Risk factors for periodontal changes in adult patients with banded second molars during orthodontic treatment

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1 Originl Article Risk fctors for periodontl chnges in dult ptients with nded second molrs during orthodontic tretment Monic M. Corcho de Melo ; Myrel G. Crdoso ; Jorge Fer c ; Adrin Sorl d ABSTRACT Ojective: To identify the risk fctors for periodontl chnges in dult ptients during orthodontic tretment y evluting the periodontl sttus of nded second molrs using the gingivl index (GI). Mteril nd Methods: The smple consisted of 100 dult ptients divided into two groups: the Orthodontics group, undergoing corrective tretment with fixed pplinces nd nds cemented to the four second molrs, nd the Control group, with no prior history of orthodontic tretment, ge nd sex mtched. Group GI vlues were compred using the Wilcoxon test. Additionlly, multivrite logistic regression ws performed to study the risk fctors for increses in the GI. Results: Individuls in the Orthodontics group showed significntly higher GI thn those in the Control group. Logistic regression reveled tht mong the risk fctors found to increse GI, the following proved significnt (in order of importnce): plque index, sugingivl encrochment of the cervicl mrgins of nds, proing depth, nd length of orthodontic tretment. Conclusions: Bnded second molrs of dult ptients during orthodontic tretment showed more clinicl signs of gingivl inflmmtion thn those of untreted individuls. Moreover, mjor risk fctors identified included the presence of plque nd the presence of sugingivl nd mrgins. (Angle Orthod. 2012;82: ) KEY WORDS: Orthodontic pplince; Molr; Periodontium; Adult; Risk fctors INTRODUCTION Any ptient undergoing orthodontic tretment should e extr creful with their orl hygiene, 1 3 especilly dults. 2 The numer of dult ptients in tretment incresed significntly during the 1980s, 4,5 ringing with it mlocclusions with their ttendnt ge limittions 6 nd vrious ggrvting periodontl conditions, rnging from lesions on one single tooth surfce to generlized periodontl disese. 2,4,5 However, it hs een rgued tht ge is not in itself contrindiction for orthodontic tretment 4 ecuse Orthodontist in privte prctice, Slvdor, Brzil. Professor of Orthodontics, Federl University of Bhi, Slvdor, Brzil. c Professor of Orthodontics, University of Brsili, Brsili, Brzil. d Periodontist in privte prctice, Slvdor, Brzil. Corresponding uthor: Dr Monic M. Corcho de Melo, Ru Rul Leite, n, 123, Edf. Cost Brv, Apt. 102 Vil Lur, CEP: , Slvdor, Bhi, Brzil (e-mil: monicorcho@superig.com.r) Accepted: July Sumitted: Mrch Pulished Online: Septemer 7, 2011 G 2012 y The EH Angle Eduction nd Reserch Foundtion, Inc. dult ptients, in certin situtions, my exhiit less plque uild-up nd gingivl inflmmtion thn dolescents. 6 Vrious fctors hve een suggested to explin these oservtions, such s the lrger size of the clinicl crown of dult teeth resulting from pssive eruption, which llows rckets to e positioned frther wy from the gingivl mrgin. 2 On the other hnd, orthodontic pplinces nd ccessories (nds, rckets, rchwires, elstics, nd springs) increse the numer of res of dentl plque retention nd consequently hinder hygiene, 7 13 prticulrly in the posterior segments of the orl cvity, given their difficult ccess. Permnent second molrs re often misligned nd therefore re included in the tretment pln, thus incresing the potentil for gingivl inflmmtion. 7,14 Technicl nd onding difficulties often rise, leding professionls to resort to the use of nds. 2,7,14 Gingivitis, especilly in the region of the interdentl ppill, hs een oserved in teeth nded for orthodontic purposes. 4,15 These hve een ssocited with higher plque rtes, 3,7,9,14 gingivl rtes 3,7,9,11,16 18 nd proing depth, 3,7,10,11,17,18 more often thn in ptients with onded rckets or no orthodontic pplince. 7,11,16 However, pprently gingivl rections 224 DOI: /

2 RISK FACTORS FOR PERIODONTIUM IN BANDED MOLARS 225 re trnsient, nd they do not cuse permnent dmge to periodontl tissues; rther, cses re rpidly resolved nd tretment completed. 10 Given tht orthodontic pplinces fvor dentl plque retention, nd tht the numer of dults undergoing orthodontic tretment hs een growing considerly (which cretes peculir periodontl conditions), this study imed to nlyze the gingivl index (GI) of nded second molrs in dult ptients nd compre it with tht of control group. Additionlly, investigtors imed specificlly to detect the presence of possile predictive fctors for increses in GI in ptients treted with orthodontic nds on the second molrs. MATERIALS AND METHODS A cross-sectionl clinicl study ws conducted y exmining mxillry nd mndiulr second molrs of 100 dults (54 women, men ge yers, nd 46 men, men ge yers). A group of 50 ptients in orthodontic tretment t the Speciliztion Progrm in Orthodontics, Federl University of Bhi (UFBA), ws rndomly selected for prticiption in the study. All hd een wering fixed stndrd edgewise orthodontic pplinces for t lest yer (to ensure tht sujects hd estlished n orl hygiene routine nd tht periodontl conditions were stle) nd orthodontic nds (Dentl Morelli Ltd, Soroc, Brzil) cemented with glss ionomer cement (Ketc-Cem, Espe, Germny) on the four second molrs (Orthodontics group). The Control group, comprising 50 individuls undergoing restortive tretment in teeth other thn the second molrs t the Deprtment of Integrted Clinic, School of Dentistry (UFBA), ws ge nd sex mtched with those wering fixed pplinces. Before tretment, the groups received equivlent guidelines with regrd to orl hygiene nd motivtion. Additionl orl hygiene instructions were given during orthodontic tretment only if necessry. Other inclusion criteri included the following: sence of chronic medicl disese or condition tht could ffect their periodontium (such s dietes mellitus, juvenile periodontitis, congenitl hert disese, lood dyscrsis, or history of rheumtic fever), did not tke ntiiotics in the 3 months preceding the study, nd hd fully erupted second molrs in the orl cvity. Informed consent ws otined from ech memer of the smple, nd the study protocol ws pproved y Committee on Reserch Involving Humn Sujects t the School of Dentistry t Slvdor, Bhi Federl University, UFBA, Brzil. Clinicl exmintion ws performed y single exminer, duly clirted (kpp.0.90) periodontics specilist using conventionl Willims -type periodontl proe (Trinity Periodontics, Jrguá, Brzil) nd dentl mirror.) The miduccl sites of the four second molrs were evluted, nd the dt were noted in individul clinicl chrts for ech study group. The independent vriles descried in Tle 1, such s the Silness nd Löe 19 plque index (PI), were recorded for ech prticipnt. The dependent vrile used in this study ws the Löe nd Silness 20 GI, used for periodontl sttus ssessment, with the following clssifiction: 0, sence of inflmmtion; 1, mild inflmmtion, with slight chnge in color nd little chnge in texture; 2, moderte inflmmtion, with reddish ppernce, mild edem, nd hypertrophy nd leeding on proing; nd 3, severe inflmmtion, with mrked reddish ppernce nd hypertrophy, ulcertion, nd tendency to spontneous leeding. Sttisticl Anlysis The miduccl GI of the Orthodontics nd Control groups ws compred using the Wilcoxon test t 5% significnce level. Next, to study potentil risk fctors tht might ccount for incresed GI in ptients with fixed orthodontic pplinces, series of logistic regressions were performed. Initilly, univrite logistic regressions were crried out using s dependent vrile the miduccl GI of ptients in the Orthodontics group, nd s independent vriles those contined in Tle 1. The significnce of univrite models ws 10%. Only those tht proved sttisticlly significnt using univrite nlysis were included in stepwise multivrite model with the sme level of significnce (5%). Sttisticlly significnt vriles in the multivrite model were found to e the odds rtios. Their respective 95% confidence intervls were therefore recorded. RESULTS The miduccl GI of second molrs in the Orthodontics group ( X +SD: ; n 5 200) ws significntly higher thn in the Control group ( , n 5 200, P,.0001). Risk fctors for increses in GI in the Orthodontics group were studied y mens of series of logistic regressions. Results of univrite logistic regressions performed for selecting vriles tht entered the multivrite model re presented in Tle 1, long with the descriptive sttistics for these vriles. None of the nds used on teeth tht were evluted showed excess cement or poor occlusl or cervicl djustment. Only significnt vriles were included in the multivrite model, whose selection ws held y the stepwise method. Selected vriles generted significnt multivrite model (x ; P,.0001); those included in the model re presented in Tle 2, long with odds

3 226 CORBACHO DE MELO, CARDOSO, FABER, SOBRAL Tle 1. Independent Vriles Used in Univrite Logistic Regressions nd Results of These Regressions in Selection of Vriles for Multivrite Model, Unit P Descriptive Sttistics of Groups Orthodontic Control Men SD Men SD Independent vrile Age Yers Tretment length Months,.0001* Clinicl crown height Millimeters.041* Plque index (PI) 0/1/2/3,.0001* Proing depth Millimeters,.0001* Clinicl ttchment level Millimeters.0018* Ctegoricl vriles Gender Mle/Femle (F) 92 (M) 108 (F) 92 (M) Lterlity Right/Left,.0001* 176 (R) 24 (L) 180 (R) 20 (L) Tooth Mxillry/Mndiulr.0020* 100 (Mx) 100 (Mn) 100 (Mx) 100 (Mn) Presence of restortion Yes/No (Y) 89 (N) 90 (Y) 110 (N) Presence of third molr Yes/No (Y) 125 (N) 109 (Y) 91 (N) Tooth extrction in upper/lower rch Yes/No (Y) 250 (N) 70 (Y) 330 (N) Elstic chin Yes/No.0008* 76 (Y) 124 (N) Intermxillry elstic Yes/No (Y) 160 (N) Sugingivl nd Yes/No,.0001* 238 (Y) 162 (N) With dependent vrile uccl gingivl index (GI) of dult ptients wering fixed pplinces. Descriptive sttistics of Orthodontic nd Control groups lso included. * Univritely significnt: 5.1. rtio nd 95% confidence intervls. The following were identified s possile risk fctors for incresed GI (in order of odds rtio importnce): PI, sugingivl cervicl mrgin of the nds, proing depth, nd length of orthodontic tretment. DISCUSSION An incresed GI index in teeth with orthodontic nds, s found in the present study, constitutes reltively frequent event. 3,7,9,11,16 18 This vrile ws selected for the study ecuse leeding on proing is the most relile clinicl indictor of significnt gingivl inflmmtion, 2,6 nd its sence indictes high likelihood of mintining periodontl helth. 21 For this reson, it cn e considered prmeter for use in dily prctice. As stted erlier, PI ws the most importnt risk fctor for n incresed GI in dult orthodontic ptients Tle 2. Vriles Included in Multivrite Model, Input String, Odds Rtio, nd 95% Confidence Intervl, Vrile Step Estimte Odds Rtio CI, 95% P PI ,.0001 Tretment length ,.0001 Proing depth Sugingivl nd Dependent vrile ws uccl gingivl index (GI) of dults wering fixed pplinces. GI indictes gingivl index; PI, plque index. ecuse plque uilds up given the difficulty involved in removing the different orthodontic pplince components The quntity nd qulity of plque re influenced y mny fctors, including surfce chrcteristics. Moreover, surfce roughness is positively correlted with plque growth nd mturtion. 17 The role of this primry etiologic fctor in gingivitis nd periodontitis hs een extensively documented in the literture, s hs periodontl rekdown resulting from n imlnce etween their constituents nd the host s defense mechnisms. 17,18,22 24 The sugingivl cervicl mrgin of the nds ws nother key fctor (ie, nds tht encroch into the sulcus sustntilly incresed the odds [odds rtio {OR} ] for developing inflmmtion). Apprently, significnt dvntges re ssocited with not llowing the cervicl mrgins of orthodontic nds to encroch into the gingivl sulcus. 1,7 Given the importnce of PI, the difficulty in removing plque from the sugingivl mrgin of nds, 1,7,15,21 often quoted in the literture, cn explin its prominence s risk fctor. Arguly, nother reson for this periodontl rection is mechnicl injury to djcent tissues during the nd plcement procedure, 1,16 or even the fct tht ttchment fiers re torn during the dpttion procedure, thus violting the iologicl spce 25 nd leding to loss of ttchment. 7 This trum my e more severe in clinicl situtions in which the teeth re improperly positioned or re not completely erupted. 7 It is lso conceivle tht the

4 RISK FACTORS FOR PERIODONTIUM IN BANDED MOLARS 227 cytotoxic effects of cement 1 nd/or nd mteril 1,16 cn prtilly explin the gingivl response. Nickel cn hve n influence over the periodontl sttus of llergic orthodontic ptients, leding to locl nd systemic inflmmtory rections tht re correlted with the gingivl index. 13 Such effects, lthough not evluted in this study, deserve further investigtion. Becuse of these rections, it would e interesting to conduct comprtive study involving second molrs with onded ccessories. According to some uthors, this method would e preferle to nding. 1,11,12,16 Proing depth ppered s nother risk fctor for increses in GI. It ws determined tht for every dditionl 1.0 mm, there is n increse of in the odds rtio towrd n increse in the gingivl index. This ssocition etween GI nd proing depth hs een explined y decresed effectiveness in orl hygiene nd, consequently, chnges in sugingivl microiot t these sites. 10,26 Increses in proing depth cn e relted to the presence of sugingivl nds in two different wys. If encrochment into the gingivl sulcus exceeds 0.5 mm, the risk tht violtion of the iologicl spce will occur is incresed, nd this might cuse recession nd/or picl migrtion of the junctionl epithelium nd consequent periodontl pocket formtion. 27 Another explntion is the formtion of hyperplsi or gingivl edem, with pseudopocket cused y locl irrittion of the nds nd the prolifertion of periodontopthogenic cteri. 7,9,17 Gingivl hyperplsi (of inflmmtory origin) ffecting orthodontic ptients is usully chrcterized y gingivl tissue growth, loclized or generlized, strting t the interdentl ppille 1 to 2 months into tretment. 28 Finlly, tretment time showed only slight influence on the occurrence of gingivl inflmmtion. This is proly result of the fct tht, s tretment progresses, the numer of orthodontic ccessories (ruer nds, springs, nd hooks) tends to increse, nd, s lredy seen, this further compromises hygiene It is therefore necessry tht orthodontists provide their ptients with orl hygiene instructions nd constnt motivtion, 10,12,29 while cting s ojectively s possile nd pplying strtegies to reduce the numer of ccessories 12 nd to shorten tretment time. Our results suggests tht when orthodontic nds re required on second molrs, fctors such s plque control, cervicl mrgin height, proing depth, nd tretment time ply n importnt role in incresing the GI index. This mens tht the clinicin should tke protective mesures to minimize periodontl risk. These mesures include monitoring nd motivting ptients orl hygiene, 10,12,29 mintining suprgingivl nd mrgins, 1,7 nd optimizing tretment, with miniml use of ccessories. 12 Thus, possily, we will improve the periodontl condition of ptients in tretment nd their orl helth. CONCLUSIONS N Orthodontic tretment in dult ptients showed more clinicl signs of gingivl inflmmtion thn were seen in those with no pplince. N Potentil risk fctors identified for incresed gingivl index, in decresing order of importnce, include the following: plque index, sugingivl encrochment of the cervicl mrgin of nds, proing depth, nd length of orthodontic tretment. N Study results suggests tht these fctors depend on the professionl responsile for tretment, dpttion of the nds during pplince set-up, nd durtion of orthodontic correction, s well s the ptient s plque control to prevent deposits from uilding up round pplince components. REFERENCES 1. Diedrich P, Rudzki-Jnson I, Wehrein H, Fritz U. 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