia ortodontico-chirurgica. Prevenzione
& Assistenza Dentale, 2012, 38; 103-109.
23. Williams P, Clerehugh V, Worthington HV,
Shaw WC. Comparison of two plaque indices for use
in fixed orthodontic appliance patients. J Dent Res.
1991; 70:703.
24. Clerehugh, V., Williams P. et al. A
practice-based randomised controlled trial of the
efficacy of an electric and a manual toothbrush on
gingival health in patients with fixed orthodontic
appliances. J Dent1998.26:633-639.
25. Lindel ID, Elter C, Heuer W, Heidenblut T. et al.
Comparative analysis of long-term biofilm formation on
metal and ceramic brackets; The Angle Orthodontist.
2011, 81.
26. Forsberg C, Brattstrom V, Malmberg E, Nord
CE. Ligature wires and elastomeric rings: Two
methods of ligation, and their association with
microbial colonization of Streptococcus mutans and
lactobacilli. Eur J Orthod. 1991; 13:416-20.
27. Saud A. Al-Anezi. Dental plaque associated with
self-ligating brackets during the initial phase of
orthodontic treatment: A 3-month preliminary study. J
Orthod Sci. 2014, 3(1); 7-11.
28. Turkkahraman H, Sain O, Bozkurt YF, Yetkin Z,
Kaya S, Onal S. Archwire ligation techniques,
microbial colonization, and periodontal status in
orthodontically treated patients. Angle Orthod. 2005;
75:227-32.

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