Prediction of dental caries in children during the correction period of dento-maxillary anomalies

Summary

Purpose: To assess the risk of dental caries in children during the correction of dento-maxillary anomalies (DMA).

Material and method: A case-control study has been performed on 84 children aged between 12 and 18 years. The research groups incorporated 42 children with DMA: 14 children undergoing orthodontic treatment with fixed systems (G₁), 14 children undergoing orthodontic treatment with removable appliances (G₂) and 14 children with DMA at the orthodontic treatment planning stage (G₃). The control group consisted of 42 conventionally healthy children (G₀). The risk of dental caries occurrence has been assessed with the Cariogram software. The study proceeded in accordance with the common ethical requirements and written consent of the parents or legal representative of the children. Epi Info software has been applied for the analysis of statistical data.

Results: In the case of most children during the DMA correction period, the collective influence of a complex of risk factors has been detected: poor oral hygiene, increased number of Streptococcus mutans in 1 ml of OF, reduced self-cleaning capacity, unhealthy eating habits etc. The average frequency of very high caries risk in children with DMA is 5,0 times higher in comparison to risk children from the control group.

Conclusions: The predisposition to developing dental caries in children during the DMA correction period was reflected by the low chances of avoiding the appearance of new carious cavities (34,97±6,3%) which were 2,12 times lower compared to the chances of conventionally healthy children (74,22±8,17%). This signals the need for regular assessment of caries risk and the implementation of specific and effective prevention programs, targeted at each group of carious risk factors.

Keywords: dental caries, caries risk, children, dental-maxillary anomalies, orthodontic treatment.

Introduction:

Disorders of growth and development of the masticatory system cause a wide range of dental-maxillary anomalies (DMA) with repercussions both in the functional area (mastication, phonation, respiration) as well as aesthetics, because the development of an inferiority complex can lead to serious problems regarding the patient’s social integration. The negative impact of malocclusion on one’s oral health and quality of life starts to be acknowledged only when children reach pre-adolescence and worsen with their growth and maturation [1, 2].

Studies by several authors [2-6] state that malocclusions are associated with the prevalence and severity of dental caries and the condition of oral hygiene in children. Kukletova M. et al., 2012, and Feldenes C. et al., 2015, noted that misalignment of teeth and dental arches creates favorable conditions for the development, accumulation of dental biofilm and  difficulties in its efficient removal [2, 7].

Avornic L., in 2008, Avornic-Ciumeico L., 2020, estimated the unsatisfactory state of oral hygiene in children during the period of correction of DMA with fixed systems [8, 9]. Patients undergoing orthodontic treatment who neglect the recommendations of the orthodontist or dental hygienist are more affected by dental caries [10-14]. This was confirmed by the study conducted by Atassi F., Awartani F., 2010, who found that plaque covers more than 50% of dental surfaces in 55,6% of patients undergoing orthodontic treatment with fixed appliances [10]. During the correction period of DMA in children with fixed systems were found: increased incidence rate of demineralization areas of tooth enamel [12-16], aggressive evolution of tooth decay [13], high caries risk (in 62% of patients) [17,18], and the fact that about 5-10% of all patients, abandon treatment due to the appearance of multiple carious cavities [15].

The analysis of the bibliographic sources showed that the high carious risk frequently manifests during the DMA correction period and presents a problem of major importance, which requires immediate solution [10-17]. Thus, only the complex identification of all caries risk factors for each patient during the DMA correction period will ensure an effective preventive treatment of dental caries and will contribute to obtaining optimal aesthetic and functional results.

Aim of study:

To assess the risk of dental caries in children during the correction of dento-maxillary anomalies (DMA).

Material and methods:

The study has been conducted within the Pediatric Oro-Maxillofacial Surgery and Pedodontics Department and the Orthodontics Department of the USMF “Nicolae Testemitanu”. The information of this work relies on the clinical examination data of 84 children aged between 12 and 18 years. The research groups (G₁ – G₃) included 42 children with DMA. Group G₁ consisted of 14 children who benefited from orthodontic treatment with fixed systems, group G₂ included 14 children who were undergoing orthodontic treatment with removable appliances, and group G₃ –14 children with DMA who were in the planning stage of orthodontic treatment. The control group (G₀) consisted of 42 conventionally healthy children. All children groups were identical by the structure.

Objective clinical examination of children included specific methods for assessing tooth decay damage: the tooth decay prevalence index (PI) and the DMFT index. The condition of oral hygiene in patients with fixed orthodontic appliances has been assessed by estimating the OPI index (Orthodontic Plaque Index after Heintze et al., 1999) recommended by most specialists in the field [18], and in children in groups G₂, G₃ and G₀ – the Quigley-Hein Plaque Index (1962) and the approximal plaque index (Approximal Plaque Index Lange, API, 1981). Colorimetric differentiation of the mature bacterial plaque from the newly formed mature one has been performed using the Plaque Indicator kit gel, GC (Fig. 1). The Saliva-Check Mutans, GC kit has been used to determine the number of Streptococcus mutans in oral fluid (OF), and the Saliva-Check Buffer, GC kit was used to assess salivary pH, OF buffer capacity and salivary flow rate.

For the complex assessment of caries risk, the Cariogram Software has been used. (D. Bratthall, 2005) It allows highlighting the chances of avoiding the appearance of new carious cavities in each person, taking into account the interaction of the following factors: psycho-somatic diseases, particularities in nutrition, hygiene of the oral cavity, carious experience, application of cariopreventive measures, the condition of oral hygiene, biophysical characteristics of saliva and the number of acidogenic bacteria in OF (Fig. 2).

The probability of avoiding the appearance of new carious lesions estimated with the use of the Cariogram program can be between 0 and 100%:

• Very low risk = 81-100% chances of avoiding the appearance of new carious cavities;

• Low risk = 61-80%;

• Moderate risk = 41-60%;

• High risk = 21-40%:

• Extreme risk (very high) = 0-20% [19, 20].

The study has been approved by the Research Ethics Committee of USMF “Nicolae Testemitanu” and conducted in accordance with ethical requirements, with the written consent of the children’s parents or their legal representatives. The analysis of descriptive and inferential statistical data using parametric and non-parametric tests (p <0.05) has been performed using the EXCEL and EpiInfo programs using the functions and modules of these programs.

Results:

The subjects are residents of the Republic Moldova. The research and control groups presented a comparable structure regarding gender, age and socio-economic conditions. The gender distribution of children studied in groups is shown in table 1.

Table 1. Gender distribution groups of children

The prevalence of dental caries in children in the research groups was 78,57±6,33% (p<0,001) exceeding by 21,43±7,84% IP estimated in children in the control group. The intensity of caries had the value of 3,49±1,02, (p<0,001) for the DMFT index in the wearers of fixed orthodontic appliances (G₁) and of 3,35±1,54, (p<0,001) in children with DMA at the planning stage of orthodontic treatment (G₃). The average value of the DMFT index in the research group was 3,07±1,49, (p<0,01), being 1,03 higher compared to the DMFT assessed in children in the control group, G₀ – 2,96±0,87 (Tab. 2).

Table 2. Prevalence index of dental caries and DMFT in children

At 40,48±7,57% of the children in the research groups, intense carious activity was detected, the highest share being registered in the children from G₁ (42,86±7,64%) and G₃ (35,71±7,57%). Moderate carioactivity was determined in 21,43±6,33% of children in G₁, in 14,29±5,06% of subjects in G₂ and in 7,14±5,06% of children in G₃.

The Cariogram software has been used to identify carious risk factors. During the correction period of DMA in most children, the cumulative influence of a complex of risk factors has been established: poor oral hygiene, increased number of Streptococcus mutans in 1 ml of OF, unhealthy eating habits etc. Poor oral hygiene was detected in 83,33±5,75% of children in the research groups. Patients with fixed orthodontic appliances showed unsatisfactory oral hygiene, the OPI index being 84,21±7,32%. Thus, the highest values ​​of the oral hygiene indices Quigley-Hein and API were recorded in children in group G₁ (2,97±2,16% and 87,49±22,73%) and in those in group G₃ (2,47±1,42% and 86±12,14%) (Tab. 3).

Table 3. Values of oral hygiene indeces OPI, Quigley Hein and Aproximal plaque index API.

The number of Streptococcus mutans exceeded the value of 5×10⁵ CFU / ml OF in 50±7,72% of the children in research groups. The highest concentration of Streptococcus mutans has been detected in 64,28±7,39% of the children in the group G₁. OF flow and pH with normal values have been assessed in most of the children examined. The rate of salivary secretion below the minimum level of 0,9 ml / min was recorded at 30,95±7,13% of the total number of children in the research groups, and in particular at 35,71±12,81% of the children with fixed orthodontic appliances. The lowest salivary pH values ​​were recorded at 21,43±10,95% of children in groups G₁ and G₃. Unhealthy eating habits were one of the risk factors for 61,9±7,49% of the children in the research groups and 64,29±7,39% of the subjects in the control group.

The extreme caries risk was estimated at 35,71±12,81%, p<0,001 within the research groups, being 5,0 times more frequent compared to the risk of conventionally healthy children (7,14±6,88%). The highest risk was determined in children with fixed orthodontic appliances (G₁=42,85±13,26%). The high and moderate caries risk was set at 23,81±6,57% in the research groups, as opposed to the estimated 14,28±9,35% in the control group. The low caries risk was found in 14,28±9,35% of the children in the period of correction of DMA, and the very low risk – not in one child. Unlike subjects in the research groups, in conventionally healthy children, the risk of caries was estimated to be very low in 35,71±12,81% of cases and low – in 28,57±3,94% of cases (Tab. 4).

Table 4. Caries risk level at children

The extreme risk of caries assessed at 35,71±7,39% of children with DMA and undergoing orthodontic treatment was influenced by the increased number of Streptococcus mutans in OF in the proportion of: 32,4±2,18% in G₁, 35,75±1,96% – in G₂ and 32,6±1,68% in G₃. The lack of implementation of fluoridation programs, low pH and low buffering capacity of OF was estimated at 26,6±1,67% in children with fixed orthodontic appliances, 29±1,39% – at those with removable appliances and 28,8±2,14% in children at the pretreatment stage (Fig. 3 – 5).

Careful analysis of caries risk factors in children within the study highlighted the high caries risks and the low chances of avoiding the appearance of new carious cavities in patients with fixed orthodontic appliances (29,21±7,44%) and those with DMA at the pretreatment stage (32,42±6,18). The highest chances of avoiding the appearance of new carious cavities were estimated in patients with removable orthodontic appliances (43,28±8,73%), due to the lower activity rate of bacterial plaque and the lower number of Streptococcus mutans in OF, regarding the groups G₁ and G₃ (Tab. 5).

Table 5. Chances of avoiding the appearance of new carious cavities (%)

Consequently, the susceptibility to dental caries in children during the DMA correction period was reflected by the low chances of avoiding the appearance of new carious cavities (34,97±6,3%) which were 2,12 times lower compared to conventionally healthy children, in which the chances of avoiding the appearance of new carious cavities were 74,22±8,17%.

Discussion:

Recent research has established a higher prevalence of dental caries in children during the period of DMA correction, caused by favorable conditions for the formation and accumulation of dental biofilm. Dental crowds create the most favorable environment to maintain the dental biofilm [8, 9]. Feldens CA and coauthors, 2015, established that in 60,8% of patients with dental crowding, poor oral hygiene and cariogenic diet favor the rapid multiplication of acidogenic bacteria colonies (as the number of Streptococcus mutans being higher than 10⁶ CFU in 1 ml of OF) [2]. Kukletova M. and coauthors, 2012, Feldenes C. A. and coauthors, 2015, reported that difficulties in dental hygienic process, accumulation of dental biofilm and predisposition to the development of dental caries is encountered in patients with dental crowding [2, 7].

Dental biofilm coverage of more than 50% of the tooth surface has been discovered in 55,6% of patients undergoing orthodontic treatment with fixed appliances [10]. Struzycka I., 2014, established that the dental biofilm stored around metal brackets is a very well structured microbial community and contributes to the formation of a cariogenic environment, which rapidly causes the appearance of demineralized areas [21]. Therefore, the prevention of dental caries in children during the correction period of DMA is a significant challenge, orthodontic treatment with fixed appliances being considered a risk factor for the development of dental caries [16, 17].

Because the effectiveness of primary and secondary prevention of dental caries is enhanced when targeting individual risk factors, this study was conducted to assess cariogenic risk in children during the correction period of DMA. The case-control study included children during the DMA correction period (with fixed, removable orthodontic appliances, during the orthodontic treatment planning period) and conventionally healthy children. The caries risk assessment was performed using the Cariogram Software that allows the graphical expression of caries risk in the near future through the “chance of avoiding new carious cavities”, but at the same time demonstrates the extent to which etiological factors affect this “chance”. On the other hand, it encourages preventive measures [19, 20].

The results of our research are comparable with data reported in several studies that found increased values ​​of bacterial plaque index and the number of Streptococcus mutans in OF in patients with fixed orthodontic appliances [22-29]. The interaction of exo- and endogenous factors had an important impact on the high and extremely high risk of tooth decay estimated in children during the DMA correction period. The most common local factors are: insufficient and incorrect oral hygiene, significant accumulation of dental biofilm, the large number of Streptococcus mutans in OF, the low pH (4,5-5,5) of saliva and the frequent consumption of easily fermentable hydrocarbons. Therefore, the excessive accumulation of dental biofilm and the increased number of Streptococcus mutans in OF within the research groups G₁ and G₃ contributed to the imbalance of environmental protection factors in the oral cavity and the creation of favorable conditions for the development of carious cavities.

The basic concept of individualized prophylaxis consists in recognizing high-risk patients and modifying individual behavioral risk factors by establishing effective preventive treatment [30, 31]. Caries risk assessment is actually determining the risk of caries incidence over a period of time or the likelihood that there will be changes in the size or activity of lesions already present [30]. Thus, in patients with DMA it is recommended to estimate the caries risk at the planning stage of orthodontic treatment and throughout its duration, 2-4 times a year.

Although the Cariogram program does not specify the exact number of carious cavities that may or may not appear later, it may illustrate a possible general risk scenario based on the interpretation of specialists, provide valuable clues and serve as a foundation for encouraging the patient to follow the individualized oral hygiene program. Several attempts have been made to select the caries risk group or to identify the individual risk, but no perfect method has been found to take into account the multifactorial etiology of dental caries. On the other hand, a number of factors accompany the occurrence of the increased number of carious lesions, which is why the evaluation of these parameters of the Cariogram would make it easier to establish the carious risk. At the same time, the application of prophylactic and/or restorative treatment is effective only if we take into account the complexity of cariogenic factors and the risk group to which the patient belongs [31].

Conclusions:

Susceptibility to dental caries in children during the DMA correction period has been reflected by the low chances of avoiding the appearance of new carious cavities (34,97±6,3%) which were 2,12 times lower compared to the chances of conventionally healthy children (74,22 ± 8,17%). This highlights the need for regular assessment of caries risk and implementation of specific and effective prevention programs, targeted at each group of carious risk factors.

References:

1. Kragt L., Dhamo B., Wolvius E., Ongkosuwito E. The impact of malocclusions on oral health-related quality of life in children-a systematic review and meta-analysis. Clin Oral Investig 2016; 20 (8): 1881-94.
2. Feldens C., Dos Santos Dullius AI., Kramer P., Scapini A., Busato A., Vargas-Ferreira F. Impact of malocclusion and dentofacial anomalies on the prevalence and severity of dental caries among adolescents. Angle Orthod 2015; 85 (6): 1027-34.
3. Buczkowska-Radlinska J., Szyszka-Sommerfeld L., Wozniak K. Anterior tooth crowding and prevalence of dental caries in children in Szczecin. Poland Community Dent Health 2012; 29 (2): 168-72.
4. Hafez H., Shaarawy S., Al-Sakiti A., Mostafa Y. Dental crowding as a caries risk factor: a systematic review. Am J Orthod Dentofac Orthop 2012; 142 (4): 443-50.
5. Caplin J., Evans C., Begole E. The relationship between caries and malocclusion in Chinese migrant Workers’ children in Shanghai. Chin J Dent Res 2015; 18 (2): 103-110.
6. Kolawole K., Folayan M. Association between malocclusion, caries and oral hygiene in children 6 to 12 years old resident in suburban Nigeria. BMC Oral Health 2019; 262. https://doi.org/10.1186/s12903-019-0959-2
7. Kukletova M., Izakovicova Holla L., Musilova K., Broukal Z., Kukla L. Relationship between gingivitis severity, caries experience and orthodontic anomalies in 13-15-year-old adolescents in Brno, Czech Republic. Community Dent Health 2012; 29 (2): 179-83.
8. Avornic L. Impactul parodontal în anomaliile dentomaxilare: aspecte de evaluare și de tratament ortodontic complex. Curierul Medical 2009; 307 (1): 47-52.
9. Avornic-Ciumeico L. Dezvoltarea și creșterea aparatului dento-maxilar: premize și influenţe. Medicina stomatologică 2020; 54 (1): 113-123.
10. Oral hygiene status among orthodontic patients. The Journal of Contemporary Dental Practice 2010; 11 (4): 1-9.
11. Subramaniam P., Babu K., Nagarathna J. Interdental spacing and dental caries in the primary dentition of 4-6 year old children. J Dent Tehran 2012; 9 (3): 207-14.
12. A contemporary review of white spot lesions in orthodontics. J Esthet Restor Dent 2013; 25 (2): 85-95. doi:10.1111/jerd.12013.
13. Gorelick L., Geiger A., Gwinnett A. Incidence of white spot formation after bonding and banding. Am J Orthod. 1982; 81 (2): 93-8. doi:10.1016/0002-9416(82)90032-X.
14. Risk factors and management of white spot lesions in orthodontics. J Orthod Sci. 2013; 2 (2): 43-9. doi:10.4103/2278-0203.115081
15. Ogaard B., Rolla G., Arends J. Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop 1988; 94 (1): 68-73. doi:10.1016/0889-5406(88)90453-2
16. Okada E., Ribeiro L., Stuani M., Borsatto M., Fidalgo T., Paula-Silva F., Kuchler E. Effects of chlorhexidine varnish on caries during orthodontic treatment: a systematic review and meta-analysis. Brazilian Oral Research 2016; 30 (1), e115. https://dx.doi.org/10.1590/1807-3107bor-2016.vol30.0115
17. Al Mulla A., Al Kharsa S., Kjellberg H., Birkhed D.Caries risk profiles in Orthodontic Patients at Follow up using Cariogram. Angle Orthodontist 2009; 79 (2): 323-330.
18. Beberhold K., Sachse-Kulp A., Schwestka-Polly R., Hornecker E., Ziebolz D.
    The Orthodontic Plaque Index: An oral hygiene index for patients with multibracket appliances. Orthodontics 2012; 13: 94-99. https://www.researchgate.net/publication /224920300_The_Orthodontic_Plaque_Index_An_oral_hygiene_index_for_patients_with_multibracket_appliances.
19. Bratthall D.  Cariogram – multifactorial risk assessment model for multifactorial disease. Community Dentistry and Oral Epidemiology 2005; 33 (4): 256-64.
20. Bicleșanu C. Diagnosticul și managementul modern al cariei dentare. Craiova Medicală 2008; 10-3: 178-182.
21. Struzycka I. The oral microbiome in dental caries. Pol J Microbiol 2014; 63 (2): 127-135.
22. Arab S., Malekshah S., Mehrizi E., Khanghah A., Naseh R., Imani M. Effect of fixed orthodontic treatment on salivary flow, ph and microbial count. Journal of Dentistry (Tehran, Iran) 2016; 13 (1): 18-22.
23. Bonetti G., Parenti S., Garulli G., Gatto M., Checchi L. Effect of fixed orthodontic appliances on salivary properties. Progress in Orthodontics 2013; 13 (4): 1-4.
24. Borutta A., Pala E., Fischer T. Effectiveness of a powered toothbrush compared with a manual toothbrush for orthodontic patients with fixed appliances. The Journal of clinical Dentistry 2002; 13 (4): 131-137.
25. Feil P., Ed. D., Grauer J., Cynthia C., Gadbury-Amyot C., Kula K., McCunniff M. Intentional Use of the Hawthorne Effect to Improve Oral Hygiene Compliance in Orthodontic Patients. Journal of Dental Education 2002; 66 (10): 1129-1135.
26. Julien K., Buschang P., Campbell P. Prevalence of white spot lesion formation during orthodontic treatment. The Angle Orthodontist 2013; 83 (4): 641-647.
27. Naif A., Al-Mulla A., Birkhed D. Caries risk profile using the Cariogram in governmental and private orthodontic patients at de-bonding. The Angle Orthodontist 2012; 82 (2): 267-274.
28. Petsi G., Gizani S., Twetman S., Kavvadia K. Cariogram caries risk profiles in adolescent orthodontic patients with and without some salivary variables. Angle Orthodontist 2014; 84 (5): 891-895.
29. Tufekci E., Dixon J., Gunsolley J., Lindauer S. Prevalence of white spot lesions during orthodontic treatment with fixed appliances. The Angle Orthodontist 2011; 81 (2): 206-210.
30. Bîcleșanu C. Diagnosticul şi managementul modern al cariei dentare. Revista Romana de Stomatologie  2009; 1: 34-38.
31. Muntean A., Mesaros A., Festila D., Mesaros M. Modern management of dental decay in children and adolescents – a review. Clujul Med 2015; 88 (2): 137-139.