Impact of Bracket Design and Oral Hygiene Maintenance on Halitosis in the Orthodontic Patient
Condition: Halitosis; Oral Hygiene
MeSH terms: Halitosis
Study type: Interventional

Summary: 
      The advantage of self-ligating brackets on periodontal health has yet to be determined. In
      addition, the utilization of tongue scraping as an adjunct to traditional oral hygiene
      measures has yet to be studied in orthodontic patients. The aim of this study is to evaluate
      the effect of bracket type on plaque accumulation and also the impact of the appliance on
      oral malodor. In addition, the effect of tongue scraping on halitosis will be studied in
      patients undergoing orthodontic treatment. We hypothesize that self-ligating brackets will
      harbor less plaque than normal brackets, that tongue scraping will significantly decrease
      halitosis in patients undergoing orthodontic treatment and that patients with self-ligating
      brackets will exhibit less halitosis as measured by halimeter.
    

Detailed description: 
      Background

      Halitosis refers to the condition of malodor of the oral cavity (2009). Halitosis is
      estimated to affect 50% of the population with varying degrees of intensity and etiology
      (Meskin 1996). In 80% of all cases halitosis is secondary to underlying oral conditions
      (Miyazaki, Sakao et al. 1995).The etiology of halitosis is often caused by food debris and
      biofilm buildup on the teeth and tongue, deep periodontal pockets, severe carious lesions and
      poor dental restorations (Yaegaki and Sanada 1992; Morita and Wang 2001; Morita and Wang
      2001). The odor emanating from the oral cavity is produced by microbial putrefaction of
      residual oral debris, resulting in production of malodorous Volatile Sulfur Compounds (VSCs)
      (Porter and Scully 2006). Previous studies have shown that the amount of VSCs in breath
      increases with the number, depth, and bleeding tendency of the periodontal pockets (Quirynen,
      Zhao et al. 2002). Therefore plaque control, which directly impacts periodontal health, is an
      important factor in the control of halitosis.

      Halitosis can be diagnosed by 3 primary methods (Yaegaki and Coil 2000; van den Broek,
      Feenstra et al. 2007)

        1. Organoleptic method: The primary reference standard for the detection of oral malodor is
           the human nose and this method involves direct sniffing of the expired air by a trained
           judge. This assessment can also be done by scraping the posterior dorsum of the tongue
           with a spoon and smelling the contents.

        2. Gas chromatography: This is the method of choice for researchers. It allows for the
           identification and quantification of individual components within the air sample. The
           measurement of VSC can be obtained and differentiated with using samples from saliva,
           tongue coating and breath. Disadvantages to this method are high cost and the
           requirement of highly trained personnel. This assessment cannot be done chairside and
           requires a separate laboratory procedure.

        3. Sulfide monitoring: This method is superior to gas chromatography in that it is possible
           to measure total VSC instead of determining individual compounds. An electrochemical
           reaction occurs with the sulfur compounds found in the expired air, which is collected
           from a tube in the patient's mouth. The halimeter (Interscan Corporation, Chatsworth CA)
           is the most recognized device for sulfide monitoring.

      Management of halitosis is approached through three primary methods: masking products,
      mechanical reduction of micro-organisms and their substances and chemical reduction of
      microorganisms (van den Broek, Feenstra et al. 2008). Masking products like mint and flavored
      chewing gum has only a short masking effect, lasting less than 3 hours (Reingewirtz, Girault
      et al. 1999). Clinical studies examining the mechanical reduction of microorganisms revealed
      that brushing the teeth exclusively was not effective in reducing oral malodor (Yaegaki and
      Sanada 1992; Kleinberg and Codipilly 2002). With approximately 60% of VSCs originating on the
      surface of the tongue, brushing the dorsum of the tongue was found to be more effective than
      tooth brushing alone (Yaegaki, Coil et al. 2002). Furthermore, cleansing the tongue with a
      tongue scraper showed superior performance when compared to use of a toothbrush (Pedrazzi,
      Sato et al. 2004). Based on previous studies, the dorsum of the tongue has been shown to be
      an important source of oral malodor (Loesche and Kazor 2002). Chemical approaches to minimize
      halitosis include mouth rinses that specifically reduce the total number of microorganisms in
      the oral cavity. Chlorhexidine mouth rinse is the most effective anti-plaque agent on the
      market today and has been shown to reduce VSCs by 43% (Rosenberg, Kulkarni et al. 1991; Addy
      and Moran 1997).

      The effect of orthodontic treatment on periodontal health has been investigated in a number
      of studies (Zachrisson and Zachrisson 1972; Zachrisson and Alnaes 1974; Atack, Sandy et al.
      1996). Inflammation of gingival tissues is observed during orthodontic treatment mainly
      because fixed appliances impede adequate oral hygiene measures resulting in an increase in
      bacterial plaque accumulation (Ristic, Vlahovic Svabic et al. 2007; Liu, Sun et al. 2011).
      Halitosis has been reported to reach critical levels during fixed orthodontic treatment
      (Babacan, Sokucu et al. 2011).

      Self-ligating brackets do not require an elastic or wire ligature, but have an inbuilt
      mechanism that can be opened and closed to secure the orthodontic archwire. In the majority
      of designs, this mechanism is a metal face to the bracket slot that is opened and closed with
      an instrument (Wenger, Deacon et al. 2008). Conventional brackets typically have multiple
      wings and the wire is ligated to the bracket using an elastomeric ring or stainless steel
      ties. The effect of self-ligating brackets on oral hygiene has yet to be fully elucidated.
      Self-ligating brackets have been reported to accumulate less plaque during orthodontic
      treatment when compared to traditional, twin brackets (Pellegrini, Sauerwein et al. 2009).
      This may be attributed to retentive area created by the elastomeric rings that favor the
      accumulation of microorganisms and food debris. However, other studies have shown that there
      is no difference in plaque accumulation between the two bracket types (Pandis, Vlachopoulos
      et al. 2008; Garcez, Suzuki et al. 2011).

      Objectives

      The advantage of self-ligating brackets on periodontal health has yet to be determined. In
      addition, the utilization of tongue scraping as an adjunct to traditional oral hygiene
      measures has yet to be studied in orthodontic patients. The aim of this study is to evaluate
      the effect of bracket type on plaque accumulation and also the impact of the appliance on
      oral malodor. In addition, the effect of tongue scraping on halitosis will be studied in
      patients undergoing orthodontic treatment.

      Aims

      The following three aims will be performed to compare the three different appliance systems:

      Aim 1: Compare the impact of self-ligating and conventional brackets on oral hygiene,
      specifically plaque accumulation.

      Aim 2: Determine if an oral hygiene regimen including tongue scraping has an impact on
      halitosis in patients undergoing orthodontic treatment.

      Aim 3: Determine self-ligating brackets have an impact on minimizing halitosis during
      orthodontic treatment.

      Hypotheses

      Hypothesis 1: Self-ligating brackets will harbor less plaque than normal brackets.

      Hypothesis 2: Tongue scraping will significantly decrease halitosis in patients undergoing
      orthodontic treatment.

      Hypothesis 3: Patients with self-ligating brackets will exhibit less halitosis as measured by
      halimeter.

      Screening Procedures and Recruitment

      Each new patient that comes to the orthodontic clinic at the University of Connecticut Health
      center is assigned to a resident or a faculty. So the treating doctor will screen the new
      patient to see whether they need orthodontic treatment or not. If the patient requires
      orthodontic treatment, the patient has an additional appointment for collecting orthodontic
      records to develop the treatment plan. Once the treatment plan is formulated, the patient
      returns to discuss the treatment options and to begin the placement of orthodontic
      appliances. At this point the patient is ready for appliance placement and the study
      coordinator will screen orthodontic patient for possible inclusion in the study by checking
      the inclusion criteria discussed later. If the patients were suitable for inclusion, the
      study will be described in detail to them, and written information will be given to them.

      Statistical Methods

      The purpose of this pilot study is to determine the number of patients needed for the
      complete study in order to determine statistical significance. Since no previous studies
      exist measuring this combination of variables, we need this pilot study to determine the
      final sample size for this project and plan to submit a modification of this protocol to the
      IRB if we deem it necessary to recruit additional patients.
    

Intervention name(s): Tongue scraping; Bracket design
Intervention type(s): Other; Other
Intervention description(s): Two of four groups will use tongue scraping in conjunction with a normal oral hygiene protocol.; Two groups will be allocated to have self-ligating (Carriere) brackets. The other two groups will receive standard twin brackets.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention