The Saudi Journal for Dental Research (2015) 6, 86–90

King Saud University

The Saudi Journal for Dental Research

www.ksu.edu.sa
www.sciencedirect.com

ORIGINAL ARTICLE

Effects of the initial stage of active fixed

orthodontic treatment and sex on dental plaque
accumulation: A preliminary prospective cohort
study
Hamid Rakhshan a, Vahid Rakhshan b,c,*

a
Orthodontist and Periodontist, Tehran, Iran
b
Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences, Tehran, Iran
c
Department of Dental Anatomy and Morphology, Dental Branch, Islamic Azad University, Tehran, Iran

Received 25 July 2014; revised 7 September 2014; accepted 17 September 2014

Available online 14 October 2014

KEYWORDS Abstract Objectives: The aim of this pilot study was to assess the effect of orthodontic treatment
Orthodontics; and gender on plaque index.
Periodontics; Materials and methods: In this prospective cohort study, the O’Leary plaque index of 25 orthodon-
Sex; tic patients was clinically examined before the beginning of treatment (as control) and after the lev-
Dental plaque eling stage (as treatment group). The role of treatment and gender was assessed using two-way
repeated-measure ANOVA, paired and independent-sample t-tests, and Pearson correlation coeffi-
cient (a = 0.05, b 6 0.1).
Results: ANOVA showed a significant increase in plaque index after treatment (P = 0.000), but with-
out any difference between the genders (P = 0.997) or any interaction between the variables gender
and treatment (P = 0.796). There were significant post-treatment increases in plaque index in males
(paired t-test’s P = 0.018) and females (P = 0.000). The plaque indices were not different between
males and females, either before leveling (independent-sample t-test’s P = 0.785) or after it
(P = 0.880). There were no correlations between patients’ gender and either of pre- or post-treatment

* Corresponding author at: #22 Behruzi Alley, Karegar St., PO Box

14188-36783, Tehran, Iran. Tel.: +98 2166929055.
E-mail address: vahid.rakhshan@gmail.com (V. Rakhshan).
Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

http://dx.doi.org/10.1016/j.sjdr.2014.09.001
2352-0035 ª 2014 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
Effect of orthodontic treatment and gender on plaque index
PI levels (both r statistics < 0.06, both P values > 0.83). However, the correlation between pre- and
post-treatment plaque indices was significant (r = 0.623, P = 0.001).
Conclusion: Initial stage of active fixed orthodontic treatment can cause considerable dental plaque
accumulation, similarly in men and women.
ª 2014 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
1. Introduction
Fixed orthodontic therapy is a risk factor for plaque accumula-
tion, because of the increases in the retention areas and disrupt-
ing the oral hygiene maintenance.1–4 Dental plaque is a highly
complex bacterial structure which when accumulated, shifts to
gram-negative anaerobic or facultative species which can cause
periodontal disease.1,4 Besides, it can cause white spot lesions,
which is again an unfavorable complication.5,6 Gingival and
periodontal inflammations might disrupt the desired effect of
orthodontic treatment by the loss of periodontal connective tis-
sue attachment and inhibiting the remodeling.7 Besides, gingi-
val damage can worsen during orthodontic treatment.1,8
Therefore, assessment of dental plaque is necessary in patients
undergoing fixed orthodontic treatment.4
Plaque accumulation caused by orthodontic treatment is
assessed in some studies.2,4,9–13 Most studies on this subject
have evaluated the effect of hygiene control measures during
treatment, not the effect of treatment itself.12,14 Although some
studies agree that plaque aggregation increases by fixed ortho-
dontic treatment,2 some studies have not found increases.10,15
This controversy might be attributed to the study durations
and educations given to patients.
Adults are much more prone to periodontal problems than
children.1,16 This implies the need to assess the subject in
adults.13,14 Moreover, most previous studies have used the Sil-
ness and Löe plaque index.4,17 This index is one of the most con-
venient ones; however, it cannot accurately discriminate the
condition of plaque accumulation.4 Therefore, the assessment
of this topic using other common indices that might give a more
objective view of the plaque might be of value. Furthermore, it
is not known if the problem of plaque accumulation is more
serious in males or females, although few studies have suggested
that males might have poorer oral hygiene.15,18 Hence, assessing
the role of sex is helpful in better understanding the topic.
Due to the abovementioned controversies and shortcom-
ings, this study was conducted to prospectively evaluate the
changes in the plaque coverage area (estimated by the O’Leary
plaque index)19 after the active initial stage of active fixed
orthodontic treatment (leveling and alignment) in young adults
and adults, and also between the sexes. The null hypotheses
were (1) there is no difference between the plaque index before
and after the treatment; (2) there is no difference between the
changes of plaque index in men and women; (3) the effect of
treatment is similar.
2. Subjects and methods
This preliminary prospective cohort study was conducted in
the Graduate School Clinic at the Manila Central University
(MCU). The sample of this study comprised 50 repeated
(before/after) observations. These 50 observations were
87
acquired from a cohort of 25 Filipino patients undergoing the
initial stage of fixed active orthodontic treatment from the
beginning. Of the samples, 7 were males and 18 were females.
The patients were young-adults and adults (aged 18 – 32).
The institutional review board of the Faculty of the Graduate
School of the Manila Central University approved the study
design. Written consent forms were acquired from all the par-
ticipants. Preliminary interviews using Inclusion/Exclusion cri-
teria as well as dental check-ups were conducted with the
respondents. Their dental and other health history recorded
to ascertain patients’ systemic and oral health. Exclusion and
Inclusion criteria specified in this study was used to guide the
random selection of respondents. Framing of sample was con-
ducted from before the start of patients’ strap-ups until the end
of their initial orthodontic treatment, the leveling stage (3–
6 months). Specifically, those included in the study satisfied
all three requirements herein enumerated: (1) Healthy oral
and gingival conditions prior to receiving the fixed labial ortho-
dontics. This was confirmed in the information record pre-
sented by the patient who signed the consent form which thus
prompted the beginning of treatment. (2) The absence of any
prior hospitalization or intake of medicines during the conduct
of this study. (3) No systemic health issues or risk factors which
can affect their oral health conditions during orthodontic treat-
ment. Explicitly, the Inclusion criteria were patients’ willing-
ness to participate, them being systemically healthy, non-
smoker, literate, having no more than 2 extraction sites before
the admission, having healthy normal gait and postures. As the
Exclusion criteria patients, participants were reported not to
have any gingival or periodontal disease prior to their ortho-
dontic treatment, although during course of orthodontic treat-
ment some patients showed signs and symptoms of mild
periodontitis or moderate to severe gingivitis due to poor oral
hygiene and resulted in oral inflammatory reactions. The other
Exclusion criteria were any removable orthodontic appliances,
any diseases or syndromes or signs/symptoms of temporoman-
dibular disorders, contraindications for radiography, being
heavy drinker or smoker, taking any NSAID medication, hos-
pitalization or hormone therapy during the past 6 months prior
to the study, being pregnant or nursing mothers, and other hor-
monal imbalances such as goiter or hyperthyroidism.
2.1. Orthodontic treatment
The leveling and alignment phase of fixed orthodontic treat-
ment lasted for 3–6 months and was carried out using merely
fixed appliances with the minimum possible forces exerted by
frictionless round nickel titanium archwires.
2.2. O’Leary plaque index (PI)
The O’Leary plaque index (PI)19 was measured for 25 patients
before fitting the brackets and after the initial phase of active
88 H. Rakhshan, V. Rakhshan

2.3. Statistical analysis and power calculation

Table 1 Pre- and post-treatment plaque indices (%) in the 25
patients.
The sample size sufficed to obtain test powers greater than
Gender Patient PI before leveling PI after leveling
90% (a = 0.05, b 6 0.1) for a paired-sample t-test. Descriptive
Males 1 20 57 statistics were calculated. The normality of sample distribu-
2 15 32 tions was confirmed in both groups, using the Shapiro–Wilk
3 12 56
normality test (both P values > 0.23). After the assessment
4 25 35
5 33 40
of the test assumptions, the data were analyzed using a two-
6 11 32 way repeated-measured analysis of variance (ANOVA), paired
7 25 59 and independent-sample t-tests, and a Pearson correlation
coefficient of SPSS 20.0 (IBM, US). The level of significance
was set at 0.05.
Females 8 10 25
9 12 55
10 20 60 3. Results
11 15 37
12 22 47 Of the 25 patients, 20%, 20%, 24%, 28%, and 8% were in age
13 22 70 groups [18–20], [21–23], [24–26], [27–29], and [30–32], respec-
14 12 22
tively. The plaque index doubled, from a baseline value of
15 26 43
16 18 56
19.60 ± 8.02 to 45.00 ± 16.44 after the leveling stage (Tables
17 19 51 1 and 2).
18 32 55 The paired t-test showed that the increase in plaque index
19 31 55 was significant both in males (P = 0.0040) and females
20 11 20 (P = 0.0000, Tables 1 and 2). The independent-sample t-test
21 5 16 showed that there were no significant differences between
22 14 29 males and females either before treatment (P = 0.84) or after
23 32 65 it (P = 0.91, Table 1).
24 18 32 The two-way repeated-measure ANOVA indicated a signif-
25 30 76
icant increase in plaque index level after treatment
(P = 0.0000). However, the difference between the genders
and the interaction of gender (P = 0.997) and treatment
effects (P = 0.796) were non-significant.
fixed orthodontic treatment (i.e., the leveling and alignment).
The Pearson correlation coefficient indicated that there
Prior to the PI assessment, the tooth surfaces were stained
were no correlations between patients’ gender and either of
by a disclosing solution as a medium to visualize the invisible
pre- or post-treatment PI levels (both r statistics < 0.06, both
dental plaque accumulation on each subject’s teeth. For plaque
P values > 0.83). However, the correlation between pre- and
index calculation, the cumulative values of only the stained
post-treatment plaque indices was significant (r = 0.623,
surfaces of bracketed teeth were divided by the total teeth sur-
P = 0.001).
faces with brackets in each subject. The result was multiplied
by 100 for the percentage of PI in each individual.15,18,19
The first record of PI (control) was taken before the fixed 4. Discussion
appliances were placed, and the second record (treatment)
was taken after successfully finishing the initial phase of ortho- By correcting the malocclusion (as the third most common
dontic therapy (leveling) which lasted between 3 and 6 months oral health issue),18,20 orthodontic treatment might improve
from the treatment initiation (on a case by case basis). In the patients’ physiologic, functional, esthetic, psychological, and
beginning and during the treatment, the patients were notified social health.18,21,22 Nonetheless, orthodontic treatment might
regarding the changes in the oral plaque due to bracket place- also hold some potential harm such as apical root resorption
ment, and their need to improve their oral hygiene to avoid of the moved teeth, enamel demineralization leading to the for-
white spots, etc. (as routine treatment protocol). mation of caries or white spots under or adjacent to brackets,

Table 2 Descriptive statistics for PI levels (in percentage).

n Mean SD Min Median Max CV (%) 95% CI
Female 18 Control 19.39 8.23 5.0 18.5 32.0 42.4 15.6 23.2
Treatment 45.22 18.08 16.0 49.0 76.0 40.0 36.9 53.6
Male 7 Control 20.14 8.05 11.0 20.0 33.0 40.0 14.2 26.1
Treatment 44.43 12.39 32.0 40.0 59.0 27.9 35.2 53.6
Sample 25 Control 19.60 8.02 5.0 19.0 33.0 40.9 16.5 22.7
Treatment 45.00 16.44 16.0 47.0 76.0 36.5 38.6 51.4
Min, minimum; Max, maximum; CV, coefficient of variation; CI, confidence interval for the mean.
Effect of orthodontic treatment and gender on plaque index
allergic reactions or systemic metal accumulation due to dis-
charge of toxic and carcinogenic metal ions from orthodontic
alloys, iatrogenic damages to enamel during bracket debonding
or procedures of bonding removal, and gingival or periodontal
problems.18,23–26 The plaque control is a critical factor that
might limit the implantation and settling of causal microorgan-
isms from caries and periodontal disease, and orthodontic
therapy might make it difficult causing plaque accumulation
and gingival inflammation.18,27 The findings of this study as
well indicated that dental plaque might increase during ortho-
dontic treatment. This was in line with experiments on the
active stage of treatment,2,9–13 because of the role of orthodon-
tic appliances in protecting the plaque from the mastication,
the tooth brushing action, and the salivary fluid.18 By review-
ing previous articles, Bollen et al.27 suggested that orthodontic
therapy might be associated with 0.03 mm of gingival reces-
sion, 0.13 mm of alveolar bone loss, and 0.23 mm of increased
pocket depth. However, the evidence was not strong.27 In our
study, gender did not have a significant effect on the plaque
accumulation, in contrast to some studies in which plaque
was more accumulated in males.15,18 There might exist
different factors affecting the role of gender, such as the larger
salivary glands in men and the female hormonal pattern that
might reduce saliva and increase plaque accumulation in
women.27 Future studies should assess this issue, as the current
literature consists of few studies.15,18
This pilot study was limited by some factors. A larger sam-
ple could favor the reliability and generalizability. It should be
noted however that the current sample of 25 · 2 highly matched
observation already sufficed to obtain a very high power. It
should be noted that excessively increasing the sample size
without considering the very high power it produces, can lead
to obtain false positive errors.28 Besides, as a prospective study,
the number of patients was close to other prospective
researches.2,13 Another constraint was the differences between
treatment plans,29 which might affect the accumulated plaque.
Future studies should also take into account enrolling ortho-
dontic patients from other age groups. Besides, additional clin-
ical parameters of gingival inflammation such as probing depth
should be assessed in further studies. Future original studies
should also establish the intrarater agreement by evaluating a
part of the sample for twice. However, the very high correlation
found between the pre- and post-treatment plaque indices still
confirmed the reliable method of measurement. Some research-
ers frequently used plaque indices which do not require staining
the teeth, such as the plaque index of Silness and Löe.17 These
are more convenient to use and possibly more acceptable to
patients, but for orthodontic patients they have disadvantages
such as for patient education. Identification of invisible dental
plaque is not as quick and easy for the clinician’s record mak-
ing. Moreover, because plaque is not stained, it is not high-
lighted for the patient to see and remove. That is why this
study used O’Leary index, through the use of disclosing solu-
tion which can easily mask the dental biofilm plaques which
can be easily recorded by naked eyes and demonstrate or exam-
ine the influences of orthodontic brackets on plaque accumula-
tion and relate it with involved pain due to the degree of
gingival inflammations among the orthodontic patients. It is
also recommended to apply newer plaque indices particularly
designed to investigate the plaque around brackets as well. A
good approach is to take photographs of teeth.2,5 This method
might improve several aspects. The pictures are permanently
89
available and enable future double evaluations.4 Although this
method might take longer to accomplish, new technologies
might reduce this time considerably. For example automatic
landmark identification programs might facilitate this pro-
cess.4,30 However with every method, measurement of plaque
coverage area is affected by subjective bias,4 although auto-
matic computed approaches might reduce or eliminate this.5,30
Future studies should assess pain in other stages of orthodontic
treatment such as canine retraction or finishing and detailing,
as some investigators reported decrease in plaque index in
longer durations (such as 2 years), which was due to the
improvement of plaque control through patient education
and plaque monitoring.13,15 Furthermore, other clinical param-
eters of gingival inflammations and periodontal disease activity
such as bleeding on probing, mobility, pocket depth, bleeding
index, etc. should be assessed. Furthermore, enrolling patients
from other age groups as well as considering other risk factors
such as smoking, hormonal imbalances should be evaluated.
5. Conclusion
Within the limitations of this pilot study, it was concluded that
the active stage of orthodontic therapy can cause considerable
dental plaque accumulation, regardless of adult or adolescent
patients’ gender. Given the potential problems caused by this
factor, more emphasis should be placed on hygiene mainte-
nance of adult patients under orthodontic treatment.
Conflict of interest
None declared.
Acknowledgment
The authors wish to express their sincere gratitude to Prof.
Federico M. Nadela for his valuable advice.
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