Aim: The aim of this study was to evaluate the oral hygiene status of patients with fixed mechanotherapy appliances.

Methods and materials: The following indices were used to evaluate the oral hygiene status of patients in orthodontic treatment: Gingival Bleeding Index (GBI), Plaque index (PI) and OrthoPlaque Index (OPI) at three intervals.T0 (day 1), T1 (15 days), T2 (30 days) for a period of one month.

Results: 10 patients (15-30 years old) were selected for the study from among the orthodontic patients treated at the Department of Orthodontics & Dentofacial Orthopedics, AIDSR, Adesh University. Results showed that the mean PI decreased significantly from T0 to T1 & then from T1 to T2, GI decreased significantly from T0 to T1, but then, no significant difference could be found in GI from T1 to T2, OPI decreased significantly from T0 to T1, but then, no significant difference could be found in OPI from T1 to T2. No significant difference was observed between male and female patients for the PI, GI and OPI.

Conclusion: Inadequate oral home care among orthodontic patients may increase their risk of gingivitis during treatment. As a result, oral hygiene instructions and a hygiene maintenance program must not be overlooked during orthodontic treatment.

Adult patients are increasingly seeking orthodontic treatment in modern dental care. Following the placement of fixed orthodontic appliances, oral hygiene becomes significantly more difficult [1-3]. As a result, patients wearing fixed orthodontic appliances are more likely to develop dental caries and gingivitis, which can lead to gingival attachment loss [4]. After three months of active orthodontic treatment, there is a statistically significant increase in stimulated salivary flow rate, pH, buffer capacity, plaque index (PLI) scores, and lactobacilli levels [5,6]. Differences in the plaque index (PI), bleeding index (BI), and pocket depth (PD) measures were found following the placement of fixed appliances, and these values were significantly greater than the baseline [7,8]. A shift to a more disease-inducing subgingival microflora was reported, with a statistically significant increase in spirochetes and fusiform bacilli. A significant change in oral microbiota was found in subjects with fixed appliances during the first six months of treatment [9,10]. Such a result suggests that the risk of gingivitis was high during their months of therapy, and the risk of periodontitis could not be ruled out. Manschot [11] described a patient who had severe mucogingival changes, such as gingival recession, as a result of orthodontic treatment and poor oral hygiene [12]. Orthodontic appliances do not usually cause gingival inflammation, but the increase in microorganisms can contribute to periodontal disease [13]. Plaque accumulation and gingival inflammation, on the other hand, can both be reduced in motivated patients [14,15].

As a result, it is critical to emphasize oral hygiene instructions to orthodontic patients who are wearing a fixed appliance [16].

The purpose of this study was to assess the level of oral hygiene in patients receiving fixed orthodontic appliances.

Ethical clearance

Ethical clearance was approved by the Ethical Committee of Adesh University before conducting the present study with letter number AU/CoE/MDS/05/17 dated 22/12/21.

Patients undergoing fixed mechanotherapy were selected randomly from the Department of Orthodontics and Dentofacial Orthopedics, AIDSR, Adesh University.

Patients in fixed mechanotherapy in the orthodontic department at Adesh Institute of Dental Sciences & Research, Bathinda were chosen for the study.

The study was conducted by one investigator so no inter-operator bias was present.

Inclusion criteria

1. Patients with full-mouth fixed orthodontic appliances that had been in place for at least six months.

2. No systemic diseases.

3. No history of taking antibiotics for the last three months.

4. No oral prophylaxis during the month preceding the study.

Exclusion criteria

1. Nonorthodontic patients.

2. Patients having systemic diseases.

3. Patients have a history of taking antibiotics for the last three months.

Orthodontic Plaque Index (OPI): Gingival Bleeding Index (GBI) & The Plaque Index (PI) were used to evaluate the patient’s oral hygiene and the gingiva. The Orthodontic Plaque Index (OPI) [17] was used to assess plaque levels in the most critical plaque accumulation zones, which are cervical to the bracket base and mesial and distal to the bracket body. The index formula shown in Table 1 was used to calculate OPI.

Gingival Index (GI): To calculate the gingival bleeding index (GI) [3], all four surfaces of the teeth were examined to see if probing caused bleeding. The severity of gingivitis was determined using the score shown in Table 2 [3].

Plaque Index: For orthodontic patients, the plaque index (PI) was measured on the bracket sides of one representative tooth from six sextants: upper right (first molar), upper center (central incisor), upper left (first molar), lower right (first molar), lower center (central incisor), and lower left (first molar) (first molar). Each tooth was divided into four zones based on its position around the brackets (mesial [M], distal [D], gingival [G] and incisal [I]) and evaluated using Loe and Silness’ PI score. In cases where the first molar was banded or missing, the sextant was represented by the second premolar. The Loe and Silness PI was used on the nonbracket side (Table 3) [3].

Data analysis

Data was entered into the computer using the FoxPro program [FoxPro 7.0; Sybase Inc., Dublin, CA, USA] and statistical analyses were performed using the Statistical Package for the Social Sciences [SPSS 10; (SPSS Inc., Chicago, IL, USA)]. To determine differences at the 5% significance level (p0.05), a one-way analysis of variance (ANOVA) was used.

The mean age of male & female study participants was found to be comparable Tables 4,5.

Intragroup comparison of the Mean Plaque Index at T0, T1 & T2 was done using the Friedman test. A statistically significant difference was found in the mean PI score at T0, T1 & T2. Post hoc pairwise comparison was done using the Wilcoxon test. It was found that the mean PI decreased significantly from T0 to T1 & then from T1 to T2 Table 6.

Intragroup comparison of the Mean Gingival Index at T0, T1 & T2 was done using the Friedman test. A statistically significant difference was found in the mean GI score at T0, T1 & T2. Post hoc pairwise comparison was done using the Wilcoxon test. It was found that the mean GI decreased significantly from T0 to T1, but then, no significant difference could be found in GI from T1 to T2 Table 7.

Intragroup comparison of Mean OPI at T0, T1 & T2 was done using the Friedman test. A statistically significant difference was found in the mean OPI score at T0, T1 & T2. Post hoc pairwise comparison was done using the Wilcoxon test. It was found that the mean OPI decreased significantly from T0 to T1, but then, no significant difference could be found in OPI from T1 to T2 Figure 1.

Because of the increased challenge to oral hygiene, patients undergoing orthodontic treatment with fixed appliances are at risk for developing gingival inflammation. Gingivitis is caused primarily by dental plaque [18,19]. The inability of the patient to adequately clean his or her teeth around fixed orthodontic devices promotes plaque accumulation, which can then lead to gingival inflammation. After orthodontic appliance placement, there is an overall increase in salivary bacterial counts, particularly Lactobacillus [20,21]. Similarly, twofold and threefold increases in clinical indexes and motile organism numbers have been reported six months after appliance placement [2], as well as an early increase in anaerobes and Prevotella intermedia and a decrease in facultative anaerobes [3,22]. This shift in subgingival microflora to a periopathogenic population is comparable to the microflora found in periodontally diseased sites [23,24]. Plaque control may be made more difficult by irregular tooth alignment. Some studies have discovered a link between crowding and periodontal disease [25], while others have not [26,27]. Nonetheless, effective plaque control is the most important factor in maintaining good oral hygiene [28]. The purpose of this study was to assess oral hygiene among orthodontic patients at Adesh Institute of Dental Sciences & Research. Despite the fact that more than half of the patients brush their teeth twice a day, their oral hygiene was poor. In general, PI and OPI were reduced after oral prophylaxis, with mean values of 1.5 to 0.5 and 2.7-1.2, respectively. This finding is consistent with previous research that found an increase in visible plaque on tooth surfaces following the placement of orthodontic appliances [25,26,29]. This is due to an increase in plaque retentive areas as well as the patient’s inability to perform adequate oral hygiene [30]. However, increasing the frequency of brushing does not guarantee clean teeth. As a result, toothbrushing frequency alone cannot be used to assess the quality of oral hygiene [31-34].

Education and motivation, as well as continuous reinforcement of oral hygiene, can improve patients’ oral home care performance. Orthodontic patients, in particular, must be educated on proper oral hygiene maintenance, and their brushing habits must be monitored on a regular basis. Following an intensive period of individual oral hygiene education, it is possible to achieve and maintain a high standard of oral health behavior [35]. When evaluating the brushing techniques used, it is clear that patients require motivation and instruction on how to use an appropriate technique. Previously, the so-called scrubbing method was recommended to patients during orthodontic treatment; however, the modified Bass technique outperformed the scrub method [36]. Many patients place the toothbrush too far coronally, ignoring the gingival third of the tooth, which can lead to increased plaque accumulation and the development of gingivitis. As a result, all patients should be instructed to clean both the tooth structure cervical to an orthodontic appliance and the remaining coronal surfaces [37]. In the presence of orthodontic appliances, some patients may find daily oral hygiene difficult. As a result, patients with orthodontic appliances should use an electric toothbrush. Indeed, Heintze, et al. [17] concluded that patients with poor oral hygiene may benefit from using an electric toothbrush, particularly because dental plaque can be easily and quickly removed. Electric toothbrushes with a rotational brush are significantly more effective than manual toothbrushes in removing supragingival plaque from bracketed teeth. In fact, differences in plaque-removing effectiveness were discovered to be especially consistent on the proximal surfaces of teeth [38]. According to the findings of this study, the majority of the patients (68 percent) did not visit a dental hygienist during their orthodontic treatment. Professional prophylaxis has been shown to be effective in patients with fixed orthodontic appliances [39]. As a result, oral hygiene instruction and reinstruction are required during orthodontic treatment. Some patients should also be reminded to clean the cervical area of their teeth below the brackets. Increased oral hygiene awareness will not only reduce the prevalence and severity of iatrogenic tissue damage but will also extend the long-term benefits of orthodontic therapy [40].

The mean GBI value was reduced from 1.0 to 0.3, which is regarded as a reasonable value. The results of this study revealed that the relationship between the three indices and gender was not significant for the PI and OPI, but significant for the GBI (p = 0.05) [41].

According to the findings of this study, patients wearing orthodontic appliances have difficulty maintaining good oral hygiene. As a result, educating and motivating these patients to maintain their oral health, as well as recommending oral home care aids to improve compliance, remains the cornerstone for achieving optimal oral hygiene results.

Patients must understand what their treatment will entail and what their responsibilities will be. They must understand that they are partners in their orthodontic treatment and that they have the opportunity to improve and then maintain good oral health.

No oral hygiene program, however, will be successful unless orthodontists accept responsibility for motivating their patients and staff. When an orthodontist offers oral hygiene advice with genuine interest and respect, patients usually respond positively and become receptive to self-improvement. As a result, any hygiene issues or limitations discovered during orthodontic treatment must not be ignored but must be addressed right away.

Clinical significance

Inadequate oral home care among orthodontic patients may increase their risk of gingivitis during orthodontic treatment. It is therefore critical that proper oral hygiene be maintained throughout orthodontic treatment.

Limitations

The limitation of the present study was that the sample size was small, and the results may not be significant or representative in nature.

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