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VOLUME 9 - NUMBER 1 - 2018
Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice



 Impellizzeri A., Samà R., Di Giorgio R., Barbato E., Galluccio G. 
Original Article, 43-52
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Aims. To evaluate how the application of orthodontic appliances influences the level of collaboration in the oral hygiene of the patient and whether a difference exists between patients treated in public and private structures. Methods. From April 2016 to December 2017, two hundred patients, 100 treated in the Orthodontics Department of “Sapienza” University of Rome and 100 treated in a private practice, have been evaluated for six months from the start of the treatment. All the 200 patients completed a questionnaire and an evaluation with OHI-S (Oral Health Index-Simplified) modified oral hygiene index, repeated every three months. All data have been statistically analyzed to evaluate the level of collaboration to oral hygiene and eventually present differences between public vs private structures. The differences in behavior in oral hygiene with reference to different orthodontic devices (fixed/removable) were also evaluated and the ability to maintain adequate oral hygiene with respect to the expected length of orthodontic treatment was assessed. Results. A statistically significant difference was found between the initial level of plaque index at the T0 and T1 time, found at a lower level. The maintenance of oral hygiene between public or private facilities, although the initial level was different, were eventually revealed to be not statistically different at the planned controls. There was indeed a difference between patients in treatment with fixed or removable appliances, showing a higher level of plaque deposition for the first group. Conclusions. The appropriate prescription of an oral hygiene protocol in orthodontic patients and the periodical reiteration of the message are positively correlated with an improvement of oral hygiene conditions, in spite of the sort of health facility and mainly related to the ability of the dental professionals. The presence of a fixed appliance strengthened the need for a close control.




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G. Galluccio 
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Annali di stomatologia
compliance
Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice
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Original Article
2022-08-10
2022-08-10
2018-03-01
2023-12-04
43-52
Ann Stomatol (Roma)
G. Galluccio 
2018
10.59987/ads/2018.1.43-52
43
1971-1441
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compliance
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Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice
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                                                                                                Original article



    Control of oral hygiene in the orthodontic patient:
    comparison between public facility and private
    practice




                                                                                             li
                                                                                           na
    Alessandra Impellizzeri DDS                            maintenance of oral hygiene between public or
    Roberto Samà DDS                                       private facilities, although the initial level was dif-
    Roberto Di Giorgio MDS                                 ferent, were eventually revealed to be not statisti-




                                                                                         io
    Ersilia Barbato PhD                                    cally different at the planned controls. There was
    Gabriella Galluccio DDS                                indeed a difference between patients in treatment
                                                           with fixed or removable appliances, showing a




                                                                     az
                                                           higher level of plaque deposition for the first
    Department of Oral and Maxillofacial Sciences,         group.
    “Sapienza” University of Rome, Rome Italy              Conclusions. The appropriate prescription of an
                                                           oral hygiene protocol in orthodontic patients and




                                                                   rn
                                                           the periodical reiteration of the message are posi-
    Corresponding author:                                  tively correlated with an improvement of oral hy-
    Gabriella Galluccio                                    giene conditions, in spite of the sort of health fa-
    Director of Post-graduate Course in Functional         cility and mainly related to the ability of the dental




                                                       te
    Orthodontics,                                          professionals. The presence of a fixed appliance
    Vice-President of the Course for Dental Degree         strengthened the need for a close control.
    Department of Oral and Maxillofacial Sciences,
    “Sapienza” University of Rome
                                                     In    Key words: oral hygiene, orthodontic appliance,
    Piazzale Aldo Moro 5                                   public health, compliance.
    00185 Rome, Italy
    E-mail: gabriella.galluccio@uniroma1.it
                                                           Introduction
                               ni

                                                           Orthodontics is a specialty of dentistry that deals with
    Summary                                                prevention, diagnosis and treatment of malposition of
                             io


                                                           teeth and facial bones. The main objectives of ortho-
    Aims. To evaluate how the application of ortho-        dontic treatment are the correct alignment of the
    dontic appliances influences the level of collabo-     teeth, in order to improve the health prospects of the
                           iz



    ration in the oral hygiene of the patient and          teeth and their supporting apparatus, efficient masti-
    whether a difference exists between patients           catory function, good facial appearance and stability
    treated in public and private structures.              of the occlusion.
           Ed




    Methods. From April 2016 to December 2017, two         For the treatment of malocclusions, the therapy re-
    hundred patients, 100 treated in the Orthodontics      quires fixed or removable devices, often used in as-
    Department of “Sapienza” University of Rome and        sociation with each other or applied in sequence, ac-
    100 treated in a private practice, have been evalu-    cording to the specific treatment objective.
    ated for six months from the start of the treat-       Oral hygiene is the set of measures taken to ensure
    ment. All the 200 patients completed a question-       cleanliness of the oral cavity and thus prevent carious
 IC




    naire and an evaluation with OHI-S (Oral Health        lesions and other diseases such as gingivitis and pe-
    Index-Simplified) modified oral hygiene index, re-     riodontitis (1-3).
    peated every three months. All data have been           For the realization of a correct hygiene during ortho-
    statistically analyzed to evaluate the level of col-   dontic treatment, the use of common aids, such as
C




    laboration to oral hygiene and eventually present      manual or electric toothbrush, is suggested and more
    differences between public vs private structures.      specific devices such as brushes, interdental brush-
    The differences in behavior in oral hygiene with       es, end tuft toothbrushes and “Super floss”. All these
    reference to different orthodontic devices             devices help to reach the more common plaque de-
©




    (fixed/removable) were also evaluated and the          position area, which is difficult to keep clean with the
    ability to maintain adequate oral hygiene with re-     standard approach, such as below the orthodontic
    spect to the expected length of orthodontic treat-     arches (1-6).
    ment was assessed.                                     The task of dentist and hygienist is to teach the most
    Results. A statistically significant difference was    suitable technique for performing correct oral hy-
    found between the initial level of plaque index at     giene, based on the characteristics of the patient’s
    the T0 and T1 time, found at a lower level. The        mouth and any dental problems (6).

    Annali di Stomatologia 2018;IX(1):43-52                                                                     43
    A. Impellizzeri et al.


    Orthodontic appliances are selected according to the        Richter et al. in 1998 reported that patient compliance
    specific treatment objective and often, more than one       could be achieved through a reward path regardless
    appliance can be used, in particular, when problems         of the repetition of instructions, for example with the
    of skeletal growth and dental misalignments are as-         use of a report card for reporting the goals, taking
    sociated (1, 6, 7).                                         care to transform them into tangible prizes (13).




                                                                                                   li
    The term “removable appliance” means each device            The importance of maximizing collaboration in proper
    that the patients can apply and remove on their own.        oral hygiene from orthodontic patients is indicated by




                                                                                                 na
    Usually, it is formed by an acrylic resin body, which       the results of studies that have assessed changes in
    retains in its structure both the elements which allow      bacterial plaque composition in patients during ortho-
    it to be anchored to the teeth properly, and the me-        dontic treatment (13).
    chanical elements, such as screws, springs and arcs,        Maret et al. carried out a study to highlight any differ-
    which, once activated, are able to move the teeth (7).      ences in salivary microbial load among orthodontic




                                                                                               io
    Mobile appliances need careful daily hygiene, be-           patients and related controls. The Authors found an
    cause bacterial plaque is deposited when they are           increase of Streptococcus mutans and Lactobacillus
    placed in the mouth and when they are stored in their       (14).




                                                                          az
    containers. It is therefore especially important to in-     Several Authors evaluated the presence of the micro-
    struct the patient to properly maintain the appliance,      bial load in the oral cavity (Streptococci, Staphylococ-
    but the patient’s compliance is limited to the perfor-      ci, Veillonelle, Lactobacilli and Mycetes) before, dur-
    mance of normal daily oral hygiene maneuvers (4,8).         ing and after orthodontic treatment. The prevalent




                                                                        rn
    The fixed orthodontic appliance is made up of metal         conclusion is that the average bacterial population in-
    or ceramic attachments, and bands fixed to the teeth,       creases and that the anaerobes become prevalent on
    that are connected and activated by further compo-          the remaining bacterial flora. Generally, the increase
    nents: wires, elastic bands, springs and extra-oral         in these bacteria is related to higher incidence of




                                                         te
    traction, so as to move the teeth into a correct posi-      caries. On the other hand, there is a decrease in the
    tion. In this case, the devices cannot be removed ex-       percentage of Actinomyces (13.3% decrease in the
    cept by the orthodontist (4, 8).                            total flora), and smaller reduction in Fusobacterium
                                                       In
    Fixed appliances reduce the physiological self-disrup-      and Bacteroides species (15).
    tion mechanisms favoring plaque retention and accu-         Although there is no general agreement in the litera-
    mulation; they also create objective difficulties in the    ture on the adhesion pattern of micro-organism dur-
    execution of daily oral hygiene techniques; therefore,      ing the orthodontic treatment, an in vitro study
                                 ni
    the patient in fixed orthodontic therapy requires a         showed a lower adhesion for the combination sap-
    strong motivation and compliance in hygiene maneu-          phire brackets/coated wire, while metallic brackets
    vers (4, 8, 9).                                             and metallic wires showed the worst performance.
    Orthodontic treatment involves a long period of col-        The Authors concluded that the capacity of micro-or-
                               io


    laboration between patient, orthodontist and hygienist      ganisms to adhere and grow is dependent on the ma-
    (10, 11).                                                   terials of the orthodontic appliance (16).
    The complete understanding of the oral hygiene prob-        Hagg et al., analyzed the prevalence of Candida and
                             iz



    lem, the manual skills of the duly educated patient         Enterobacteria in a group of adolescents in orthodon-
    and the appropriate use of tools and materials are in-      tic treatment with fixed appliances. They conclude
    dispensable, but not sufficient conditions for the daily    that the presence of these appliances alters the eco-
            Ed




    practice of oral hygiene (12). The “motivation” is the      logical balance in the oral cavity, due to the introduc-
    decisive key, that is the complex of factors that instill   tion of new stagnant areas of plaque and debris re-
    in the patient “mental orientations tending to be con-      tention, with a direct effect on the plaque index but a
    cretized through actions and behaviors aimed and co-        contrary and transitory effect over the prevalence and
    herent” (2, 11).                                            density of Candida and the transmission of Coliforms
    All patients, although informed, trained and motivated      (9).
 IC




    by the dentist and/or hygienist, through appointments,      The fixed appliances, therefore, interfere with the
    sessions and oral hygiene instructions, tend to lose        practice of oral hygiene and should be considered as
    motivation relatively quickly, in a few days to a few       parts of the surface of the teeth (17).
    months. This phenomenon requires great consistency          The level of collaboration offered is fundamental for
C




    in continuously providing the patient with the neces-       the success of orthodontic treatment. While the pa-
    sary reinforcements to maintain motivation over time        tient is asked to use the appliance in the most correct
    (10).                                                       way, it is also necessary to respect scheduled ap-
    Collaboration is essential for successful treatment in      pointments and to maintain an adequate level of oral
©




    orthodontic patients. Failure to collaborate leads to       hygiene in order not to make the benefits of the entire
    an increase in working time for the patient, the parent     treatment questionable. So, orthodontic treatment en-
    and the orthodontist; moreover, in some cases, the          visages a constant commitment on the part of the pa-
    treatment may be compromised, and it may be nec-            tient, the parents, the orthodontist and the hygienist,
    essary to interrupt it prematurely, due to the risk of      both as regards the maintenance of oral hygiene and
    tissue damage, such as demineralization enamel and          the duration of treatment and the subsequent thera-
    recurring gingival inflammation (11).                       peutic results (13).

    44                                                                               Annali di Stomatologia 2018;IX(1):43-52
    Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice


    Beckwith et al. (18) have identified some of the pri-           males and 61 females of average age 12.3. Of these
    mary factors that influence the duration of orthodontic         100 patients, 33 were treated with removable ortho-
    treatment. In this study, parameters were collected             dontic devices, while 67 were in orthodontic therapy
    from 140 cases completed consecutively, including               with fixed multiband equipment, 32 of whom also had
    data from patients being treated in 5 different private         a fixed palatal expander appliance.




                                                                                                        li
    studies. Significant correlations were found for factors        All the 200 patients initially completed a question-
    related to patient collaboration (number of missed ap-          naire, which was repeated every three months over a




                                                                                                      na
    pointments, number of rebonded brackets and bands,              total period of six months.
    number of treatment steps, detection of poor oral hy-           The questionnaire is a re-elaboration of a pre-existing
    giene) and only two related to the treatment modality           folder concerning oral hygiene in pediatric dentistry,
    (more than one treatment phase, prescription of ex-             modified according to the aims of the present work.
    traoral traction use).                                          In the first survey, data were collected regarding age,




                                                                                                    io
    In a review of the factors concerning the duration of           sex, type of orthodontic appliance, methods of oral
    orthodontic treatment, Mavreas and Athanasiou con-              hygiene, number of meals taken during the day and
    clude that extraction treatment lasts longer than the           any reference to oral hygiene; plaque and bleeding




                                                                               az
    non-extraction therapy, while age does not seem to              indices were also detected. In the following two ap-
    play an important role. Several conditions appear to            pointments with the patient, only the detection of the
    be operator-sensitive; at least various factors includ-         oral hygiene indexes was performed.
    ing the compliance of the patients seem to play a role          Oral hygiene instructions were given by the operators




                                                                             rn
    in prolonging the treatment (19).                               both to the sample examined in the public sphere and
    The aim of the study was to evaluate how the appli-             in the private sector, before orthodontic treatment.
    cation of orthodontic appliances influences the level           19% of the patients treated in private practice and 5%
    of collaboration in the oral hygiene of the patient.            of patients treated in the public facility had fluoropro-




                                                           te
    The present work also evaluated if the behavior in              phylaxis treatments during orthodontic treatment, due
    oral hygiene is different between patients treated in           to previously detected caries susceptibility.
    public and private structure, as the patient’s coopera-         The index considered by this study was the OHI-S
    tion is based on motivation, information and sense of
                                                         In         (Oral Health Index-Simplified) modified oral hygiene
    appreciation and interest. This behavior is transmitted         index, which is a reversible index used to measure
    by dental health staff through a program of instruc-            the degree of oral hygiene.
    tions that must be developed for each patient, ac-              This epidemiological index allowed the evaluation of
                               ni
    cording to their needs and the type of appliance ap-            the amount of soft residues present on the teeth, and
    plied.                                                          regardless of whether they are plaque or alba matter,
    The different structuring of the service in the public          only the explorer was used, without using revealing
    sector could be less followed by the individual path of         solutions; this system was preferred to simplify the
                             io


    the patient about the maintenance of oral hygiene               detection of indices by operators.
    and the maintenance of compliance, for reasons of               To perform this study, 8 maxillary teeth (1.6; 1.3; 1.2;
    organization of the structure, while greater personal-          1.1; 2.1; 2.2; 2.3; 2.6) and 8 mandibular teeth (4.6;
                           iz



    ization and monitoring could be envisaged in the pre-           4.3; 4.2; 4.1; 3.1; 3.2; 3.3; 3.6) were examined; the
    vention path in the private structure, especially with          eventually present plaque was probed, by using an
    regard to the implementation of the protocols.                  explorer, around the mesial, buccal and lingual/palat-
           Ed




    The present work also aimed to compare how differ-              al distal surfaces of the examined teeth (for a total of
    ent treatment methods can affect the patient’s ability          64 surfaces).
    to maintain proper oral hygiene.                                By summing up all the values of the surfaces positive
                                                                    to the presence of plaque and dividing by the total
                                                                    number of surfaces of the teeth considered, multiply-
    Materials and methods                                           ing by one hundred, the percentage (%) of plaque
 IC




                                                                    present on the teeth was obtained.
    The study was conducted on a sample of 200 pa-                  All data were subjected to statistical analysis with
    tients in orthodontics, 100 of whom were treated in             SPSS software, to evaluate the correlations between
    the Orthodontics Unit of the Department of Dentistry            the indexes collected and the arguments presented in
C




    and Maxillo Facial Sciences, “Sapienza” University of           the aim of the work:
    Rome – named group G1 – and 100 treated at a pri-               • evaluation of the influence of orthodontic applica-
    vate practice – group G2. The observations took                      tion on the level of collaboration to oral hygiene
    place between April 2015 and December 2017.                          by the patient;
©




    N. 57 males and n. 43 females of average age 15.2               • evaluation of differences in behavior in oral hy-
    formed the sample of the public hospital G1.                         giene between patients followed in public struc-
    Of these 100 patients, 16 were in orthodontic therapy                ture and patients followed in private practice;
    with removable devices, 84 in orthodontic therapy               • evaluation of differences in behavior in oral hy-
    with a multiband fixed device, 24 of whom also had a                 giene in the presence of different orthodontic de-
    fixed palatal expansion appliance.                                   vices (fixed/removable);
    The private practice sample, G2, was formed by 39               • assessment of the ability of patients to maintain

    Annali di Stomatologia 2018;IX(1):43-52                                                                              45
    A. Impellizzeri et al.


       adequate oral hygiene with respect to the expect-       The average measured at time T0 was equal to:
       ed length of orthodontic treatment, assessed as         T0=0.4994 while at T1 it was equal to: T1=0.4534; this
       short treatment (<1 year of therapy), or long treat-    result, statistically significant since P is equal to:
       ment (>1 year of therapy).                              P=0.000, indicated how, even in the presence of an or-
    The statistical evaluations carried out on the collected   thodontic device, if an appropriate oral hygiene proto-




                                                                                                  li
    data were:                                                 col is applied, plaque indices can improve their level.
    1. descriptive statistical analysis of the data;           The ANOVA test for repeated measurements, per-




                                                                                                na
    2. double-tailed test T to evaluate the variation of       formed at the time T0, T1, T2, showed that there
       the plaque index both in the presence of an ortho-      were no statistically significant changes in the plaque
       dontic appliance and in relation to the different       index over 6 months; this is probably due to the im-
       types of appliances (fixed and removable) and to        provement of the patient’s compliance which, when
       compare the values of the plaque index in relation      properly stimulated, manages to maintain sufficient




                                                                                              io
       to the various care structures;                         oral hygiene control over time (Tab. 2, Fig. 2).
    3. regression test and linear correlation to compare       The same result also comes from the T test for paired
       results on the progress of the plaque index with        data, compared to the plaque index measurements




                                                                         az
       respect to the duration of orthodontic treatment.       made at the time T1 and at the time T2 in the two
                                                               welfare structures: private and public (Tab. 3, Fig. 3).
                                                               As can be inferred from the analysis of Table 3, there
    Results                                                    was no statistically significant modification (P=0.407)




                                                                       rn
                                                               in the plaque index, which remained constant in the
    Table 1 and Figure 1 showed the results of the T test      controls following the time T1.
    for paired data referred to the plaque index in the        The results of the plaque index measurements in re-
                                                               lation to the different types of appliance: fixed or re-




                                                        te
    presence of an orthodontic device at time T=0 and
    T=1. Through the measurement, we wanted to evalu-          movable, carried out at time T=0 and T=1, on the pa-
    ate whether the presence of an orthodontic appliance       tients followed both in the public and private struc-
    produced a difference in behavior in oral hygiene of       ture, are reported in Tables 4, 5 and in Figure 4.
    the patients of the whole sample examined both in
                                                      In       The analysis of these results confirmed a tendency
    the public and private structure.                          for the plaque index to decrease in the presence of
                                                               an orthodontic device in the first three months of the
                                                               observation; in both cases, in fact, there were statisti-
                                 ni
                                                               cally significant data: P=0.002 and P=0.000, indica-
    Table 1. Plaque indexes at T0-T1.                          tive of an effective improvement of the plaque index.
    Time         Group       Media       Dev Std   ESM         From the comparison of these tables, however, it ap-
                                                               peared that the patients treated with removable de-
                               io


    T0           200         0.4994      0.2749    0.0194      vices presented better values of plaque index at de-
    T1           200         0.4534      0.2512    0.0178      tection performed at time T=1 compared to those who
                                                               were subjected to a fixed therapy.
                             iz



    Difference               0.0460      0.0237    0.0016      In Table 6 and Figure 5, the results of the plaque in-
                                                               dex value at time T1 in the fixed therapy patients were
    95% Confidence Interval of diff. average: 0.03132 to
                                                               compared with those in mobile therapy and elaborated
            Ed




    0.06068;
    T = 6.181 with 199 degrees of freedom; P 0.000.            with the T test for paired data. It was possible to no-
 IC
C
©




    Figure 1. Variation of plaque indices.


    46                                                                              Annali di Stomatologia 2018;IX(1):43-52
    Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice


    Table 2. ANOVA for repeated measures.


    Time                                                Group          Media       Dev Std                          ESM

    T0                                                  200            0.4994      0.2749                           0.0194




                                                                                                        li
    T1                                                  200            0.4534      0.2512                           0.0178




                                                                                                      na
    T2                                                  200            0.4675      0.3338                           0.0236

    Variation source                                    SS             GL          Estimated variance (MS)
    Between subjects                                    557.9536       199




                                                                                                    io
    Within subjects                                     1051.8080

    Treatments                                          3.8786         2           1.9393




                                                                               az
    Residue                                             1047.9294      398         2.6330

    Total 1609.7616 600




                                                                             rn
    MStreat 1.939

    F = ------------ = --------- = 0.737P = 0.479




                                                            te
    MSres 2.633
                                                          In
                                ni
                              io
                            iz
            Ed
 IC
C




    Figure 2. Variation of plaque indices at time T0-T1-T2.

    tice a statistically significant difference in plaque index     though the absolute values showed a difference be-
    in the two different types of appliances for P=0.040.           tween the two types of facilities, the values obtained
©




    From the analysis of this result, therefore, it emerged         through the elaboration, presented in Table 7 and
    that the presence of fixed appliances determined the            Figure 6, showed statistically insignificant results
    need for greater collaboration in oral hygiene, com-            (P=0.573).
    pared to the presence of mobile devices.                        Finally, the results reported in Table 8 showed that
    We then compared the plaque index values in pa-                 the expected duration of orthodontic treatment, as
    tients under orthodontic treatment followed in the              communicated to the patients before the acceptance
    public structure, to those in the private structure. Al-        of the therapy, did not determine a statistically signifi-

    Annali di Stomatologia 2018;IX(1):43-52                                                                                  47
    A. Impellizzeri et al.


                                                                                        Figure 3. Variation of plaque indices at T1
                                                                                        and T2 (public structure + private struc-
                                                                                        ture).




                                                                                                            li
                                                                                                          na
                                                                                                        io
                                                                                 az
    Table 3. Change of the T1 and T2 time plaque index (pub-          Table 4. Plaque indices in mobile devices (public structure




                                                                               rn
    lic structure) (private structure).                               + private structure).

    Time         Group       Media      Dev Std        ESM            Time         Group       Media        Dev Std        ESM

    T1           200         0.4534     0.2512         0.0178         T0           45          0.4374       0.2584         0.0385




                                                            te
    T2           200         0.4675     0.3338         0.0236         T1           45          0.3856       0.2400         0.0358

    Difference               -0.0140    0.2391         0.0169         Difference -             0.0518       0.0184         0.0027
                                                          In
    95% Confidence Interval of diff. average: 0.04739 to              95% Confidence Interval of diff. average: 0.01964 to
    0.01929;                                                          0.08396;
    T = -0.831 with 199 degrees of freedom; P= 0.407.                 T = 3.246 with 44 degrees of freedom; P= 0.002.
                                 ni
                               io
                             iz
            Ed
 IC
C
©




    Figure 4. Total change of the plaque indices to T1 and T2 (public structure + private structure) for different types of appli-
    ances (removable/fixed).



    48                                                                                        Annali di Stomatologia 2018;IX(1):43-52
    Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice




                                                                                                               li
                                                                                                             na
                                                                                                           io
                                                                                   az
                                                                                 rn
    Figure 5. Plaque indices difference at time T1 in public and private structures between mobile and fixed devices.




                                                              te
    Table 5. Plaque indices in fixed appliances (public struc-          Table 6. Test T. Plaque indices comparison between fixed
    ture + private structure).                                          and mobile devices (public structure + private structure).
    Time          Group      Media       Dev Std         ESM
                                                            In
                                                                        Time          Group      Media       Dev Std         ESM
    T0            155       0.5170       0.2777          0.0223         T1            155        0.4728      0.2516          0.0202

    T1            155       0.4728       0.2516          0.0202
                               ni
                                                                        T1            45         0.3856      0.2400          0.0358

    Difference              0.0442       0.0261          0.0021         Difference               0.08728     0.04218
                             io

    95% Confidence Interval of diff. average: 0.02751 to                95% Confidence Interval of diff. average: 0.004112 to
    0.06076;                                                            0.1705;
    T = 5246 with 154 degrees of freedom; P=0.000                       T= 2.070 with 198 degrees of freedom; P=0.040.
                           iz
           Ed
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©




    Figure 6. Difference of time T1 plaque indices in the different welfare structures (public structure vs private structure).


    Annali di Stomatologia 2018;IX(1):43-52                                                                                        49
    A. Impellizzeri et al.


    Table 7. Differences between the different welfare struc-     so in the presence of orthodontic appliances.
    tures. (public structure vs private structure).               The average improvement of the level achieved in the
                                                                  first months, as evidenced by the modified OHI-S found
    Time          Group      Media     Dev Std         ESM
                                                                  in the study conducted, was significant in all cases.
    T1            100        0.4434    0.2598          0.0260     Nevertheless, at inter-proximal level, where the pa-




                                                                                                     li
                                                                  tient’s greatest difficulty in maintaining an adequate
    T1            100        0.4635    0.2432          0.0243     level of hygiene is usually found, and also in this




                                                                                                   na
                                                                  study, we have always found a greater accumulation
    Difference               0.0201    0.03558
                                                                  of plaque and food residues, compared to other den-
    95% Confidence Interval of diff. average:-0.09027 to-         tal surfaces.
    0.05007.                                                      This data probably demonstrates both a poor habit
    T= 0.565 with 198 degrees of freedom; P=0.573.                prior to keeping the interdental spaces clean, and the




                                                                                                 io
                                                                  need for a greater degree of manual skill that is re-
                                                                  quired in the presence of an orthodontic appliance,
    Table 8. Plaque index correlation with respect to length of
                                                                  especially if fixed, in keeping such surfaces clean.




                                                                            az
    the orthodontic treatment. Regression and linear correla-
    tion.                                                         Usually, in patients who had not been recalled and
                                                                  did not receive oral hygiene instructions again, the
    Total sample group                           200              plaque tends to increase or at least to return to the
                                                                  initial levels, before the hygienist appointments (21).
    Angular coefficient                          -0.0658




                                                                          rn
                                                                  In our sample, the control performed at the time T2=6
    Intercept                                    30.317           months indicated an almost overlapping value with
    es slope                                     0.5862           the other controls; it is to be emphasized that proba-
                                                                  bly the demotivation occurs quickly in patients without




                                                            te
    es Int                                       0.3471           planned recall, indicating how crucial their continuous
    es r                                         24.659           and constant reinforce is.
                                                                  From a comparison of the data obtained both from
    r                                            0.0092
                                                          In      clinical and statistical observations regarding the cor-
    t                                            -0.1122          relation between the different type of orthodontic de-
                                                                  vices and plaque indices, we can state that in pa-
    GL                                           198
                                                                  tients in fixed orthodontic therapy, we have a more
    P                                            0.9108
                                 ni
                                                                  difficult control of hygiene is present, compared to pa-
                                                                  tients in mobile orthodontic therapy.
                                                                  This aspect is certainly affects by the presence, as
                                                                  we know, of brackets and bands that with their irregu-
                               io


    cant value, P=0.9108 and r=0.0092, between the
                                                                  larities, retain food residues with formation of greater
    plaque index and the duration of therapy.                     percentage of plaque, if the hygiene maneuvers are
    This result, however, did not imply a lack of correlation     not carried out correctly (16).
                             iz



    between the real treatment duration and bacterial plaque      The role of the hygienist is therefore essential, in con-
    index. It is therefore important to stimulate the patient’s   stantly keeping alive the motivation of the orthodontic
    motivation for oral hygiene maneuvers and orthodontic         patient and to be ready to stimulate it when compli-
             Ed




    collaboration; it is very much possible to obtain the best    ance is reduced.
    results in terms of orthodontic treatment by reducing the     Otherwise, the use of a removable appliance with the
    risk of diseases such as caries or gingivitis.                possibility of being able to be removed both during
                                                                  meals and during daily hygiene maneuvers, allows
                                                                  the patients to carry out the instructions indicated by
    Discussion                                                    dentists with greater ease.
 IC




                                                                  Based on clinical data and statistical results related to
    In collecting our records of oral and food hygiene            oral hygiene behavior in the two different care facili-
    habits and the level of compliance, we found a series         ties examined, it was shown that there are no statisti-
    of parameters that were not analyzed in the present           cally significant differences. This result is probably
C




    study but which we propose to include in a prospec-           because both samples under examination were sub-
    tive study of wider scope.                                    jected to a hygiene education program, as a function
    This study highlighted that, even in the presence of          of a subsequent orthodontic treatment. This protocol
    orthodontic devices, usually considered responsible           probably produced a positive behavioral response in
©




    for the increase of plaque, gingival inflammation and         patients, resulting in improved plaque index even at
    demineralization around orthodontic brackets and              the first control performed three months after the hy-
    bands (20), in the presence of a correct oral hygiene         giene instructions given to them.
    prevention and instruction program, plaque indices            In fact, the statistical comparison of the data related
    can improve.                                                  to the plaque index shows that there is a statistically
    The importance of a high level of oral hygiene care,          significant improvement in patients in orthodontic
    so fundamental in everyday life, becomes even more            treatment in the two different samples belonging to

    50                                                                                 Annali di Stomatologia 2018;IX(1):43-52
    Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice


    both the public and private structure. This situation           of oral hygiene, while there is a slight difference be-
    reflects the importance of health education through             tween fixed and removable appliances in the level of
    motivation and oral hygiene instructions and the im-            plaque index.
    plementation of prevention programs and oral hy-                Orthodontic treatment performed in different care fa-
    giene protocols.                                                cilities has shown statistically insignificant results,




                                                                                                             li
    A further elaboration concerning the different types of         even if in the public structure it is more complex to
    apparatus (removable, fixed) gave a statistically sig-          rigorously implement the oral hygiene protocols be-




                                                                                                           na
    nificant P=0.040 value. The value highlights how mo-            cause of the large number of patients daily coming for
    bile devices, when it is possible to use them, would            the control before, during and after orthodontic treat-
    be preferable to fixed devices in patients with special         ment, compared to the private structure.
    needs or in patients with cooperating difficulty.               From the data shown, the importance that health edu-
    The patient in fixed orthodontic therapy must have              cation assumes during these treatments is finally evi-




                                                                                                         io
    greater motivation to maintain hygiene, since the re-           dent, as is the fact that, to obtain significant results, a
    tention of bacterial plaque by fixed orthodontic de-            simple act of motivation, performed at the beginning
    vices providing additional retention areas can lead to          of orthodontic treatment, is not sufficient, and this




                                                                                az
    gingivitis, from the lightest to the most severe forms,         must necessarily be repeated periodically, with a min-
    with gingival hypertrophy, in particular of the papillae        imum interval of three months.
    and presence of pseudo-pockets (14).                            About the methods used to monitor the patient’s ac-
    In the last question addressed in the present study,            quisition of the correct oral hygiene technique, we be-




                                                                              rn
    concerning the course of the plaque index with re-              lieve that the simplified oral hygiene index (OHI-S),
    spect to the expected duration of treatment, we found           alone or associated with the bleeding index, is a sim-
    the lack of a statistically significant linear correlation      ple method of good practical efficiency.
    between plaque index and the possible duration of




                                                            te
    the therapeutic treatment.
    This does not mean that a long treatment duration               Conflict of interest
    does not affect the worsening of patient plaque in-
    dices; however, if they are frequently monitored and
                                                          In        No sources of support in the form of grants was re-
    subjected to hygiene sessions, the risk of damage to            ceived for the present paper.
    the gingival tissues can be reduced in some way,
    throught the least accumulation of potentially harmful
                               ni
    plaque (15).                                                    References
    On the basis of this research and the experience of
    other Authors, the following recommendations to the             1.  Guastamacchia C, Ardizzone V. Igiene orale domiciliare. Pre-
                                                                        venzione e igiene dentale. Ed. Masson. 2001;200-209.
                             io

    patient assume importance:
    • carefully brush both the surface of the attach-               2. Darby ML, Walsh M. Dental Hygiene Theory and Practice.
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                                                                    3. O’Neill J. Little evidence exists about optimal caries-prevention
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                           iz



                                                                        strategies during orthodontic treatment. Evid Based Dent.
    • use interdental brushes for interdental spaces,
                                                                        2004;5(4):97.
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                                                                        Jagtman AM. Caries-inibiting effect of preventive measures
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 IC




                                                                        in ortodonzia. Elsevier 1999.
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                                                                        ture review. J Orthod. 2008 Dec;35(4):262-269.
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©




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    Annali di Stomatologia 2018;IX(1):43-52                                                                                          51
    A. Impellizzeri et al.


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                                                                                                                  li
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                                                                                                                na
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                                                                                      az
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    52                                                                                             Annali di Stomatologia 2018;IX(1):43-52
