| Abstract|| |
Aim: Awareness on oral hygiene is important during the orthodontic phase. The aim of the present study was to assess the effectiveness of an oral hygiene program (knowledge, attitude, and practice of oral hygiene) for patients seeking fixed orthodontic treatment. Evaluating the knowledge, attitude, and practice on gingival health was the aim of the present study.
Materials and Methods: The sample consisted of 150 patients who had a full complement of permanent dentition. One hundred and fifty orthodontic patients from the Department of Orthodontics and Dentofacial Orthopedics, Rural Dental College, Loni, Maharashtra, India were included in the questionnaire study. Questions were based on the knowledge, attitude, and practice on oral hygiene, i.e., gingival health at the time of orthodontic treatment. All answers were recorded and analyzed statistically.
Results: The results of the study showed that nearly 50% of the patients were unaware about gingival health, 78% did not follow the oral hygiene instructions, and despite being given instructions, most of them were reluctant in practicing them strictly. It was very good that all patients used the toothbrush as an aid used to clean teeth and 72% of the patient did not have any previous dental exposure.
Conclusion: The knowledge, attitude, practice of oral hygiene among orthodontic patients were poor and showed the need of better education and motivation. Many factors may be responsible for the non-maintenance of gingival health practices. There is a need to incorporate and evaluate more intense oral hygiene programs in the future.
Keywords: Gingiva, oral hygiene, orthodontic correction
|How to cite this article:|
Baheti MJ, Toshniwal NG. Survey on oral hygiene protocols among orthodontic correction-seeking individuals. J Educ Ethics Dent 2015;5:8-13
|How to cite this URL:|
Baheti MJ, Toshniwal NG. Survey on oral hygiene protocols among orthodontic correction-seeking individuals. J Educ Ethics Dent [serial online] 2015 [cited 2019 Jul 18];5:8-13. Available from: http://www.jeed.in/text.asp?2015/5/1/8/178020
| Introduction|| |
Orthodontic treatment is widely acknowledged and accepted in everyday dental practice due to the positive effects it has on dentofacial complex. With fixed orthodontic appliances, clinicians can offer patients the establishment of functional occlusion, improvement of oral health, and aesthetic improvement of dentofacial complex. Anomalies in development of the face and jaws as well as orthodontic treatment can influence oral health. Deviations from an ideal arrangement and position of teeth (lack of space, tooth rotation or open bite, a deep bite, and cross-bite) facilitate dental plaque accumulation. It has to be pointed out that malocclusion is not a primary etiological factor but an auxiliary factor, which facilitates dental plaque accumulation. The main principle of orthodontic therapy is to correct tooth and jaw position and thus, indirectly improve the health of the periodontium and durability of teeth. 
By accepting an orthodontic treatment, a patient makes a firm commitment to maintain oral hygiene regularly and thus, prevent potential iatrogenic damages, which may occur during therapy. Importance of oral hygiene in orthodontic patients is always intensified to prevent any further periodontal disease. Numerous studies show a significant increase in the quantity of dental plaque as well as the occurrence of gingivitis in patients with fixed orthodontic appliances because they make removal of dental plaque difficult.  Fixed orthodontic appliances, such as orthodontic braces, arches, and rings increase the number of retention places for dental plaque accumulation. All these factors make it even more difficult to maintain oral hygiene.  Self-cleaning is also more difficult because of the reduced effect of mechanical chewing and rinsing the food residues off by saliva. All preventive programs referring to the prevention and treatment of gingivitis and parodontopathy include regular removal of dental plaque as a part of an adequate daily oral hygiene.
The following factors are necessary for adequate oral hygiene: Adequate devices (equipment), correct technique of using those devices, regular toothbrushing, and sufficient length of brushing every single tooth. Recommendations for adequate devices for oral hygiene maintenance include the following factors: Specific needs of patients (disease predisposition or state of the mouth) and individual characteristics (age, affinities, manual dexterity, or lifestyle). All these factors should be adjusted to individual patients in order to enable perfect oral hygiene at home. Individual preventive programs should be implemented for patients with fixed orthodontic appliances and they should, apart from health education, include education about the importance of regular and correct oral hygiene maintenance and checkups. Patients need to be demonstrated the correct technique and frequency of toothbrushing. They also need to learn about the right toothbrushes, interdental and orthodontic brushes as well as about auxiliary devices for oral hygiene maintenance (adequate toothpaste and mouthwash). 
Active cooperation of orthodontic patients is essential over a prolonged treatment and involves keeping appointments and the maintenance of an adequate level of oral hygiene and refraining from hard and sticky foods.  The choice of patients, education, and training about a regular and correct oral hygiene maintenance together with preventive and prophylactic measures and patients' motivation will increase the comfort of patients undergoing orthodontic therapy and contribute to the functional and aesthetic success of it. Regular oral hygiene maintenance is of great importance for the preservation of gingival health until the end of orthodontic therapy as well as after its ending. Apart from having a regular dental arch, the habit of regular oral hygiene will help preserve the health of the gingiva and contribute to lifelong oral health. 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 the patients themselves. Patients not given proper instructions  may be one big reason for their non-compliance. However, despite receiving appropriate instructions, many individuals fail to follow instructions; also, many of them lack knowledge on maintenance. During a fixed orthodontic appliance therapy, the technique and duration of toothbrushing and constant motivation of patients are key factors of oral hygiene maintenance. It is always needed to assess the knowledge of orthodontic patients on oral hygiene.
The aim of this study was to assess the knowledge, attitude, and practice of oral hygiene protocols among orthodontic patients.
| Materials and Methods|| |
Study design: Questionnaire
The present survey was conducted by simple random sampling method; around 150 orthodontic patients were selected from the Department of Orthodontics and Dentofacial Orthopedics, Rural Dental College, Loni, Maharashtra, India for the questionnaire survey study. Both male and female patients were included.
Both open- and closed-ended questions were included in the questionnaire survey. To assess awareness on gingival health, the questionnaire covered knowledge on gingival health, practices of oral hygiene, and attitude toward dental treatment. Questions were given with answer choices that were easily understandable and brief in manner. The questionnaire was given to all the selected patients to complete the answers, with prior explanation to fill the questionnaire. One investigator was available while filling the questions, and participants were encouraged to approach the investigator for any clarification. All answers were kept confidential, and no individual patient was identified. Patients who completed their minimum of 6 months of orthodontic treatment were included in the survey.
The study was conducted from December 2013 to July 2014, with a questionnaire with open- and closed-ended questions, which consisted of 13 questions assessing the awareness of gingival and oral health and the attitude of orthodontic correction-seeking individuals treating in Rural Dental College, Loni, Maharashtra, India. The inclusion criteria were patients treating for orthodontic malocclusion more than 4 months and should be on fixed appliances.
Ethical clearance was obtained from the institutional review board of Pravara Institute of Medical Sciences (PIMS) Ethical Committee.
All answers were collected and recorded. All recorded data were statistically analyzed using Statistical Package for the Social Sciences (SPSS) version 15 data analyzer (IBM company, Armonk, New York). Chi-square test was used and the level of significance was P < 0.05.
| Results|| |
The study was conducted to assess the knowledge of gingival health, attitude, and practice of oral hygiene among orthodontic patients around 150 orthodontic patients from the Department of Orthodontics and Dentofacial Orthopedics, Rural Dental College, Loni, Maharashtra, India. Chart 1 [Additional file 1] shows that the participant population sample consisted of 60% of the 13-20-year-old age group population, 32% of the 21-28-year-old age group, and 8% of those more than 28 years. Chart 2 [Additional file 2] shows knowledge on gingival health −52.77% of the participants felt that they saw their gingiva in a good condition after the starting of orthodontic treatment, 34.16% of the participants felt that their gingiva was in a fair condition, and 13.05% of the participants felt that they see their gingiva was in a bad condition after the starting of orthodontic treatment. Chart 3 [Additional file 3] shows that the effects of prolonged brushing were known by only 8.5% while most of them (91.5%) were not aware of the effects of prolonged brushing. as shown in the survey. Also, nearly 5.7% on the study felt halitosis in the oral cavity. Only 28% of the individuals had previous dental exposure before this orthodontic treatment and 21.33% of the individuals followed the oral hygiene instruction strictly [Table 1]. 91.33% of the individuals used toothpaste and 8.66% used toothpowder for cleaning teeth and most of them brushed twice daily. Regarding other oral hygiene practices, only 31.33% of the individuals used mouthwash in their oral hygiene practice and 22.66% of the individuals used interdental toothbrush as a cleaning aid during orthodontic treatment [Table 1].
31.33% used soft type of bristle, 58.66% used medium type of bristle, and 10% used hard type of bristle. Oral hygiene index (OHI) reiterates bedtime brushing importance; more than two-third (86%) brushed twice daily. 60.66% changed their brushes in 1-3 months interval, 31.33% changed their brushes in 3-6 months interval, and 8% changed their brushes in more than 6 months [Table 2]. Among mouthwash users, 65.95% used mouthwash once daily and 34% used it twice a day. Regarding the usage of mouthwash, 57.44% used it when needed, 25.53% used it once daily after brushing, and 17.02% used it when there was no brushing [Table 3]. Among those who used the interdental toothbrush, 64.70% used the interdental brush once daily, 23.52% used it more than once, and 11.76% used it sometimes. 76.47% used the interdental toothbrush after meals and 23.52% used it when needed [Table 4].
| Discussion|| |
The periodontal status of patients receiving fixed orthodontic appliances has been the focus of attention, both by orthodontists and periodontists. It is believed that greater plaque retentive nature of orthodontic appliances aid in plaque accumulation at the gingival margins, contributing to gingival inflammation ,,,, Monitoring of gingival status and periodontal status by orthodontists throughout the treatment period and enforcement of an acceptable oral hygiene program have become an integral part of modem orthodontic treatment. ,
Mostly young patients are referred for orthodontic treatment and they often suffer from plaque-related gingivitis. An obvious sign of periodontal disease in adults is a hindrance to being referred for orthodontic treatment. Almost every fixed orthodontic patient develops gingival disease at some time during treatment period.  Gingival enlargement and inflammation are often transient and resolve within weeks of deband. Contemporary bonded orthodontic appliances cause less gingivitis than banded appliances.  Adolescents have certainly been shown to suffer worse gingivitis than adults during orthodontic treatment. 
The primary aim before any orthodontic intervention is to stabilize the periodontal condition.  Stable gingival health status throughout the orthodontic treatment would deliver accurate treatment result. Delivering proper instructions on gingival health maintenance to orthodontic patients plays a vital role in this aspect. Motivating and making orthodontic patients practice oral hygiene measures at a young age group will certainly enhance the levels of oral hygiene standards. , It takes a lot of patience, effort, and time for the patients with fixed orthodontic appliances to master a quality technique of toothbrushing. At the beginning, it takes up to 15 min or 20 min to brush teeth if three different brushes are used. In time, when patients master the technique of performing oral hygiene, the duration of toothbrushing shortens. Many patients do not exactly know how to maintain high oral hygiene standards, which may be conducive to excellent orthodontic treatment outcome.  Proper brushing is ideal for good gingival health while prolonged brushing may distort the gingival tissues. Wasting diseases such as abrasion are mainly caused by improper brushing. A study by Dr. Elanchezhiyan et al.  showed that the effects of prolonged brushing were known by only 8.5% while 91.5% were not aware of the effects of prolonged brushing as shown in the survey. Nearly 5.7% felt halitosis in the study. In this study, the effects of prolonged brushing were known by only 7% while most of them (93%) were not aware of the effects of prolonged brushing as shown in the survey. Also, nearly 33% felt halitosis in the study. On awareness of gingival health, very few comparatively had awareness while most of them were not aware of it.
Attitude toward dental exposure
Among all participants, 28% only had previous dental exposure while 72% did not have any experience. Among those having exposure, only 42.85% underwent scaling, which was once only while the others had not experienced any professional cleaning. Following and maintaining OHI will be a vital part in gingival health status; despite given proper instructions, noncompliance of instructions by patients may be the reason for tissue destruction. In the survey, only 21.33% of the persons followed the instructions in a strict manner; the major portion (67.33%) followed instructions but very often a certain portion of patients (11.33%), even when given proper instructions, were not concerned about it.
The study showed some good signs as all were using the toothbrush, 91.33% of the individuals were using toothpaste, and 8.66% of the individuals were using toothpowder for cleaning teeth, and most of them brushed twice daily. Because this study was conducted in a rural place, some people used toothpowder as a cleaning aid. Regarding other oral hygiene practices, in a study by Berlin-Broner et al.  only 31.5% used mouthwash as an oral hygiene aid while in this study, only 31.33% of the individuals used mouthwash in their oral hygiene practice and 22.66% of the individuals used interdental toothbrush as a cleaning aid during orthodontic treatment.
Practices of oral hygiene maintenance
The study showed that all individuals used the mechanical type of toothbrush for cleaning teeth. In the study, 31.33% used the soft type of bristle, 58.66% used the medium type of bristle, and 10% used the hard type of bristle. OHI reiterates the importance of bedtime brushing; more than two-third (86%) brushed twice daily and 6% brushed thrice daily, which showed a good aspect. Regarding brush change, if the bristles had worn out as indicated by OHI, nearly 60.66% changed their brushes in 1-3 months interval and 31.33% changed their brushes in 3-6 months interval. Few (8%) took more than 6 months to change their brushes as shown by the study that indicate concern regarding gingival health. Among mouthwash users, 65.95% used mouthwash once daily and 34% used it twice a day. Regarding the usage of mouthwash, 57.44% used it when needed, 25.53% used it once daily after brushing, and 17.02% used it when no brushing was done. Somewhat similar findings were noted by these authors in another study. 
Among those who used the interdental toothbrush, 64.70% used it once daily, 23.52% used it more than once, and 11.76% used it sometimes. 76.47% used the interdental toothbrush after meals and 23.52% used it when needed.
The survey indicated that the individuals' knowledge on their gingival health was poor, in that many of them were not aware of gingival diseases, gum problems, and the effects of prolong brushing. All were using toothpaste, brush, and nearly 2/3 brushed twice daily that indicated a good aspect of oral hygiene maintenance. Many (65.5%) practicing scrub method of brushing indicated inadequate knowledge on oral hygiene practice and the need for more intense OHI delivery and motivation. Also, the survey indicated that only less than 1/3 (28%) had previous dental exposure, which showed that look alone acted as an important factor that drove individuals to orthodontic correction and they were not aware of or concerned about other dental issues. The duty of an orthodontist or dental surgeon, whom the patients approach for orthodontic corrections, will be instructing and motivating individuals in oral hygiene practices. Following of instructions is the most important aspect in gingival health management; following was inadequate since nearly 67.33% of the persons were found to be following the instructions very often but not strictly. The study conducted by Fredrik Lundstrom, Sven-Erik Hamp, and Sture Nvman  also supports somewhat similar findings.
The final picture of this study gives inadequate awareness and inappropriate practice of oral hygiene among orthodontic patients. The need for educating and motivating orthodontic patients on oral hygiene is elicited by the end of the study.
| Conclusion|| |
The knowledge, attitude, and practice of oral hygiene among orthodontic patients showed the need for better education and motivation. Many factors may be responsible for the non-maintenance of gingival health practices. There is a need to incorporate and evaluate more intense oral hygiene programs in the future. Extra attention should be given in educating and motivating the patients on oral hygiene practices during orthodontic treatment in a proper manner, which will definitely be helpful to the patients in maintaining their gingival health and oral hygiene.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bimstein E, Becker A. Malocclusion, orthodontic intervention, and gingival and periodontal health. In: Van Dyke TE, editor. Periodontal and Gingvinal Health and Diseases. London: Martin Dunitz Ltd; 2001. p. 250-90.
Thornberg MJ, Riolo CS, Bayirli B, Riolo ML, Van Tubergen EA, Kulbersh R. Periodontal pathogen levels in adolescents before, during, and after fixed orthodontic appliance therapy. Am J Orthod Dentofacial Orthop 2009;135:95-8.
Krishnan V, Ambili R, Davidovitch Z, Murphy NC. Gingiva and orthodontic treatment. Semin Orthod 2007;13:257-71.
Matić S, Ivanović M, Mandić J, Nikolić P. Possibilities to prevent gingivitis during fixed orthodontic appliance therapy. Stom Glas S 2008;55:122-32.
Becker A, Shapira J, Chaushu S. Orthodontic treatment for disabled children - A survey of patient and appliance management. J Orthod 2001;28:39-44.
Alstad S, Zachrisson BU. Longitudinal study of periodontal condition associated with orthodontic treatment in adolescents. Am J Orthod 1979;76:277-86.
Yeung SC, Howell S, Fahey P. Oral hygiene program for orthodontic patients. Am J Orthod Dentofacial Orthop 1989;96:208-13.
Sinclair PM, Berry CW, Bennett CL, Israelson H. Changes in gingiva and gingival flora with bonding and banding. Angle Orthod 1987;57: 271-8.
Anderson GB, Bowden J, Morrison EC, Caffesse RG. Clinical effects of chlorhexidine mouthwashes on patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop 1997;111:606-12.
Kilicoglu H, Yildirim M, Polater H. Comparison of the effectiveness of the two types of toothbrushes on the oral hygiene of the patients undergoing orthodontic treatment with fixed appliances. Am J Orthod Dentofacial Orthop 1997;111:591-4.
McGlynn FD, LeCompte EJ, Thomas RG, Courts FJ, Melamed BG. Effects of behavioral self-management on oral hygiene adherence among orthodontic patients. Am J Orthod Dentofacial Orthop 1987;91:15-21.
Zachrisson S, Zachrisson BU. Gingival conditions associated with orthodontic treatment. Angle Orthod 1972;42:26-34.
Zachrisson BU, Zachrisson S. Gingival conditions associated with partial orthodontic treatment. Acta Odont Scand 1972;30:127-36.
Boyd RL, Baumrind S. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissue versus those of adolescents. Angle Orthod 1992;42:117-26.
Hamp SE, Lundström F, Nyman S. Periodontal conditions in adolescents subjected to multiband orthodontic treatment with controlled oral hygiene. Eur J Orthod 1982;4:77-86.
Boyd RL, Murray P, Robertson PB. Effects of rotary toothbrush versus manual tooth brush on periodontal status during orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:342-7.
Polson AM, Subtelny JD, Meitner SW, Polson AP, Sommers EW, Iker HP, et al
. Long-term periodontal status after orthodontic treatment. Am J Orthod Dentofacial Orthop 1988;93:51-8.
Eliasson LA, Hugoson A, Kurol J, Siwe H. The effects of orthodontic treatment on periodontal tissues in patients with reduced periodontal support. Eur J Orthod 1982;4:1-9.
Sundaram E, Raja. Awareness on gingival health among orthodontic correction seeking individuals. JIADS 2011;1:19-21.
Berlin-Broner Y, Levin L, Ashkenazi M. Awareness of orthodontists regarding oral hygiene performance during active orthodontic treatment. Eur J Paediatr Dent 2012;13:187-91.
Zhao H, Xie Y, Meng H. Effect of fixed appliance on periodontal status of patients with malocclusion. Zhonghua Kou Qiang Yi Xue Za Zhi 2000;35:286-8.
Lundström F, Hamp SE, Nyman S. Systematic plaque control in children undergoing long term orthodontic treatment. Eur J Orthod 1980;2:27-39.
Mayuresh J Baheti
Department of Orthodontics and Dentofacial Orthopedics, Rural Dental College, Pravara Institute of Medical Sciences, Loni - 413 736, Maharashtra
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]