Comparative Assessment of Three Different Orthodontic Brushes in Oral Hygiene Maintenance during Fixed Orthodontic Treatment: An In Vivo Study

INTRODUCTION

Dental caries and periodontal disease are the most commonly found oral diseases in human population and the causative factor for both of them is dental plaque. Adequate removal of dental plaque is a challenging task among patients undergoing fixed orthodontic therapy. The brackets and other fixed orthodontic components, such as brackets, wires, bands, and ligatures lead to compromised oral hygiene and rapid plaque accumulation which results in demineralization and incipient carious lesions, gingival inflammation, gingival hyperplasia and minimal periodontal disease associated with bone loss.¹

Regular tooth brushing is advised daily to patients undergoing fixed orthodontic therapy to prevent the occurrence of gingival and dental disease. In the present day, a wide variety of toothbrushes are available in the market.² Many innovative design improvements have been introduced to increase the efficacy of a toothbrush for fixed orthodontic patients. Normal orthodontic brushes, interdental brushes (prescribed by some clinicians in addition to orthodontic brushes), battery-powered brushes, etc. are various brushes available for fixed orthodontic patients.

In literature, many studies have been done to compare the effectiveness of manual with powered toothbrushes in fixed orthodontic patients and show conflicting results. Some authors have found powered toothbrushes to be more effective than manual toothbrushes as mechanical cleansing aids in fixed orthodontic patients, while others could not confirm this superior effect or found manual toothbrushes to be superior to electric toothbrushes.^3–8 However, a limited number of studies could be found in the literature that investigated the effectiveness of inter-proximal brushes for orthodontic patients.^9,10 Also the studies comparing the oral hygiene maintenance efficiency between orthodontic toothbrushes, orthodontic toothbrushes supplemented with interdental brushes, and sonic toothbrushes in patients during fixed orthodontic appliance therapy were not observed in literature. The purpose of this study is to evaluate the plaque removal and gingival health maintenance efficiency between orthodontic brush, orthodontic brush supplemented with interdental brush, and sonic power brush in fixed orthodontic patients.

MATERIALS AND METHODS

The study was carried out in patients undergoing fixed orthodontic therapy in the Department of Orthodontics, Annoor Dental College & Hospital, Muvattupuzha, Kerala. A total of 60 participants were recruited into the study and the recruited participants were informed about the study in detail and a written informed consent for the same was obtained.

RESULTS

The comparison of mQHI between the time points for three groups separately by repeated measure ANOVA. For group I, the mean value at T0, T1, T2, T3, and T4 were 2.15, 2.04, 1.97, 1.94, and 1.99, respectively. The calculated F value was 9.783 with p-value < 0.001. So there was a significant difference in mQHI between the time points in group I. For group II, the mean value at T0, T1, T2, T3, and T4 were 2.11, 1.63, 1.47, 1.42, and 1.46, respectively. The calculated F value was 20.119 with p-value < 0.001. So there was a significant difference in mQHI between the time points in group II. For group III, the mean value at T0, T1, T2, T3, and T4 were 1.86, 1.60, 1.55, 1.54, and 1.57 respectively. The calculated F value was 26.137 with p-value < 0.001. So there was a significant difference in mQHI between the time points in group III.

The pairwise comparison of mQHI between three groups at different time points by Dunnett’s post hoc analysis is given in Table 1. At T0, there were no significant differences between all the combinations, since all the p-values > 0.05. At T1, T2, T3, and T4, there was a significant difference between group I and group II, group I and group III, since all the p-values < 0.05. There were no significant differences between group II and group III at T1, T2, T3, and T4, since all the p-values > 0.05 Table 1).

The comparison of the gingival index between the time points for three groups separately by repeated measure ANOVA. For group I, the mean value at T0, T1, T2, T3, and T4 were 0.85, 0.78, 0.76, 0.74, and 0.76, respectively. The calculated F value was 13.901 with p-value < 0.001. So there was a significant difference in the gingival index between the time points in group I. For group II, the mean values at T0, T1, T2, T3, and T4 were 0.67, 0.42, 0.37, 0.35, and 0.37, respectively. The calculated F value was 26.854 with p-value < 0.001. So there was a significant difference in the gingival index between the time points in group II. For group III, the mean values at T0, T1, T2, T3, and T4 were 0.57, 0.44, 0.41, 0.40, and 0.42, respectively. The calculated F value was 15.051 with p-value < 0.001. So there was a significant difference in the gingival index between the time points in group III.

The Pairwise comparison of the gingival index between three groups at each time point by Dunnett’s post hoc analysis is given in Table 2. At T0, there was no significant difference between all the combinations, since all the p-values > 0.05. At T1, T2, T3, and T4, there was a significant difference between group I and group II, group I and group III, since all the p-values < 0.05. There were no significant differences between group II and group III at T1, T2, T3, and T4, since all the p-values > 0.05 Table 2).

DISCUSSION

The results obtained from the present study showed that, in all the three groups compared, a statistically significant reduction in mQHI and gingival index scores was found from baseline to final review. No significant difference in mQHI and gingival index scores was found between the three groups at baseline. However, there was a significant difference found in both indices at other time points, i.e., 3, 6, 9, and 12 weeks within all three groups. A mild increase in mQHI and gingival index scores was found on the final review in all three groups.

On intergroup comparison, no statistically significant differences were detected among mQHI and gingival index scores at baseline between group I, group II and group III. But there was a significant difference found in both indices at 3, 6, 9, and 12 weeks between the three groups. There was a higher reduction in mQHI and gingival index scores found in group II and group III when compared to group I which was statistically significant.

The results showed a slight increase in the parameters on the fourth review which can be attributed to a reduction in the novelty effect. Another factor that may influence the study was the Hawthorne effect, where the participants in the study tend to brush more effectively because they are under observation. An increase in the mQHI and gingival index on the fourth review can also be due to a reduction in the Hawthrone effect.

At present, there are only limited plaque indices developed specifically for fixed orthodontic patients for evaluation of plaque retention.¹¹ Therefore, the present study used a modified Quigley–Hein plaque index which was developed specifically to record plaque around both the brackets and the gingival margin for subjects wearing fixed orthodontic appliances. Since an inflammatory gingival reaction is a common response to plaque retention in subjects with fixed orthodontic appliances, the Loe & Silness gingival index is used to assess the gingival response to plaque.

In this study, a drop out of one participant from each test groups were observed. The dropout of two participants was acceptable and did not influence the results of the study. To avoid any bias due to the difference in oral hygiene maintenance in different fixed orthodontic patients, a chart to assess the oral hygiene performance along with instructions were given to each patients participating in the study.

The results of the present study showed that orthodontic brushes had less oral hygiene maintenance efficiency when compared to orthodontic brushes supplemented with interdental brushes and sonic power brushes. The reason behind this could be the inability of the orthodontic brushes to clean interproximal areas adequately. Because of the better cleaning of interproximal areas by the interdental brushes, the orthodontic brush supplemented with interdental brush showed a superior effect than conventional orthodontic brush. Also, it provides the same cleaning effectiveness as that of a sonic power brush. In sonic brushes, the fluid dynamic activity generated by sonic vibrations removes microbial plaque even at a distance of 3 mm beyond its bristle tips and helps to reach inaccessible areas which is difficult to accomplish with manual brushes.¹² That could be the reason for its better performance in oral hygiene maintenance than conventional orthodontic brushes.

When compared to sonic power brushes, the combination of orthodontic brush and interdental brush is less expensive. The results of our study showed that the groups using orthodontic brush supplemented with interdental brush and sonic power brush have the same oral hygiene maintenance effectiveness and both are superior in oral hygiene maintenance compared to the group using orthodontic brush. Regarding the high cost, the group II using an orthodontic brush supplemented with an interdental brush is cheaper and delivers the same performance as that of group III using a sonic power brush. So, orthodontic brush supplemented with interdental brush can be considered as a better alternative to sonic power brush. Fixed orthodontic patients with a low financial backgrounds can also afford that and get similar oral hygiene maintenance effectiveness as that of sonic power brush.

The studies comparing the oral hygiene maintenance efficiency between orthodontic brush, orthodontic brush in combination with interdental brush, and sonic power brush in fixed orthodontic patients were not found in the literature. The superior effect of powered toothbrushes over manual brushes has been proved in many studies. The studies conducted by Wilcoxon et al., Boyd et al., Biavati et al., Clerehugh et al., Erbe et al., and Bilen et al. found that powered brushes more effectively removed dental plaque than manual toothbrushes.^{3–5,13–15} However, a study by Trimpeneers et al. found manual toothbrushes to be superior to electric toothbrushes.⁸ The studies conducted by Thienpont et al., Hickman et al., Heasman et al., Costa et al., and Sharma et al. found similar oral hygiene maintenance effectiveness for both powered and manual brushes in fixed orthodontic patients.^6,7,11,16,17

Only a few studies compared the effectiveness of orthodontic toothbrushes in combination with interproximal toothbrushes. A study conducted by Arici et al. found that orthodontic toothbrushes in combination with interproximal toothbrushes produced better oral hygiene maintenance effectiveness when compared to orthodontic and manual brushes.⁹ But the results of a systematic review showed that there was no evidence so far for recommending the use of interdental brushes for patients undergoing fixed orthodontic treatment.¹⁰

From this study, we can infer that the conventional orthodontic brush supplemented with interdental brush and sonic power brush has a higher reduction in mQHI and gingival index when compared to conventional orthodontic brush. When comparing the cost-effectiveness, the orthodontic brush supplemented with an interdental brush is definitely a better option than the sonic power brush, because the former which is more economical provides the same oral hygiene maintenance efficiency as the latter. However, the efficiency and relative effectiveness of these toothbrushes should be confirmed through long-term studies and with larger sample size.

CONCLUSION

On intragroup comparison, orthodontic brush, orthodontic brush supplemented with interdental brush, and sonic power brush performed effectively on plaque removal and gingival health maintenance in fixed orthodontic patients. On intergroup comparison, the orthodontic brush supplemented with interdental brush and sonic power brush showed a higher reduction in plaque accumulation and gingival inflammation when compared to the orthodontic brush group. Thus the orthodontic brush supplemented with an interdental brush which has a lower cost when compared to the sonic brush has the same oral hygiene maintenance effectiveness. So, the orthodontic brush supplemented with an interdental brush can act as a better alternative to high-cost sonic power brushes. More studies with larger sample sizes are required for further evaluation.

ORCID

Irin Sebastian https://orcid.org/0000-0002-5580-1521

Gopikrishnan Santhakumar https://orcid.org/0009-0002-8504-7838

Pradeep P George https://orcid.org/0009-0000-2594-2625

Biju Kalarickal https://orcid.org/0009-0003-9267-1812

Joseph Sebastian https://orcid.org/0009-0009-3654-6391

Rahul S Thalanany https://orcid.org/0009-0009-3377-1825

REFERENCES

1. Acharya S, Goyal A, Utreja AK, et al. Effect of three different motivational techniques on oral hygiene and gingival health of patients undergoing multibracketed orthodontics. Angle Orthod 2011;81(5):884–888. DOI: 10.2319/112210-680.1.

2. Naik SP, Punathil S, Shetty P, et al. Effectiveness of different bristle designs of toothbrushes and periodontal status among fixed orthodontic patients: A double-blind crossover design. J Contemp Dent Pract 2018;19(2):150–155. DOI: 10.5005/jp-journals-10024-2229.

3. Wilcoxon DB, Ackerman Jr RJ, Killoy WJ, et al. The effectiveness of a counterrotational-action power toothbrush on plaque control in orthodontic patients. Am J Orthod Dentofacial Orthop 1991;99(1):7–14. DOI: 10.1016/S0889-5406(05)81674-9.

4. Clerehugh V, Williams P, Shaw WC, et al. A practice-based randomised controlled trial of the efficacy of an electric and a manual toothbrush on gingival health in patients with fixed orthodontic appliances. J Dent 1998;26(8):633–639. DOI: 10.1016/s0300-5712(97)00065-1.

5. Erbe C, Klees V, Braunbeck F, et al. Comparative assessment of plaque removal and motivation between a manual toothbrush and an interactive power toothbrush in adolescents with fixed orthodontic appliances: A single-center, examiner-blind randomized controlled trial. Am J Orthod Dentofacial Orthop 2019;155(4):462–472. DOI: 10.1016/j.ajodo.2018.12.013.

6. Sharma R, Trehan M, Sharma S, et al. Comparison of effectiveness of manual orthodontic, powered and sonic toothbrushes on oral hygiene of fixed orthodontic patients. Int J Clin Pediatr Dent 2015;8(3):181. DOI: 10.5005/jp-journals-10005-1310.

7. Thienpont V, Dermaut LR, Van Maele G. Comparative study of 2 electric and 2 manual toothbrushes in patients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop 2001;120(4):353–360. DOI: 10.1067/mod.2001.116402.

8. Trimpeneers LM, Wijgaerts IA, Grognard NA, et al. Effect of electric toothbrushes versus manual toothbrushes on removal of plaque and periodontal status during orthodontic treatment. Am J Orthod Dentofacial Orthop 1997;111(5):492–497. DOI: 10.1016/s0889-5406(97)70285-3.

9. Arici S, Alkan A, Arici N. Comparison of different toothbrushing protocols in poor-toothbrushing orthodontic patients. Eur J Orthod 2007;29(5):488–492. DOI: 10.1093/ejo/cjm038.

10. Goh HH, Mauleffinch LM. Interspace/interdental brushes for oral hygiene in orthodontic patients with fixed appliances. Cochrane Database Syst Rev 2007;3:CD005410. DOI: 10.1002/14651858.CD005410.pub2.

11. Heasman P, Wilson Z, Macgregor I, et al. Comparative study of electric and manual toothbrushes in patients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop 1998;114(1):45–49. DOI: 10.1016/s0889-5406(98)70236-7.

12. Singh G, Mehta DS, Chopra S, et al. Comparison of sonic and ionic toothbrush in reduction in plaque and gingivitis. J Indian Soc Periodontol 2011;15(3):210. DOI: 10.4103/0972-124X.85662.

13. Boyd RL, Murray P, Robertson PB. Effect of rotary electric toothbrush versus manual toothbrush on periodontal status during orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96(4):342–347. DOI: 10.1016/0889-5406(89)90354-5.

14. Biavati AS, Gastaldo L, Dessı M, et al. Manual orthodontic vs. oscillating-rotating electric toothbrush in orthodontic patients: A randomised clinical trial. Eur J Paediatr Dent 2010;11(1):200–202. PMID: 21250772.

15. Bilen YZ, Cokakoglu S, Ozturk F. The short-term effects of manual and interactive powered toothbrushes on the periodontal status of orthodontic patients: A randomized clinical trial. J World Fed Orthod 2021;10(1):14–19. DOI: 10.1016/j.ejwf.2020.11.003.

16. Hickman J, Millett DT, Sander L, et al. Powered vs manual tooth brushing in fixed appliance patients: A short term randomized clinical trial. Angle Orthod 2002;72(2):135–140. DOI: 10.1043/0003-3219(2002)072<0135:PVMTBI>2.0.CO;2.

17. Costa MR, Silva VC, Miqui MN, et al. Efficacy of ultrasonic, electric and manual toothbrushes in patients with fixed orthodontic appliances. Angle Orthod 2007;77(2):361–366. DOI: 10.2319/0003-3219(2007)077[0361:EOUEAM]2.0.CO;2.