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MDJ Periodontal health status and treatment need among Iraqi orthodontic patients wearing fixed appliance

Authors:
  • Al-Mustansiriya University-College of dentistry

Abstract

Back ground/Aim: Orthodontic treatment enables the establishment of functional occlusion and improvement of oral health, however, it increases the risk of periodontal disease development through plaque retention and difficulty of keeping a good oral hygiene. So the present study was performed to evaluate the periodontal health status and determination of treatment need among Iraqi orthodontic patients wearing fixed appliance. Material and method: A total number of 224 orthodontic patients wearing fixed appliance were enrolled in the study. They were attending Al-Mustansiria teaching hospital at college of dentistry/Al-Mustansiria University /department of orthodontics, pedodontics and preventive dentistry for follow up visits of their orthodontic fixed appliances in addition to the patients attending the private clinic of the researchers. Evaluation the periodontal health status and determination of treatment need were achieved using CPITN (Community Periodontal Index for Treatment Need), the degree of gingival enlargement and high frenal attachment. The sample was divided into 2 groups according to age factor (adolescents and adults). Results: The total number & percentages of CPITN scores for the total sample were calculated. The highest number and percentage were of (scores 0, 1 &2), {258 (19.19 %), 250 (18.60 %) & 800 (59.52 %)} respectively with highly significant difference of score 2 from other scores. The percentages of scores (0, 1 & 2) in the two age groups (adolescents and adults). The percentages of scores (0, 1 & 2) in the adolescents were (17.32 %, 20.47 % & 60.67 %) respectively with highly significant difference of score 2. The percentages of scores (0, 1 & 2) in the adults were (30.51 %, 27.69 % and 39.90 %) respectively with significant difference of score 2. The treatment need for the whole sample was 100% for codes 1 and 2 of treatment need (oral health instructions & scaling and root planing) also these codes of treatment were higher than other codes significantly, especially code 3 (complex treatment, deep scaling ,surgical intervention) in adolescents and adults were (4.5% and 3%) respectively. Regarding the gingival enlargement the numbers and percentages of the enlargement scores (0, 1, 2 & 3) of the total sample were 115 (43%), 85 (31%), 52 (19%) and 14 (5.26%) respectively.
MDJ Periodontal health status and treatment need among … Vol.:10 No.:1 2013
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Periodontal health status and treatment need among
Iraqi orthodontic patients wearing fixed appliance
Dr. Raed A. Badeia. *
Dr. Suhad M. Ali. **
Abstract
Back ground/Aim: Orthodontic treatment enables the establishment of functional
occlusion and improvement of oral health, however, it increases the risk
of periodontal disease development through plaque retention and difficulty of
keeping a good oral hygiene. So the present study was performed to evaluate the
periodontal health status and determination of treatment need among Iraqi
orthodontic patients wearing fixed appliance.
Material and method: A total number of 224 orthodontic patients wearing fixed
appliance were enrolled in the study. They were attending Al-Mustansiria teaching
hospital at college of dentistry/Al-Mustansiria University /department of
orthodontics, pedodontics and preventive dentistry for follow up visits of their
orthodontic fixed appliances in addition to the patients attending the private clinic
of the researchers. Evaluation the periodontal health status and determination of
treatment need were achieved using CPITN (Community Periodontal Index for
Treatment Need), the degree of gingival enlargement and high frenal
attachment. The sample was divided into 2 groups according to age factor
(adolescents and adults).
Results: The total number & percentages of CPITN scores for the total sample were
calculated. The highest number and percentage were of (scores 0, 1 &2), {258
(19.19 %), 250 (18.60 %) & 800 (59.52 %)} respectively with highly significant
difference of score 2 from other scores. The percentages of scores (0, 1 & 2) in the
two age groups (adolescents and adults). The percentages of scores (0, 1 & 2) in
the adolescents were (17.32 %, 20.47 % & 60.67 %) respectively with highly
significant difference of score 2. The percentages of scores (0, 1 & 2) in the adults
were (30.51 %, 27.69 % and 39.90 %) respectively with significant difference of
score 2. The treatment need for the whole sample was 100% for codes 1 and 2 of
treatment need ( oral health instructions & scaling and root planing) also these
codes of treatment were higher than other codes significantly, especially code 3
(complex treatment, deep scaling ,surgical intervention) in adolescents and adults
were (4.5% and 3%) respectively. Regarding the gingival enlargement the
numbers and percentages of the enlargement scores (0, 1, 2 & 3) of the total
sample were 115 (43%), 85 (31%), 52 (19%) and 14 (5.26%) respectively.
Introduction
Orthodontic therapy may affect the
periodontium by favoring plaque retention, by direct injury to the
gingiva as a result of overextended
MDJ
* Assitant prof./Department of Periodontics/College of dentistry/Al-Mustansiria University
**Assitant prof./Department of Orthodontics/College of dentistry/Al-Mustansiria University
MDJ Periodontal health status and treatment need among … Vol.:10 No.:1 2013
44
bands, and by creating excessive
forces, unfavorable forces, or both on
the teeth and supporting structures (1)
.Orthodontic appliances not only tend
to retain bacterial plaque and food
debris, resulting in gingivitis, but also
are capable of modifying the gingival
ecosystem. An increase in Prevotella
melaninogenica, Prevotella
intermmedia, and Actinmyces
odontolyticus and a decrease in the
proportion of facultative
microorganisms was detected in the
gingival sulcus after the placement of
orthodontic band (2). More recently,
aggregatibacter
actinomycetemcomitance was found in
at least one site in 85% of the children
wearing orthodontic appliances (3). In a
study (4) about the change of the
composition of plaque after removal of
orthodontic appliances, periodontal
health improved, and the carriage and
amount of subgingival P. gingivalis
decreased. Nevertheless, the amount of
subgingival P. gingivalis remained
high for 6 months after appliance
removal, and this finding might imply
a potential risk to periodontal health in
certain patients. Treatment with fixed
appliances in adolescents may
transitionally increase the values of all
periodontal indices and stimulate the
growth of periodontopathogenic
bacteria, but without destructive effects
on deep periodontal tissues (5).
Importance of oral hygiene in
orthodontic patients is always
intensified to prevent any further
periodontal disease. In the absence of
oral hygiene maintenance, plaque
accumulation on orthodontic appliance
components is paving way to
destruction of periodontal tissues (6,7).
Due to greater tooth area covered and
complex nature of the orthodontic
appliances make it difficult to maintain
oral hygiene. Maintaining oral hygiene
during orthodontic treatment will help
in good gingival health, which reflects
in final orthodontic treatment outcome.
But the level of gingival health
knowledge among orthodontic patients
is not adequate. Poor maintenance of
oral hygiene is due to either lack of
knowledge or negligence by patients
themselves. Patients are not given
proper instructions (8,9,10), may be one
big reason for patient’s
noncompliance. However, despite
receiving appropriate instructions,
many individuals fail to follow
instructions; also many of them lack
knowledge on maintenance. It is
important to motivate them to compile
the instructions and maintain oral
health. It is always needed to assess the
knowledge of orthodontic patients on
gingival health. The patients
undergoing fixed appliance orthodontic
treatment produces chronic
inflammatory gingival enlargement
originates as a slight ballooning of the
interdental papilla and/or the marginal
gingiva. In the early stages it produces
a life preserver-shaped bulge around
the involved teeth. The need for
reliable indices that not only assess the
causative factors of the disease, but
also provide a virtual image on the
financial resources seems to be
implemented by Community
Periodontal Index for Treatment Need
(CPITN) proposition in1982 and the
rapid acceptance of this index that
gives the scientific community with
huge amount of epidemiological data
(11). The CPITN has proven to be a
useful tool for planning the periodontal
treatment needs, establishing
population periodontal health goal, and
evaluating changes in the periodontal
status of a given population after a
program implementation (12-15).
The present study was conducted
because of recognition of a clear,
obvious deterioration and
inflammation of the periodontium in
orthodontic patients wearing fixed
appliance and the desire to assess the
MDJ Periodontal health status and treatment need among … Vol.:10 No.:1 2013
45
amount of periodontal breakdown and
treatment need using CPITN which is
used for the first time in Iraq in respect
to the evaluation of periodontal heath
status and treatment need. (This is
according to the best of our
knowledge)
Materials and methods
Collection of data in the present
study lasted about (2 years) due to
relatively high number of the sample.
A total number of (224) orthodontic
patients wearing fixed appliance were
enrolled in the study and were
attending Al-Mustansiria teaching
hospital/department of orthodontics,
pedodontics and preventive dentistry at
college of dentistry/Al-Mustansiria
University/Baghdad Iraq, for follow
up visits of their orthodontic treatment
with fixed appliances in addition to
the patients attending the private clinic
of the researchers. The total sample
was allocated into 2 groups according
to the age (adolescents and adults).
The present study was carried out
using CPITN. This index was designed
to assess the periodontal health and
periodontal treatment needs of specific
groups. It can be used as a screening
monitoring tool to determine the
periodontal treatment needs of either a
community or individuals. Only six
measurements per person are recorded,
so it is time saving when a large
samples are examined. The whole
dentition is divided into 6 sextants in
each sextant only one tooth is
examined; the index teeth are
maxillary right central incisor, with left
and right maxillary first molars, with
their corresponding mandibular first
molar teeth and mandibular left incisor.
A color coded can be used and the
periodontal treatment needs can be
reported as the number or percentage
in each treatment need category. The
examination of the patients was
achieved by dental mirror and WHO
periodontal probe. Collection of data
was achieved by filling annexure that
contains information and 2 tables (each
one contains 6 cells representing the 6
sextants of patient dentition) that filled
by the scores of CPITN and gingival
enlargement. The total sample was also
allocated into three groups according
to the duration of wearing the fixed
appliance (6 months, 12 months and 18
months) approximately, the CPITN
scores were also recorded for these 3
groups.
The CPITN scores are:
0 = Healthy periodontium.
1 = Bleeding observed, directly or
by using mirror, after gentle
probing.
2 = Supra & subgingival calculus
felt during probing, but entire
black area is visible.
3 = Pocket 4-5mm (gingival
margin is located on black area
of probe).
4 = Pocket greater than 6mm (black
area of probe not visible).
For each patient, 6 scores of 6
sextants were recorded and the
treatment need for each patient was
determined by taking the highest
score of CPITN with corresponding
code of treatment need. The
treatment need codes are:
0 = No treatment need. (score 0 in
CPITN ).
1 = Oral hygiene instructions OHI.
(score 1 in CPITN).
2 = OHI+ scaling and polishing +
elimination of plaque retentive
margins (2&3 CPITN).
3 = OHI + scaling and root planing.
4 = Complex periodontal therapy
that may include surgical
intervention and/or deep
scaling and root planing.
Also high frenal attachment which
was thick, fibrous and may cause
central diastema was recorded. The
gingival enlargement was also assessed
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46
in the study by an index includes 4
grades (16) .
Grade 0: No signs of gingival
enlargement.
Grade I: Enlargement confined to
interdental papilla.
Grade II: Enlargement involves
papilla and marginal gingiva.
Grade III: Enlargement covers three
quarters or more of the crown.
Results
The distribution of the sample
according to the age and gender is
revealed in (Table: 1). The range of the
age was (13-37 years) and the average
of the age was (19.43 years) The
sample was divided into 2 groups
(adolescents and adults). (Table 2)
demonstrates the total number &
percentages of CPITN scores for the
total sample. The highest number and
percentage were of (score 0 , 1 & 2 ),
258 (19.19 %), 250 (18.60 % ) & 800
(59.52 %) respectively with highly
significant difference from other
scores.
In (Tables 3 & 4), the adolescent
and adult group showed that the
number of scores (1,2&3) were also
higher than other scores significantly (
score 2 was the highest significantly
P value < 0.01 ). In adolescent group
number & percentages of CPITN
scores were (score 0 =159 17.32 %),
(score 1= 188 (20.47%) & (score 2 =
557 (60.67 % ). In adult group the
number & percentages of CPITN
scores were (score 0 =130 (30.51 %),
(score 1= 118 (27.69 %) & ( score 2 =
170 (39.90 %). Table 5 illustrates the
treatment need for the whole sample, it
was 100% for codes 1 and 2 of
treatment need (oral health
instructions & scaling and root
planing) also these codes of
treatment were higher than other
codes significantly P value < 0.01.
Regarding code 3 (complex treatment,
deep scaling, surgical intervention) in
adolescents and adults were (4=
(2.61%), 3= (4.22%)) respectively. In
respect to the gingival enlargement
(table 6) revealed that the numbers and
percentages of the enlargement scores
(0,1,2&3) of the total sample were 48
(21.42%), 91 (40.62%), 74 (33.03%)
and 11 (4.91%) respectively. (Table 7)
shows the number & percentages of
CPITN scores for the total sample
according to the duration of wearing
the appliance and it is obvious that the
number & percentages of CPITN
scores increased in positive relation
with the duration of wearing the
appliance. (Figure 1 bar chart)
illustrates the percentages of high
frenal attachments in maxilla and
mandible. For maxilla the number &
percentage of high frenal attachments
were 29 (11.88%) while for the
mandible it was 7 (3.12). (Figure 2 a
photograph shows the gingival
enlargement with degrees (1,2 and 3).
Figure 3 shows the high frenal
attachment that required surgical
removal).
Discussion
The present study revealed
alarming findings regarding the
periodontal conditions of the patients
wearing fixed orthodontic appliances.
In fact, we felt that it is very necessary
to carry out this study to evaluate the
periodontal health status and treatment
need, this was because of observation
of increased prevalence of the
gingivitis among fixed appliance
wearing patients to threatening states
for the final outcome of the treatment
and according to the best of our
knowledge that there is no recent
comprehensive study that assess the
periodontal tissue conditions and
treatment need especially using
CPITN and the evaluation included
the degree of gingival enlargement in
MDJ Periodontal health status and treatment need among … Vol.:10 No.:1 2013
47
addition to determination of the
prevalence of maxillary &
mandibular high frenal attachment
in one study for Iraqi patients wearing
fixed orthodontic appliances. The
study was performed to assess the
status of the periodontium clinically
not only around the brackets but also
around the bands placed on the molars
during the course of the orthodontic
treatment. The hypothesis of study was
that there is a change in the periodontal
status of the patients receiving fixed
orthodontic treatment. The study
results supported this hypothesis and
showed a highly significant change in
periodontal status of the patients
(p < 0.00). There was a marked change
in the CPITN score (Bleeding On
Probing, presence of calculus) after the
placement of fixed appliances. These
findings are in agreement with the
results of Naranjo et al (17), who
reported that the placement of brackets
influenced the ecological environment
by the accumulation of the bacterial
biofilm at the retentive sites. There was
a (marked increase in scores 0,1 & 2)
in all groups resulting in more bleeding
and gingival inflammation. Similar
results were observed by Ristic and
coworker 2008 (18) as there was a
marked increase in both the clinical
and microbiological parameters in 3
months time after the fixed appliance
placement. The obvious high
percentages of the scores (0-2)
indicated that the major change with
orthodontic appliance is gingivitis
which did not progress to the deeper
tissues and this result is in accordance
with the studies of Honda et al 2006 &
Miller 2013 (19,20). The periodontal
disease (PDD) is accumulative in
nature i.e. the PDD progressed with the
age and in the present study the
patients were mostly young, this may
also confirm the marked increase of
scores 0-2 and a low percentages of
scores (3 & 4). The periodontal disease
also is episodic in nature and a lot of
gingivitis sites may remain arrested for
a long period of time (21). In terms of
treatment need evidence based
dentistry over the last few decades
found that non surgical treatment
(scaling & root planing) was found to
have equal results as surgical treatment
even in deep pockets as 7-8 mm (22) . In
the present study gingival enlargement
has been measured and recorded using
an index of 4 grades which resulted in
specification and accuracy of the
distinguishing the severity and
distribution of gingival enlargement.
The current study revealed that grade 1
and 2 were the higher grades of the
gingival enlargement, Thus
gingivectomy are required in advanced
enlargement that restricts the oral
hygiene procedure and causes
discomfort for the patients esthetically
and functionally.
There was also a marked difference
in the scores as the time progressed in
all study groups (p <0.05). It was
therefore determined that the
placement of fixed appliances resulted
in the increase in the CPI scoring in
both anterior as well as posterior
segment showed change in the CPI
score (p<0.05). Therefore it was found
that not only the brackets but also the
bands influence the periodontal health.
Similar observations were reported by
many others (23-24). This indicates that
the plaque accumulation may be risk
factors for the increase in the clinical
parameters i.e. BOP, Plaque
accumulation and pocket depth. Mostly
the young patients are referred for
orthodontic treatment and they often
suffer from plaque related gingivitis.
Obvious signs of periodontal disease in
adults are a hindrance to being referred
for orthodontic treatment. Almost
every fixed orthodontic patient
develops gingival disease at some time
during treatment (25).Gingival
enlargement and inflammation is often
MDJ Periodontal health status and treatment need among … Vol.:10 No.:1 2013
48
transient and resolves within weeks of
rebonding. Contemporary bonded
orthodontic appliances cause less
gingivitis than banded appliances (26).
Adolescents have certainly been shown
to suffer worse gingivitis than adults
during orthodontic treatment. Primary
aim before any orthodontic
intervention should be to stabilize the
periodontal condition (27). Stable
gingival health status throughout the
orthodontic treatment would deliver
accurate treatment results. Delivering
proper instructions on gingival health
maintenance to orthodontic patients
plays vital role in this aspect.
Motivating and making them to
practice oral hygiene measures in
young age groups will certainly
enhance the levels of oral hygiene
standards (28,29). Many patients do not
exactly know how to maintain high
oral hygiene standards which may be
conducive to excellent orthodontic
treatment outcomes (30). Proper
brushing is ideal for good gingival
health, while prolong brushing may
distort the gingival tissues. Wasting
diseases like abrasion are mainly
caused by improper brushing. On
awareness of gingival health,
comparatively very few are having
awareness while most of them are not
aware of that (31). An
orthodontic oral health promotion OHP
program for patients
undergoing fixed appliance orthodontic
treatment produces a short-term
reduction (up to 5 months) in plaque
and improvement in
gingival health. No particular OHP
method a greater short term benefit
to periodontal health during fixed
appliance orthodontic treatment further
studies using appropriate methods and
in particular longer follow up periods
are required (32).
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(Table: 1) The distribution of the sample according to the age and gender.
(Table: 2) The total number & percentages of CPITN scores for the total sample.
* The % were calculated as No. of score 0 (258 from 1344 the total No. of all scores of total sample =
224 patients x 6 = 1344 scores
(Table:3) The number & percentages of CPITN scores for the adolescent sample.
* The % was calculated as No. of score 0 (159 from 918 the total No. of all scores of adolescent sample
= 153 patients x 6 = 918 scores
(Table: 4) The number & percentages of CPITN scores for the adult sample.
* The % were calculated as No. of score 0 (130 from 426 the total No. of all scores of adult sample =
71 patients x 6 = 426 scores
(Table 5) The number & percentages of PD treatment need codes.
Sample age
Male
Female
Total
Adolescents
65
88
153
Adults
23
48
71
Total
88
136
224
CPITN scores
Total number of scores
0
258
1
250
2
800
3
26
4
10
CPITN scores
number of scores adolescents
Percentages of scores
0
159
17.32 %*
1
188
20.47 %
2
557
60.67 %
3
10
1.08 %
4
4
0.43 %
CPITN scores
number of scores adult
Percentages of scores
0
130
30.51 % *
1
118
27.69 %
2
170
39.90 %
3
5
1.17 %
4
3
0.70 %
PD treatment need codes
No.& % of adolescent patients
No.& % of adult patients
0
0
0
1
153 (100%)
71 (100%)
2
71 (100%)
71 (100%)
3
4 (2.61%)
3 (4.22%)
MDJ Periodontal health status and treatment need among … Vol.:10 No.:1 2013
51
(Table: 6) The number & percentages of gingival enlargement degrees of the two
patient samples & the total sample .
(Table 7) The numbers and percentages of CPITN scores according to the duration of
wearing fixed appliance.
* = The percentages were calculated = 65 score 0 from the total number of score 0 (258)scores
(Figure 1) The No. & percentages of high maxillary & mandibular frenal attachments
that required frenectomy.
Degree of G.
enlargement
No. & % of
adolescent patients
No.& % of adult
patients
No.& % of total patients
0
20 (8.92%)
28 (12.5%)
48 (21.42%)
1
68 (30.35 %)
23 (10.26%)
91 (40.62%)
2
59 (26.33 %)
15 (6.69%)
74 (33.03%)
3
6 (2.67%)
5 (2.23%)
11 (4.91%)
CPITN scores
6 months
1 year
18 months
0
65 (25.19%) *
89 (34.49%)
104 (40.31%)
1
70 (28.0 %)
68 (27.20%)
112 (44.80%)
2
198 (24.75%)
202 (25.25%)
400 (50.0%)
3
7 (26.9%)
9 (34.61%)
10 (38.46%)
4
2 (20.0%)
3 (30.0%)
5 (50.0%)
0
50
29 ( 11.88 %)
maxillary high
frenal
7 (3.12%)
Man.frenal attach.
Fig. 2. High frenal attachment
Fig. 3 Gingival enlargement
(Grade 1, 2, 3, )
... We also used two clinical indices: DMFT (Decayed, Missing, and filled) index following WHO guidance [16] and CPITN (Community Periodontal Index of Treatment Need) [17] to determine and compare the association of caries (DMF) and periodontal disease (CPITN) with OHRQoL among PLHIV and HIV-negative adults. Clinical data (DMF and CPITN) information were delivered from the broader PhD project that aimed to assess risk factors for caries and periodontal diseases among PLHIV and HIV-negative persons in Kigali, Rwanda. ...
Article
Full-text available
Background Assessing health-related quality of life has become integral to people living with HIV (PLHIV) follow-up. However, there is a lack of data regarding the impact of oral health on quality of life, known as Oral health-related quality of life (OHRQoL) among PLHIV compared to HIV-negative individuals in Rwanda. Aim The study aimed to assess OHRQoL among PLHIV compared to HIV-negative counterparts in Kigali, Rwanda. Methods The Oral Health Impact Profile short version (OHIP-14) questionnaire was interviewer-administered to 200 PLHIV and 200 HIV-negative adults (≥ 18 years old) at an HIV clinic of Kigali Teaching Hospital (CHUK). Socio-demographic characteristics, including age, sex, occupation, and socioeconomic status (SES) of participants, were collected using a survey questionnaire. A 4-point Likert scale was used to assess the frequency of oral impacts for all 14 items within 7 domains of the OHIP tool. The descriptive statistics were used to see frequencies and percentages of OHRQoL among PLHIV and HIV-negative persons, respectively. The Chi-square test was used to determine the association of OHRQoL with caries (DMFT) and periodontal disease (CPITN) among PLHIV compared to HIV-negative individuals. Results The results revealed a higher prevalence of PLHIV with poor OHRQoL than HIV-negative individuals in 5 domains and almost all items of OHIP-14 except for the OHIP 3 (found it uncomfortable to eat any foods because of problems with teeth or mouth) and OHIP-14 (being totally unable to function because of problems with teeth or mouth). The findings showed statistically significant results (p ≤ 0.05) for the OHIP1 item “trouble pronouncing any word,” with a prevalence of 2.5% (n = 11) and 2.25% (n = 9) in PLHIV and HIV-negative, respectively. Also, PLHIV had a significantly higher prevalence, 2.75% (n = 11) for the OHIP 13 item “life not satisfying due to teeth and mouth problems compared to HIV-negative individuals 2% (8) p ≤ 0.05. Moreover, dental caries was significantly associated with poor OHRQoL among PLHIV and HIV-negative adults and for all 14 items of the OHIP tool. Periodontal disease was not significantly associated with OHRQoL among PLHIV and HIV-negative adults. Conclusion This study revealed poor OHRQoL among PLHIV compared to HIV-negative adults. There is a need for further longitudinal studies to investigate the OHRQoL in Rwanda, especially among PLHIV. It is essential to include oral health care as one of the components of the medical health care programs for PLHIV in Rwanda.
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