Comparative Study of the Plaque Removal Efficacy of Three Types of Toothbrushes in Patients with Fixed Orthodontic Appliances

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1 /jp-journals ORIGINAL ARTICLE Comparative Study of the Plaque Removal Efficacy of Three Types of Toothbrushes in Patients with Fixed Appliances Comparative Study of the Plaque Removal Efficacy of Three Types of Toothbrushes in Patients with Fixed Appliances 1 Tanvir Singh, 2 Bhavana Bhatia, 3 Gunita Singh, 4 P Narayana Prasad ABSTRACT Introduction: Patients undergoing orthodontic treatment with fixed appliances have a challenging oral hygiene situation because brackets tenaciously trap food and other oral debris. Good plaque control is an important factor in the maintenance of dental health during fixed appliance therapy. Many different types of specially designed es have been developed in recent years in order to improve the plaque removal. One of these new developments is a manual triple brush which is called 'superbrush' which is intended to clean the oral, buccal and occlusal surfaces of the teeth at one time. A clinical study was planned to evaluate the effectiveness of plaque removal by using the new triple compared to the conventional manual and an orthodontic. Methods: A total of 75 patients, aged between 18 and 28 years, were equally divided into three groups: Group I (triple ), group II (orthodontic ) and group III (conventional ). The gingival index (Loe and Silness, 1963) and plaque index (Turesky Gilmore and Glickman, 1962) were recorded at baseline, month 1, month 2, month 3 and month 4, and results were subjected to statistical analysis utilizing ANOVA one way and multiple comparison test. Results: Comparison of the mean gingival and plaque index scores and difference in mean plaque scores between the groups was done and found to be statistically significant (p < 0.05). Conclusion: The study indicated that the triple was more efficient in reduction of plaque scores and improvement in gingival index scores overall, and more effective in removal of plaque from tooth surfaces compared to the other two es. Keywords:, Plaque,. How to cite this article: Singh T, Bhatia B, Singh G, Prasad PN. Comparative Study of the Plaque Removal Efficacy of Three Types of Toothbrushes in Patients with Fixed Appliances. J Ind Orthod Soc 2011;45(2): INTRODUCTION A well accepted rationale for orthodontic treatment is to prolong the life of the individual s dentition. 1 Several researchers 2-5 have investigated, what effect orthodontic treatment has on periodontal health. Broadly, these longitudinal studies concentrated on reviewing any effects during treatment and for a short period of time (up to 2 years) post-treatment. Most conclude that overall gingival changes produced by appliances are transient with no permanent damage to the periodontal 1 Senior Professor, 2 Consultant Periodontist, 3 Consultant Dental Surgeon 4 Professor and Head 1 Department of s, Anand Niketan, New Delhi, India 2 The Dental and Clinic, Vasant Vihar, New Delhi, India 3 Anand Niketan, New Delhi, India 4 Department of s and Dentofacial Orthopedics, Seema Dental College and Hospital, Virbhadra Road, Rishikesh, Uttarakhand India Corresponding Author: Tanvir Singh, D-123, Anand Niketan New Delhi , India, drsinghtanvir@gmail.com Received on: 3/10/10 Accepted after Revision: 13/2/11 tissues. The level of oral hygiene during treatment has a direct bearing on periodontal health. 2 Patients undergoing orthodontic treatment with fixed appliances have a challenging oral hygiene situation because brackets tenaciously trap food and other oral debris. 6 Good plaque control is an important factor in the maintenance of dental health during fixed appliance therapy. 7-9 Brackets, archwires and other appliance components are both a focus for plaque accumulation and an obstruction to plaque removal, thereby promoting gingivitis. 3 Plaque also harbors cariogenic bacteria potentially capable of hard tissue damage, especially at the bracket margins. 8,9 While mouth rinses may aid to reduce plaque formation 7,10 and mechanical cleaning of tooth surfaces can be accomplished in many forms, regular tooth brushing is advised routinely as the means of preventing gingival and dental disease during orthodontic appliance therapy. It is well established that dental plaque is an essential etiological factor of caries and gingivitis. Bacterial plaque initiates an inflammatory process in the supporting structures of the tooth and, if allowed to continue, ultimately may lead to the loss of the teeth in most individuals. 14 Tooth brushing is the most common method of controlling dental plaque. Other aids, such as interdental cleansers (dental floss, tape, toothpicks, interdental brushes) and oral irrigation devices are also used, but much less commonly. These The Journal of Indian Society, April-June 2011;45(2):

2 Tanvir Singh et al mechanical cleansing procedures are efficient, provided the method used is sufficiently thorough and performed regularly. However, the maintenance of satisfactory standards of oral hygiene for a longer period of time by mechanical tooth cleaning measures is laborious Several es have been designed to increase plaque removal efficacy in orthodontic patients. Most orthodontic es have a V-shaped groove along the long axis of the head. The shorter nylon bristles in the V-shaped groove are progressively firm and more efficient in removing food debris from the midbracket region, whereas longer and softer filaments are positioned in the bracket-wing region. 6 Complete plaque removal with a conventional does not seem to be realistic for the major part of the population. For this reason, many different types of specially designed es have been developed in recent years in order to improve the plaque removal. 14 One of these new developments is a manual triple brush is called Superbrush. This is intended to clean the oral, buccal and occlusal surfaces of the teeth at one time. 15 This clinical study was planned to evaluate the effectiveness of plaque removal by using the new triple compared to the conventional manual and an orthodontic in subjects undergoing orthodontic treatment. MATERIALS AND METHODS The subjects for the study were selected from among the outpatients undergoing orthodontic treatment at the Dental and Clinic, Vasant Vihar and Anand Niketan, New Delhi. Prior to commencing the study, the subjects were assessed daily, over a period of two weeks, for their ability to follow oral hygiene instructions and maintain oral hygiene; and only those subjects who followed the instructions meticulously were included in the study. A total of 75 patients within the age group of 18 to 28 years were selected to participate in the study. They were randomly divided into three groups comprising of 25 subjects each. A structured form was designed to collect demographic and dental s, including the patient s age, sex, type of, plaque (tooth and bracket) indices and gingival index. All subjects were given fixed orthodontic 022 inch Roth straight wire metal appliance systems and two weeks time to get well versed with the appliance. Teeth without brackets and nonbanded molars were excluded from the study. Criteria for Subject Selection 1. Subjects should have a minimum of 20 sound permanent teeth. 2. No use of antibiotics in the last 6 months. 3. No history of drug allergy, systemic disease, pregnancy and lactating conditions. 4. Subjects in the gingivitis group should have the gingival index (Loe and Silness) score ranging between 1.1 and 2.0 (moderate gingivitis). 62 Scaling and root planning was done two weeks prior to commencement of the study and then the subjects were provided with the specific according to the group. Group I: Subjects were instructed to brush with Dr Barman s triple (Superbrush ) Group II: Subjects were instructed to brush with Stim orthodontic Group III: Subjects were instructed to brush with Oral-B conventional tooth brush. Dentifrice Used One brand of dentifrice (Colgate ) was used throughout the experimental study. Oral Hygiene Instructions Standardized oral hygiene instructions were given to all subjects by the same clinical investigator at baseline and all subsequent visits. The subjects were advised to brush for 2 minutes in the morning and 2 minutes in the evening. The specific verbal instructions for each type of was followed by a demonstration on a clinical model. brush: Subjects using the conventional were instructed to make ten strokes each on labial, lingual and occlusal surfaces. : Subjects were instructed to make ten strokes with the triple. : Subjects using the orthodontic were instructed to make ten strokes each on labial, lingual and occlusal surfaces. Questionnaire: A two part questionnaire was formulated for the study: The first part was pertaining to demographics, along with a subject s past medical and dental history, personal history and habits. The second part consisted of tables for recording the gingival index and plaque index scores. Clinical parameters of gingival index (Loe and Silness, 1963) and plaque index (Turesky, Gilmore and Glickman, 1962) were recorded at baseline, 1 month, 2 months, 3 months and 4 months for each group. Values thus obtained were tabulated and were subjected to statistical analysis using paired t-test, ANOVA one way and multiple comparisons test. The statistical analysis for the study was assessed as under: 1. The mean scores of the plaque index and gingival index for triple, battery powered and conventional groups were analyzed by ANOVA one way test 2. Multiple comparisons test was used for comparison of score between each group. RESULTS Table 1 and Figure 1 shows that at baseline the differences in plaque scores between the groups were found to be statistically JAYPEE

3 Comparative Study of the Plaque Removal Efficacy of Three Types of Toothbrushes in Patients with Fixed Appliances Table 1: Comparison of the mean difference between the plaque scores of the three groups at baseline, month 1, month 2, month 3 and month 4 Multiple comparisons Mean difference Std. error p-value baseline * * 0.022* month * * * * * month * * month Contd... The Journal of Indian Society, April-June 2011;45(2):

4 Tanvir Singh et al Mean difference Std. error p-value month * * * * *The mean difference is significant at the 0.05 level; **High correlation Table 2: Comparison of mean gingival index scores among the three groups at baseline, month 1, month 2, month 3 and month 4 Multiple comparisons Mean difference Std. error Sig. 95% confidence interval Lower Upper GI baseline GI month GI month Contd JAYPEE

5 Comparative Study of the Plaque Removal Efficacy of Three Types of Toothbrushes in Patients with Fixed Appliances Contd... Mean difference Std. error Sig. Lower Upper GI month * * GI month * * *The mean difference is significant at the 0.05 level; **High correlation Fig. 1: Shows difference in plaque scores at baseline, month 1, month 2, month 3, month 4 among triple, orthodontic and conventional insignificant when subjected to multiple comparison test (p > 0.05). At month 1, the differences between the groups were found to be statistically significant (p < 0.05) for group I and the other two groups. At month 2, the difference between plaque scores of group I (triple ) and group II (orthodontic ) was found to be statistically significant (p < 0.05). At month 4, the difference between plaque scores of group I (triple ) and group II (orthodontic ) was found to be statistically significant (p < 0.05). At month 4, the differences between the groups were found to be statistically insignificant (p > 0.05). Table 2 shows that at baseline the differences in gingival index scores between the groups were found to be statistically insignificant when subjected to multiple comparison test (p > 0.05). At month 1, 2 and 3, the differences between the groups were again found to be statistically insignificant (p > 0.05). At month 4 and month 3, the difference between gingival index scores of group I ( triple ) and group II (orthodontic ) was found to be statistically significant (p < 0.05). At month 4, again the difference between gingival index scores of group I (triple ) and group III (conventional ) was found to be statistically The Journal of Indian Society, April-June 2011;45(2):

6 Tanvir Singh et al significant (p < 0.05) as well as between group II and III was found to be statistically significant (p < 0.05). DISCUSSION Our results indicate that the triple is statistically superior to the orthodontic and conventional as expressed by a significantly lower score in both the plaque index and gingival index. The reason for these results can be attributed to the unique inclination of the bristles to reach the gingival margins of the brackets where the plaque is trapped, without the need of special manual skills. Furthermore, the triple is easier to handle. Most patients brush their teeth, on average, for less than 90 seconds, so a more effective is important. 15 Toothbrushing technique has a significant effect on plaque removal, but it is very difficult to influence personal ing behavior to maximize efficacy. A simple scrubbing technique is most commonly employed and is used consistently during brushing. 6 Most people brush their teeth for a shorterthan-optimal period, many of them using techniques that are inadequate to remove plaque from the gingival margins and approximal surfaces, areas that are important in maintaining periodontal health Given these constraints, a practical approach to improving dental health is to develop a more effective, one that has the potential to remove plaque more completely from tooth surfaces, is less dependent on ing technique and provides positive sensory cues that may improve motivation and possibly increase brushing time. 19 Buccal surfaces and anterior teeth are usually brushed most thoroughly perhaps because these are the most accessible surfaces. Lingual surfaces are much more difficult to clean because less visibility and accessibility makes it difficult to clean these areas effectively. In the lingual molar area the tongue on the lingual aspect of molar may interfere in using the brush. 20 When the mean difference in the gingival index and plaque index among the three groups was calculated, triple showed a significant difference (p < 0.05). A study was conducted by Zimmer et al (1999) to determine the plaque removing ability of a new with a U shaped head (Superbrush ) compared to a conventional manual (Elmex ) and an electric with a rotating head (Braun Plak control ). The study indicated that Superbrush was more effective in removing plaque compared to the other two es. 14 This is in concurrence with the findings of the present study. A study was conducted in 2006 by Zvi Rafe et al to compare the triple with conventional and orthodontic es and examine its effectiveness in improving the oral health in orthodontic patients. It was concluded that the triple was significantly more effective than conventional and orthodontic. 6 These findings are in agreement with our results that the triple is more effective in plaque removal than the conventional. Our results are in agreement with a study conducted by Emling et al (2005) 21 in which they concluded that the triplehead had demonstrated superiority to a traditional flat-head. CONCLUSION We found that the triple was significantly more effective in plaque removal and in improving the gingival health of patients with orthodontic fixed appliances. It could be a better alternative to the conventional or the orthodontic es. REFERENCES 1. Kessler M. Interrelationships between orthodontics and periodontics. Am J Orthod 1976;70: Kloehn JS, Pfeifer JS. The effect of orthodontic treatment on the periodontium. Angle Orthod 1974;44: Zachrisson S, Zachrisson BU. Gingival condition associated with orthodontic treatment. Angle Orthod 1972;42: Trossello VR, Gianelly AA. treatment and periodontal status. J Periodontol 1979;50: Alstad S, Zachrisson BU. Longitudinal study of periodontal conditions associated with orthodontic treatment in adolescents. Am J Orthod 1979;76: Rafe Zvi, Vardimon Alexander, Ashkenazi Malka. Comparative study of 3 types of es in patients with fixed orthodontic appliances. Am J Orthod and Dentofac Orthop 2006;130: Zachrisson BU. Cause and prevention of injuries to teeth and supporting structures during orthodontic treatment. Am J Orthod 1976;69: Mitchell L. Decalcification during orthodontic treatment with fixed appliances: An overview. Br J Orthod 1992;19: Atack NE, Sandy JR, Addy M. Periodontal and microbiological changes associated with the placement of orthodontic appliances: A review. J Periodontol 1996;67: Millar RA, McIver JE, Gunsolley JC. Effects of sanguinaria extract on plaque retention and gingival health. J Clin Orthod 1988;22: Huber SJ, Vernino AR, Nanda RS. Professional prophylaxis and its effect on the periodontium of full-banded orthodontic patients. Am J Orthod Dentofac Orthop 1987;91: Boyd RL, Murray P, Robertson PB. Effect of rotary electric versus manual on periodontal status during orthodontic treatment. Am J Orthod Dentofac Orthop 1989;96: Yeung SCM, Howell S, Fahey P. Oral hygiene program for orthodontic patients. Am J Orthod Dentofac Orthop 1989;96: Zimmer S, Didner B, Roulet JF. Clinical study on the plaque removing ability of a new triple. J Clin Periodontol 1999;26: JAYPEE

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