Evaluation of oral health status for a group of orthodontic patients

Background : Malocclusion and fixed orthodontic appliance convoluted the ordinary oral hygiene measures, which may lead to accumulation and prolonged retention of dental plaque on tooth surfaces particularly around the orthodontic brackets and auxiliaries of the fixed orthodontic appliance. Objective: To evaluate the oral health status among a group of orthodontic patients by evaluating the plaque, gingival, calculus, and Enamel Decalcification indices. Patients and Methods: This study was conducted among 128 persons (64 with fixed orthodontic appliance as a study group and 64 without fixed orthodontic appliance as a control group. An assessment of related clinical parameters as plaque, gingival, as well as enamel decalcification indices were done. Results: The present study revealed that the mean plaque, gingival, as well as enamel decalcification indices for the total sample were (1.182±0.356), (1.230±0.269), and (1.329±0.413) respectively. Additionally, all of these indices were higher among study group (fixed orthodontic patient) than among control group (persons without orthodontic appliance) with statistically significant difference among groups for each. Conclusion: Fixed orthodontic appliance is an effective plaque retentive factor that accumulate dental plaque which is the main causative factor for development of enamel white spot lesion and periodontal disease.


Introduction
One of well-known oral disorders is malocclusion, this disorder has the ability to increase the risk of other oral diseases as dental caries and periodontal disease.Thus, it is very important to maintain a healthy periodontium during the period of orthodontic treatment because the fixed orthodontic appliance may accumulate the dental plaque which in turn contribute to develop dental caries as well as periodontal disease [1,2,3,4].
The dental plaque pathogenicity may be enhanced by fact that, in dental plaque biofilm the bacteria may have increased antibiotic and chemotherapeutic agent resistance and less phagocytized by the host inflammatory cell, for this reason the dental plaque biofilm control is the major dental professional objective for maintaining an optimal oral health.In addition to providing a source of acid production, the dental plaque provides a physical barrier which limit the acid diffusion away from the tooth enamel surface and thus preventing enamel remineralization by calcium and phosphate ions from saliva [5].
In fixed orthodontic appliances patients it is difficult to achieve good oral hygiene because these appliances make obstruction for the typical mechanical brushing, also after meal the food may trapped around bonded orthodontic brackets and under the arch wires, so a good oral health maintenance may become challenged and thus increasing the risk of enamel demineralization, periodontal disease, as well as teeth staining.The numerous components of fixed orthodontic appliance may encourage the accumulation and proliferation of dental plaque and periodontal microorganisms (Treponema denticola and Porphyromonas gingivalis) respectively thus generating an excessive or unfavorable forces on teeth and their supporting structures resulting in an elevated risk of periodontal diseases [6].

Patients and Methods
The present study was conducted between June 2023 and September 2023 at orthodontic department in second specialized dental health center in Baquba City/ Diyala Governorate/ Iraq for orthodontic patients aged between 30 and 35 years old after expressing the research to those patients and obtaining an informed consent from them.For Standardization purposes all the persons included in this study were male and brush their teeth twice a day.The total sample size was 128 person those include 64 persons in study group (with fixed orthodontic appliance) and the remaining (without orthodontic appliance) in control group.
Concerning the plaque index, it was assessed according to previously described criteria by Silness and Loe where the dental plaque biofilm thickness at the gingival area of the entire dentition was assessed (7) .Thus, by the naked eye and under good lighting, mouth mirror as well as periodontal probe were used in scoring the dental plaque biofilm immediately adjacent to gingiva margin, Figure ( 1) and (2).were assessed starting from the upper left second molar through the midline of the jaw to the upper right second molar.Moreover, in the lower jaw the entire dentition was examined starting from the lower left second molar and preceding through the midline to the lower right second molar.Concerning the sequence of surfaces examination, it was opposite to that of upper jaw where the sequence was distal, facial, and mesial for the teeth that are located on the left side, and mesial, facial, and distal for the teeth that are located on the right side of the jaw midline.Additionally, the lingual surfaces of lower dentition were scored starting from the lower left second molar and preceding through the midline to the lower right second molar [8].The plaque index examination preceded the calculus and gingival indices examination.
Concerning the gingival condition, it was evaluated according to the criteria that were presented by Loe and Silness.The sequence of the examination was done similarly to that used for dental plaque biofilm assessment, additionally in this study the periodontal probe was used for examining the entire dentition.Furthermore, the gingivitis severity was assessed according to the classification presented by Loe and Silness (9) .The presence or absence and distribution of white spot lesions around the bonded orthodontic brackets might be assessed on the basis of Enamel Decalcification Index criteria described by Banks and Richmond [10].In accordance to this index, the right second premolar to left second premolar in both dental arches were examined, in this study the molars were excluded due to the presence of cemented orthodontic bands which make the visibility of white spot lesions difficult.The facial surfaces of included teeth were examined after removing dental plaque and dryness.After that dividing the facial surface of each included teeth into four areas that include the gingival, mesial, distal, as well as incisal\occlusal around the orthodontic bracket, Figure (3).

Statistical Analysis
Data description, analysis and presentation were performed using Statistical Package for social Science (SPSS version -22, Chicago, Illionis, USA), Independent Sample t test used to test the difference between the two groups.Level of significance as: Not significant P> 0.05, Significant P< 0.05.Additionally.

Results
Table (1) shows that the mean plaque index for the total sample was (1.182±0.356),additionally it was higher among study group (1.531±0.621)than among control group (0.833±0.277) with statistically significant difference.

Discussion
Most of patients with malocclusion including those who are treated with fixed orthodontic appliance have a relatively large number of retention sites due to their teeth irregularity .In present study the mean plaque index was significantly higher among study group than control group this due to the presence of fixed orthodontic appliance that considered as an effective plaque retentive factor .Additionally, the oral ecology appeared to be altered by insertion of fixed orthodontic appliance as the orthodontic treatment considered as a serious invasion of the oral environment because it provides a solid surface retentive sites of appliance which in turn favor the colonization of microorganisms that introduce another variable into the system [11,12,13].This finding is in agreement with other studies which showed that the orthodontic patients had higher amount of dental plaque as compared to non-orthodontic patients [14,15].
Concerning gingival condition, the present study reveals that the study group have moderate gingivitis while control group have mild gingivitis where the gingival index was significantly higher among study than control group due to dental plaque accumulation around the components of fixed orthodontic appliance, this accumulated dental plaque is considered as an important causative factor for development of gingivitis, this finding is in agreement with other previous study [16,17,18] .
Regarding the white spot lesion development, the present study shows that mean enamel decalcification index was significantly higher among study group than control group, this may be due to the accumulation of dental plaque around the orthodontic brackets which make the removal of this dental plaque difficult, so this accumulated dental plaque may provide a reservoir for cariogenic bacteria which invade between the enamel surface and adhesive material as a result of polymerization shrinkage of the adhesive material, then these bacteria metabolize the carbohydrate and produce acid which in turn demineralize the tooth enamel especially around the orthodontic brackets, this finding is in agreement of other previous study [19,20,21].

Conclusions
Patients with fixed orthodontic appliance Patients with fixed orthodontic appliance are at high risk for developing white spot lesion and periodontal disease as those patients may show a high rate of gingivitis and dental plaque accumulation around the components of fixed orthodontic appliance which make the removal of dental plaque difficult.As the dental plaque considered as causative factor for development of dental caries and periodontal disease, so it is important to maintain a healthy periodontium during the period of orthodontic treatment.

Recommendations
Further studies needed to be conducted with larger sample size.

Source of funding:
The current study was funded by our charges with no any other funding sources elsewhere.