Efficacy of Three Types of Plaque Control Methods During Fixed Orthodontic Treatment: A Randomized Controlled Trial.

AIM: The aim of this study was to evaluate and compare the efficacy of three types of plaque control methods among 13- to 35-year-old subjects receiving fixed orthodontic treatment in Coorg Institute of Dental Sciences, Virajpet, Coorg district, Karnataka, India.
MATERIALS AND METHODS: A total of 111 subjects who fulfilled the inclusion and exclusion criteria were randomly included in the study. The subjects were recalled after 1 month of the commencement of fixed orthodontic treatment for the recording of baseline data including plaque index (PI), gingival index (GI), and modified papillary bleeding index (MPBI). After recording of the baseline data, the subjects were randomly allocated into each of the intervention groups, i.e., group A (manual tooth brush), group B (powered tooth brush), and group C (manual tooth brush combined with mouthwash) by lottery method. Further, all the subjects were recalled after 1 and 2 months for recording the data.
RESULTS: Regarding plaque levels, it was seen that there was a highly statistically significant difference between the three groups (P = 0.001), with the manual tooth brush combined with chlorhexidine mouthwash group recording the lowest mean PI score of 0.5 ± 0.39. A comparison of the mean GI scores among the groups at the end of 2 months shows a highly statistically significant difference (P = 0.001). The mean MPBI scores at the end of 2 months were highly statistically significant among the three groups (P = 0.001), with the group C recording the lowest mean MPBI score of 0.3 ± 0.3.
CONCLUSION: The powered tooth brush group subjects exhibited significantly lesser PI, GI, and MPBI scores than the manual tooth brush group at the end of 2 months, whereas the manual tooth brush combined with chlorhexidine mouth wash group subjects showed maximum improvement, having significantly lesser PI and GI scores than the powered tooth brush group.

INTRODUCTION

Dental plaque is a structurally and functionally organized biofilm. It is the community of microorganisms found on a tooth surface as a biofilm, embedded in a matrix of polymers of host and bacterial origin.[1] Plaque has been described as the soft, tenacious material found on the tooth surfaces, which is not readily removable on rinsing with water.[2]

Dental plaque is the primary cause of gingivitis (gum inflammation), which is recognized by redness of the gums at the junction with the teeth, together with slight swelling and bleeding from the gingival margin.[3] Personal oral hygiene is the maintenance of oral cleanliness for the preservation of oral health, whereby microbial plaque is removed and prevented from accumulating on teeth and gingiva.[4]

The benefit derived from oral hygiene depends on the oral condition of the individual, manual dexterity, lifestyle, motivation, knowledge, oral hygiene instruction, and oral hygiene aids.[5] The most widespread mechanical means of controlling plaque at home is tooth brushing. There is substantial evidence that shows that through tooth brushing and other mechanical cleansing procedures, plaque and gingivitis can be controlled most reliably, provided that cleaning is sufficiently thorough and performed at appropriate intervals.[6] When fixed orthodontic appliances are placed intraorally, effective plaque removal becomes obstructed to a discernible degree. Oral health professionals and orthodontists equipped with a better idea of the current scenario can pave the way for improved and effective preventive methods during fixed orthodontic treatment. This will also lead to an increased awareness regarding effective oral hygiene practices among patients. Hence, this study was conducted with an aim to evaluate and compare the efficacy of a manual tooth brush, powered tooth brush, and manual tooth brush combined with mouthwash in plaque removal and maintenance of gingival health among subjects receiving fixed orthodontic treatment in the region of Coorg district, Karnataka, India.

MATERIALS AND METHODS

This study was an interventional, randomized, controlled, examiner-blind, parallel arm study. It was conducted among 13- to 35-year-old subjects receiving fixed orthodontic treatment in Coorg Institute of Dental Sciences, Virajpet, Karnataka, India. Ethical clearance for this study was obtained from the Institutional Review Board and informed consent was taken from the study participants. The Consolidated Standards of Reporting Trials guidelines on reporting randomized controlled trials have been followed throughout the study.

Total number of subjects was calculated by taking into account the total number of patients in the waiting list of the out patient department register in the Department of Orthodontics and Dentofacial Orthopaedics, Coorg Institute of Dental Sciences, Virajpet. Thus, the sample size was derived as 111 to facilitate uniform distribution of 37 subjects into each of the 3 intervention groups.

Subjects who were aged 13–35 years old volunteering to take part in the study till its completion with full consent, right handed, without any systemic conditions/diseases, and not allergic to chlorhexidine, and all the subjects who underwent simultaneous full arch upper and lower fixed mechanotherapy of MBT prescription (0.022 slot sliding mechanism) were included in the study. Subjects under antibiotics, under lingual orthodontic treatment, and using any other supplemental plaque control devices such as dental floss or interdental brushes were excluded from the study.

The total 111 subjects who fulfilled the inclusion and exclusion criteria and who gave their informed consent were randomly included in the study. Immediately after oral prophylaxis and commencement of the fixed orthodontic treatment, a washout period of 1 month was awaited to nullify the effect of scaling and all the subjects were recalled after 1 month for the recording of baseline data including Silness and Loe Plaque Index (PI), Loe and Silness Gingival Index (GI) and Modified Papillary Bleeding Index (MPBI). Calibration of the examiner was carried out; assessment of intra-examiner variability using kappa variability test showed the mean kappa coefficient value to be 0.8, implying good agreement.

Method of randomization

After recording of the baseline data, the subjects were randomly allocated into each of the intervention groups, i.e., group A, group B, and group C by lottery method. Codes were given for the products by a person not involved in the examination, i.e., the coinvestigator.

Each of the 3 groups consisted of 37 subjects:

Group A (n = 37)—Manual tooth brush (Colgate Orthodontic V-Trim Toothbrush [Soft])

Group B (n = 37)—Powered tooth brush (Oral-B Cross Action Power Toothbrush [Soft])

Group C (n = 37)—Manual tooth brush combined with 0.2% Chlorhexidine gluconate mouthwash (Colgate Orthodontic V-Trim Toothbrush [Soft] + Hexidine BP [ICPA Health Products Ltd., Ankleshwar, India])

The subjects were provided with oral hygiene instructions along with proper tooth brushing technique demonstration at baseline and all subsequent visits. Subjects were provided with a compliance chart to be marked each time after the completion of the oral hygiene regimen. Any failure to comply with the schedule was to be left unmarked. Weekly reminders through SMS were also given to the subjects during the course of the study. Subsequently, the subjects were recalled at 1-month and 2-month intervals, wherein oral examination was performed along with recording of the indices. Soft tissue examination was also carried out to check for any adverse changes attributable to usage of mouthwash.

Statistical analysis

The results were statistically analyzed using the statistical software SPSS (version 20.0). The comparison of mean values between the three intervention groups and within the groups at different time points (baseline, 1 month, and 2 months) was performed using ANOVA. Tukey’s post hoc analysis was performed for groupwise comparisons.

RESULTS

It can be observed from Table 1 there was no significant difference between the study groups with respect to the PI, GI, and MPBI scores at baseline. At the end of 1 month, there was a highly significant difference between groups A and B as well as groups A and C with respect to PI, GI, and MPBI scores, but there was no statistically significant difference between groups B and C. At the end of 2 months, only the MPBI scores between the groups B and C were not statistically significant.

Table 1

Comparison between the study groups with respect to mean PI, GI, and MPBI scores at baseline, 1-month, and 2-month intervals

Study Group		At Baseline			After 1 Month			After 2 Months
		PI	GI	MPBI	PI	GI	MPBI	PI	GI	MPBI
		Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD
Group A		1.2 ± 0.32	1.3 ± 0.37	1.1 ± 0.75	1.3 ± 0.36	1.5 ± 0.43	0.9 ± 0.56	1.5 ± 0.35	1.8 ± 0.29	1.0 ± 0.40
Group B		1.3 ± 0.46	1.4 ± 0.47	1.0 ± 0.22	1.0 ± 0.41	1.0 ± 0.43	0.6 ± 0.39	0.8 ± 0.36	0.7 ± 0.32	0.5 ± 0.41
Group C		1.3 ± 0.25	1.3 ± 0.34	1.1 ± 0.40	0.9 ± 0.36	0.8 ± 0.35	0.5 ± 0.42	0.5 ± 0.39	0.5 ± 0.37	0.3 ± 0.30
ANOVA	F valve	0.962	0.759	0.470	11.001	28.637	7.413	70.528	163.442	33.732
	P value	0.385 (NS)	0.47 (NS)	0.626 (NS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)
Tukey’s post hoc		—			Group A and B—0.003 (HS)	Group A and B—0.001 (HS)	Group A and B—0.018 (S)	Group A and B—0.001 (HS)	Group A and B—0.001 (HS)	Group A and B—0.001 (HS)
					Group B and C—0.5 (NS)	Group B and C—0.095 (NS)	Group B and C—0.626 (NS)	Group B and C—0.002 (HS)	Group B and C—0.03 (S)	Group B and C—0.06 (NS)
					Group A and C—0.001 (HS)	Group A and C—0.001 (HS)	Group A and C—0.001 (HS)	Group A and C—0.001 (HS)	Group A and C—0.001 (HS)	Group A and C—0.001 (HS)

HS = highly significant, S = significant, NS = not significant

It can be observed from Table 2 that there was no significant difference in the MPBI scores of the subjects in group A between the various time intervals. However, the PI, GI, and MPBI scores improved very significantly between baseline and 1 month as well as between baseline and 2 months for group B. It must be noted that there was also a significant improvement in the oral health of the subjects in group C between all the time intervals.

Table 2

Comparison of the mean PI, GI, and MPBI scores between different time intervals within the study groups

Time Interval		Group A			Group B			Group C
		PI	GI	MPBI	PI	GI	MPBI	PI	GI	MPBI
		Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD
Baseline		1.2 ± 0.32	1.3 ± 0.37	1.1 ± 0.75	1.3 ± 0.46	1.4 ± 0.47	1.0 ± 0.22	1.3 ± 0.25	1.3 ± 0.34	1.1 ± 0.40
1 month		1.3 ± 0.36	1.5 ± 0.43	0.9 ± 0.56	1.0 ± 0.41	1.0 ± 0.43	0.6 ± 0.39	0.9 ± 0.36	0.8 ± 0.35	0.5 ± 0.42
2 months		1.5 ± 0.35	1.8 ± 0 .29	1.0 ± 0.40	0.8 ± 0.36	0.7 ± 0.32	0.5 ± 0.41	0.5 ± 0.39	0.5 ± 0.37	0.3 ± 0.30
ANOVA	F value	7.206	17.054	1.063	13.419	26.383	20.628	50.343	46.158	43.453
	P value	0.001 (HS)	0.001 (HS)	0.349 (NS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)
Tukey’s post hoc		Baseline and 1 month— 0.431 (NS)	Baseline and 1 month— 0.057 (NS)	—	Baseline and 1 month— 0.007 (HS)	Baseline and 1 month— 0.001 (HS)	Baseline and 1 month— 0.001 (HS)	Baseline and 1 month— 0.001 (HS)	Baseline and 1 month— 0.001 (HS)	Baseline and 1 month— 0.001 (HS)
		1 month and 2 months— 0. 038 (S)	1 month and 2 months— 0.002 (HS)		1 month and 2 months— 0.103 (NS)	1 month and 2 months— 0.007 (HS)	1 month and 2 months— 0.448 (NS)	1 month and 2 months— 0.001 (HS)	1 month and 2 months— 0.002 (HS)	1 month and 2 months— 0.069 (NS)
		Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)		Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)

HS = highly significant, S = significant, NS = not significant

Regarding plaque levels, it can be seen that there was a highly statistically significant difference between the three groups (P = 0.001), with the manual tooth brush combined with chlorhexidine mouthwash group recording the lowest mean PI score of 0.5 ± 0.39. A comparison of the mean GI scores among the groups at the end of 2 months shows a highly statistically significant difference (P = 0.001), with the Tukey’s post hoc test indicating highly significant improvement in the powered tooth brush group when compared to the manual tooth brush group regarding gingival health (group A = 1.8 ± 0.29; group B = 0.7 ± 0.32; P = 0.001). It is also observed that the mean MPBI scores at the end of 2 months were highly statistically significant among the three groups (P = 0.001), with the group C recording the lowest mean MPBI score of 0.3 ± 0.3 [Table 3].

Table 3

Comparison of the study groups with respect to mean PI, GI, and MPBI scores between different time intervals

Time Interval		PI			GI			MPBI
		Group A	Group B	Group C	Group A	Group B	Group C	Group A	Group B	Group C
		Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD
Baseline		1.2 ± 0.32	1.3 ± 0.46	1.3 ± 0.25	1.3 ± 0.37	1.4 ± 0.47	1.3 ± 0.34	1.1 ± 0.75	1.0 ± 0.22	1.1 ± 0.40
1 Month		1.3 ± 0.36	1.0 ± 0.41	0.9 ± 0.36	1.5 ± 0.43	1.0 ± 0.43	0.8 ± 0.35	0.9 ± 0.56	0.6 ± 0.39	0.5 ± 0.42
2 Months		1.5 ± 0.35	0.8 ± 0.36	0.5 ± 0.39	1.8 ± 0.29	0.7 ± 0.32	0.5 ± 0.37	1.0 ± 0.40	0.5 ± 0.41	0.3 ± 0.30
ANOVA	F value	7.206	13.419	50.343	17.054	26.383	46.158	1.063	20.628	43.453
	P value	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.001 (HS)	0.349 (NS)	0.001 (HS)	0.001 (HS)
Tukey’s post hoc		Baseline and 1 month— 0.431 (NS)	Baseline and 1 month— 0.007 (HS)	Baseline and 1 month— 0.001 (HS)	Baseline and 1 month— 0.057 (NS)	Baseline and 1 month— 0.001 (HS)	Baseline and 1 month— 0.001 (HS)	—	Baseline and 1 month— 0.001 (HS)	Baseline and 1 month— 0.001 (HS)
		1 month and 2 months— 0.038 (S)	1 month and 2 months— 0.103 (NS)	1 month and 2 months— 0.001 (HS)	1 month and 2 months— 0.002 (HS)	1 month and 2 months— 0.007 (HS)	1 month and 2 months— 0.002 (HS)		1 month and 2 months— 0.448 (NS)	1 month and 2 months— 0.069 (NS)
		Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)		Baseline and 2 months— 0.001 (HS)	Baseline and 2 months— 0.001 (HS)

HS = highly significant, S = significant, NS = not significant

DISCUSSION

Orthodontic treatment contributes to improved self-image of patients by providing better aesthetics and attractive smile.[7] The plaque scores of manual tooth brush group at 1 month displayed a slight increase when compared to baseline, which was not significant. It further increased significantly at 2 months when compared to the baseline and 1-month intervals. Similarly, the GI scores increased significantly after 2 months when compared to the scores at baseline and 1-month intervals. The bleeding index scores of the manual tooth brush group were not significantly different at 1-month and 2-month intervals when compared to baseline. The findings are similar to the study by Misra et al.,[8] where the control manual tooth brushing group showed an increase in the PI and GI scores, indicating no improvement in plaque control and gingival health at the end of 1 month. In contrast, the study by Hickman et al.[9] revealed that for the manual toothbrush group, there was a significant reduction in plaque from baseline to 1 month, with the significant improvement being still apparent at 2 months and a reduction in gingivitis from baseline to 1 month, but the change from baseline was no longer significant by 2 months. In addition, Hickman et al. found that a significant, but less marked, reduction in bleeding also occurred in the manual toothbrush group from baseline to 1 month, but by 2 months the change from baseline was no longer significant.

The subjects of the powered tooth brush group exhibited a significant reduction in the PI and GI scores at 1 month and 2 months when compared to the baseline. The bleeding points, as measured by the MPBI scores, reduced significantly in the powered tooth brush group at both the 1-month and 2-month intervals. The results are similar to the study by Silvestrini et al.,[10] where there was significant reduction in both the plaque levels and gingival bleeding index scores among the subjects of the electric brush group at both 1 month and 2 months. Sadiq et al.[11] observed that the mean gingivitis scores were reduced significantly at 4 and 8 weeks in electrical brush group, and that the electrical tooth brush group exhibited a significant reduction in mean plaque scores over an 8-week period. A statistically significant reduction in the modified PI between baseline and week 8 in the group who used the electric toothbrush, a 32% reduction, was found in the study by Clerehugh et al.[12] In contrast, the study by Hickman et al.[9] revealed that, for the powered toothbrush group, there were no statistically significant differences observed for the plaque and gingival indices.

An examination of the manual toothbrush combined with chlorhexidine mouth wash group revealed that PI and GI reduced significantly both at the 1-month and 2-month intervals when compared to baseline and between the 1-month and 2-month intervals. The bleeding scores also reduced highly significantly at 1 month and 2 months when compared to baseline, but the scores were not significantly different between the 1-month and 2-month intervals. Similar results were reported in the study by Al-Sayagh et al.[13]. In a study by Ousehal et al.[14] and as recommended by Haas et al.[15], it was observed that a reduction in gingivitis was only significant in the group where chlorhexidine mouthwash was used followed by manual toothbrushing.

The presence of Hawthorne effect among the subjects as a result of participating in the study cannot be ruled out, and studies over a longer duration of 6-8 months must be carried out to further ascertain the results.

CONCLUSION

This study concluded that the manual tooth brush combined with chlorhexidine mouth wash group had significantly lesser PI and GI scores than the powered tooth brush group at the end of 2 months.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.