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MDJ A comparison between two methods of brushing on clinical… Vol.:6 No.:1 2009
32
A comparison between two methods of brushing on
clinical periodontal parameters in patients with fixed
orthodontic appliance
Dr. Suhad M. A. Sadiq B.D.S., M.Sc. Lecturer.*
Dr. Raed A. Badea B.D.S., M.Sc. Ass. Prof..*
Abstract
Fifty four orthodontic patients wearing upper and lower fixed appliances were
assigned either an electric tooth brush or a manual tooth brush. Each patient was
instructed and trained on the proper use of the allocated brush. Clinical parameters
included (Plaque index, Gingival index and Eastman interdental bleeding index) were
measured at base line, at 4 weeks and at 8 weeks. Data for each group were analyzed
using paired t-test.
Patients using electric tooth brush and manual one showed a significant reduction
in all clinical parameters at 4 and 8 weeks, but the reduction of the values of all
parameters in electric brush group is higher than in manual group and the difference is
statically significant.
The present study concluded that electric tooth brush is real alternative to the often
laborious manual tooth cleaning procedures used during active appliance therapy.
Introduction
Periodontal diseases and dental
caries, both plaque related diseases are
recognized as two of the most common
diseases world wide and it has long
been recognized that the presence of
dental plaque leads to gingivitis and
periodontal disease, as well as caries.
(1,2) Fixed orthodontic appliances are
found to be one of the most common
retentive factors of dental plaque (3,4).
Trapped debris and plaque that
accumulate gingivally to orthodontic
wire are difficult to remove (5-9). Today
tooth brushing is the most widely
accepted method of removing plaque
and has a very high degree of social
acceptability (10). Tooth brushes now
come in bewildering range of styles
and varieties accomplished by complex
product descriptions and scientific
design theories, but no research team
has yet come up with conclusive proof
that one brand performs better than
others (11). Good plaque control is an
important factor in the maintenance of
dental health during fixed appliance
therapy (12-14).
In pursuit of enhanced plaque
control, manual tooth brushes have
been designed specifically for use by
orthodontic patients but have not been
deemed superior to conventional brush
in reducing gingivitis (15,16). Rotary and
counter rotational electrical brushes,
however, have generally demonstrated
greater plaque capabilities compared to
various types of manual tooth brushes
in orthodontic patients (17-19).
Only one study has shown plaque
removal to be superior with a manual
MDJ
College of Dentistry, Al-Mustansiria University.
MDJ A comparison between two methods of brushing on clinical… Vol.:6 No.:1 2009
33
brush (20). Electric tooth brushes using
a normal brush head or a brush
designed specifically for use by
orthodontic patients has also been
shown to be as effective as a manual
brush in removing plaque (21-23).
Despite reduced plaque accumulation
in electric brushing studies,
concomitant improvements in the
health of the gingiva of fixed
orthodontic patients are not as
convincing. Only one long-term study
(24) has demonstrated a significantly
persistent reduction in gingival
inflammation levels in the electric
tooth brush group compared to the
manual tooth brush group.
The present study was conducted to
evaluate the effectiveness of electric
and manual tooth brushing in
orthodontic patients with fixed
orthodontic appliances and make a
comparison between the two methods
of brushing on clinical periodontal
parameters.
Materials and methods
The sample of this study consisted
of fifty four patients who attended the
consultant orthodontic clinic at college
of dentistry, Al-Mustansiria
University. Those patients were
undergoing treatment with both upper
and lower fixed orthodontic appliances
who fulfilled the inclusion and
exclusion criteria listed in table I.
The sample of the study included
27 subjects (12 boys and 15 girls) were
allocated the electric brush and the
other 27 subjects (13 boys and 14 girls)
were allocated the manual brush. The
mean age for subjects in electric brush
group was 14.1 ± 1.7 years and in the
manual brush group 15.6 ± 1.9 years.
These patients were randomly
assigned to the test electrical tooth
brush (Triza, Switzerland) or to the
control group manual tooth brush
(Triza, Switzerland). Baseline
measurements of plaque and gingival
health were recorded for each
participant. After patients were
assigned to the trial groups, oral
hygiene instruments were given to
each patient for the use of allocated
brush. Each subject's brushing
competency and understanding were
checked and no further tooth brushing
instruction was given throughout the
study. The participants were instructed
to brush two times daily, after
breakfast and before retiring at night,
using the allocated brush. The use of
interdental cleaning aids was not
permitted during the study. Each
patient was issued a fluoride
containing tooth paste free from anti-
plaque and anti-calculus agents. All
patients were also supplied with a
fluoride mouth rinse and asked to rinse
with 10 ml once daily throughout the
study.
The examinations at baseline, 4
weeks and 8 weeks were conducted.
The participants had brushed their
teeth after breakfast as usual.
Recordings were made by using the
plaque index (25), gingival index (26),
and Eastman interproximal bleeding
index (27). Plaque scores were recorded
for 4 zones (incisal, distal, mesial and
gingival to the bracket or band) on the
labial or buccal aspects of the teeth. A
WHO periodontal probe was used
inside the gingival crevice to record the
gingival index. All traces of gingival
bleeding were removed by rinsing or
by gentle stream of air and water
before recording the Eastman
interdental bleeding index. From the
buccal aspect, a wooden interdental
stick was inserted four times between
the teeth, depressing the interdental
papilla by 1-2 mm. After 15 seconds,
the presence or absence of bleeding
was noted and recorded.
The Eastman interdental bleeding
index was calculated from the number
MDJ A comparison between two methods of brushing on clinical… Vol.:6 No.:1 2009
34
of bleeding sites as a percentage of the
total sites that were assessed.
The mean and standard deviation
for each of the 3 parameters recorded
(plaque index, gingival index and
interdental bleeding) was calculated for
each time point. Analyses looking for
changes within the individual groups
were conducted using paired t-test.
Comparisons of the 2 study groups
were made using LSD test.
Results
For both study groups, the
reduction in the three parameters
assessed were seen among and this
reduction is apparent. In electrical
group, the PI was reduced from 1.32 in
(V1) to 0.31 in (V3), while for manual
group the mean PI was decreased from
1.28 in (V1) to 0.62 in (V3).
The same trend of changes was
observed for GI, the mean was reduced
from 1.82 in (V1) to 0.6 in (V3) and
from 1.77 in (V1) to 0.98 in (V3) for
electrical and manual group
respectively. For interproximal
bleeding in electrical group, the
bleeding percentage was reduced from
47.9% in (V1) to 22.2% in (V3) for
electrical group and from 49.5 % to
37.8 % for manual group.
For comparison between the two
study groups, t-test was used and the
results showed that for plaque index,
gingival index and we used Chi square
for bleeding index. The difference was
significant in (V2) and (V3) while it is
not in (V1). (Tables II, IV, and VI).
The LSD test and Chi square were
used to compare the differences in
mean values for all parameters
between visits in both study groups.
The reduction was significant from
visits to another for both study groups
in all clinical parameters studied.
(Tables III, V, VII)
Discussion
The current study gives important
information on the efficacy of an
electrical tooth brush, compared to a
manual tooth brush on the periodontal
health of patients undergoing
orthodontic fixed appliance therapy in
a hospital clinic.
Observation of plague removal in
tooth brushing trials in orthodontic
patients vary in one day to two
months.(21,22) Those which incorporate
measurements of gingival changes
usually run for a minimum of 4 weeks
as over this period clinically
meaningful alterations in plague and
gingival bleeding have been recorded
in orthodontic groups.(28,29) The eight-
week duration of the present study falls
in line with recommendation in the
ADA acceptance program guide lines
for tooth brush. That the trial should
extend over a minimum of 30 days (30).
While long term dental hygiene
practices at home are more likely to be
reflected in trial regime can become
problematic, there by providing an
imprecise assessment of the efficacy
and usefulness of a tooth-brush (28).
Over an eight-week period, the
electrical tooth brushing group
exhibited a significant reduction in
mean plague scores, which may be due
to involvement in the trial; the formal
hygiene instruction given at the time of
tooth brush allocation especially the
subjects allocated the electric brush
were given specific instructions with
regard to tooth brushing. This result
confirms the finding of other
studies.(7,12,31)
Mean gingivitis scores were
reduced significantly at 4 and 8 weeks
in electrical brush group and this result
supposed to be reasonable and
proportional with the reduction of
plague accumulation that occurred in
this group of the study. Similar results
were found in other previous trials (12).
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The usefulness of each brush in the
interdental area was assessed using
Eastman Bleeding Index. The value of
this index in assessment of the efficacy
of interdental hygiene measures has
been emphasized. (32)
Subjects allocated the electric tooth
brush exhibited a statistically
significant reduction in mean
percentage of interdental bleeding
scores over the trial period, confirming
the findings of Clerehugh et al.(21)
This most likely reflects the ability
of the specific small head design to
access interdental areas, but also may
be due to a caustic micro streaming (33).
It may be concluded that electric
toothbrushes are real alternative to the
often laborious manual tooth cleaning
procedures used during active
appliance therapy. Patients with poor
oral hygiene and inefficient manual
dexterity and compliance may benefit
from electric tooth brushes especially
because the plaque removal can be
achieved easier and faster.
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Table I: Inclusion and Exclusion Criteria for the Trial subjects
Exclusion Criteria
Inclusion Criteria
Medical contra-indications including those requiring
antibiotic cover
Immunosuppressant drugs Poor manual dexterity Poor compliance
Poor periodontal health including presence of
supragingival calculus, subgingival calculus, or
periodontal pocketing Active caries
Oral prophylaxis in previous 4 weeks
Use of antibiotics or antibacterial mouth rinses during
the trial
Current use of a powered tooth brush
Good general health
Aged between 10 and 20 years
Wearing upper and lower pre-adjusted
edgewise fixed appliances
Brush at least once per day willing and
able to comply with trial regime Dentally fit
Gingival bleeding on at least 20% of sites
Tables II: Mean per visit of Plaque, Gingivitis and Percent of bleeding for Electrical
and Manual toothbrushes
Manual brush mean
Electrical brush mean
Plaque
1.28
1.32
Visit 1
0.9
0.67
Visit 2
0.62
0.31
Visit 3
Gingivitis
1.77
1.82
Visit 1
1.32
0.95
Visit 2
0.98
0.6
Visit 3
Bleeding (%)
49.5
47.9
Visit 1
43.9
31.2
Visit 2
37.8
22.2
Visit 3
Tables III: T-test between electrical and manual tooth brush for Plaque index
Sig.
t-test
N.S.
0.3517
Visit 1
S.
5.645
Visit 2
S.
3.278
Visit 3
Tables IV: LSD test between visits in Plaque index
Electrical brush
Manual brush
test
Sig.
test
Sig.
V.1 vs V.2
82.68
H.S.
3.014
S.
V.1 vs V.3
82.7
H.S.
4.83
S.
V.2 vs V.3
3.617
S
2.632
S.
Tables V: T-test between electrical and manual tooth brush for Gingival index
Sig.
t-test
N.S.
0.375
Visit 1
S.
5.016
Visit 2
S.
8.406
Visit 3
MDJ A comparison between two methods of brushing on clinical… Vol.:6 No.:1 2009
38
Tables VI: LSD test between visits in Gingival index
Electrical brush
Manual brush
test
Sig.
test
Sig.
V.1 vs V.2
5.418
S.
3.09
S.
V.1 vs V.3
7.137
H.S.
5.04
S.
V.2 vs V.3
3.133
S
2.69
S.
Tables VII: Chi-square test for percentage of bleeding index
Sig.
χ 2
S.
6.87
Visit 1
H.S.
21.03
Visit 2
H.S.
32.99
Visit 3
Tables VIII: Chi-square test between visits in bleeding index
Electrical brush
Manual brush
χ 2
Sig.
χ 2
Sig.
V.1 vs V.2
25.601
H.S.
3.99
S.
V.1 vs V.3
33.36
H.S.
21.03
H.S.
V.2 vs V.3
16.18
H.S.
12.71
H.S.