Effectiveness of three different types of educational methods on implementation of proper oral hygiene behaviour prior to orthodontic treatment

ABSTRACT Objective: The aim of this study was to compare three teaching methods’ time and personnel requirements, and their effects on plaque and gingival indices. Methods: This study was a single-blind randomized controlled trial on fixed orthodontic appliance candidates (n = 90), assigned into a control group (n = 30) and two different study groups (n = 30 each). The control group received standard printed educational material and was assisted with verbal information. The study groups either received video-assisted or hands-on training about fixed orthodontic appliance and oral hygiene. The time requirements for all three educational interventions was recorded during the initial visit. The adequacy of oral hygiene was documented through plaque and gingival indices during the initial visit and eighth week of the treatment. The continuous variables were analyzed using 1-way ANOVA. Tukey HSD and Student t-tests were used for post-hoc comparisons (α?#8197;= 0.05). Also, a chi-square test was used for the analysis of categorical variables. Results: Standard education failed to maintain the plaque and gingival indices at the eighth week of the treatment. Although both video-assisted and hands-on training took a considerable amount of time, they served well in preserving both of the indices at the eighth week. The longer the educational intervention was, the better the preservation of the plaque and gingival indices. Conclusion: Educational intervention, either with video-assisted or hands-on programs, provided better results in oral hygiene depending on the time and personnel constraints of the orthodontist.


INTRODUCTION
Orthodontic treatment using fixed orthodontic appliances that prevent patients from effectively cleaning their teeth results in increased plaque formation and deterioration of oral hygiene. 1 Inappropriate oral hygiene behaviour during the fixed orthodontic appliance treatment causes gingival enlargement, gingivitis, enamel decalcification and white spots in the vicinity of the applied therapeutic material in 50-70% of patients with fixed appliances. [1][2][3][4][5] Also, inappropriate oral hygiene has been shown to prolong the treatment duration and may result in poor treatment outcomes. 6 Of all the orthodontic treatments, 5-10% fail because of inappropriate oral hygiene caused by patient incompliance. 7 For these reasons, proper oral hygiene behaviour is of great importance to the treatment period of almost two years. Oral hygiene can only be achieved through patient compliance, which is built up through communication between the orthodontist, the patient and the family by means of verbal and written educational material. 8 Routine oral hygiene instruction given to the patients by the orthodontist may be insufficient to provide proper oral hygiene. 5,6 The implementation of oral hygiene in fixed orthodontic appliance treatment candidates through verbal, written and visual information materials has been evaluated in a couple of studies. They either calculated the ratio of disclosed plaque, [9][10][11][12] or plaque and gingival indices [13][14][15] were objectively Dental Press J Orthod. 2021;26(1):e2119248 Cakmak Ozlu F, Aktunc E, Yilmaz H, Karadeniz EI -Effectiveness of three different types of educational methods on implementation of proper oral hygiene behaviour prior to orthodontic treatment 5 used in order to evaluate the implementation of learned information. In these studies, plaque disclosing - one of the methods of oral hygiene motivation -has been shown to increase the patient's motivation through visualization and presentation. 11,12 However, the messages delivered through text, WhatsApp, etc. indicate that motivation is effective in patients' oral hygiene motivation, 14,16 and even better than plaque disclosing tablets. 10 Studies comparing the effectiveness of different oral hygiene training methods found that video-assisted and hands-on training have also been effective approaches. 15,17 In recent reviews, motivational approaches with the potential to make more behavioural changes than traditional health education have been found to have different effects on success rates. 18,19 However, motivation of patients through various methods plays a crucial part in maintaining proper oral hygiene.
In all of these studies, different methods of implementing the proper oral hygiene were evaluated only for their effectiveness. As education is the most important part of building rapport between the clinician and patient, it is also a time and effort-consuming process. Moreover, it may not be as fruitful as expected due to patient compliance problems. 19 Patient motivation and willingness to persist with lifestyle changes are prone to wear out as they require constant effort on the patients' behalf to change improper but ingrained habits. Cakmak Ozlu F, Aktunc E, Yilmaz H, Karadeniz EI -Effectiveness of three different types of educational methods on implementation of proper oral hygiene behaviour prior to orthodontic treatment 6 The two possible restrictions influencing the transfer of information -either positively or negatively-to any patient are time and personnel requirements in busy orthodontic clinics, which have not been addressed in previous studies.
Therefore, the aim of this study was to compare the time requirements of three types of information transfer techniques, which were all proven to be effective to different degrees in improving oral hygiene in fixed orthodontic appliance treatment candidates. 18,19 We have also documented the effectiveness rate for each method through plaque and gingival indices. The first null hypothesis was that none of the oral hygiene education methods would affect oral hygiene. The second null hypothesis was that there is no difference in duration of oral hygiene adoption either with video-assisted or hands-on training.

MATERIAL AND METHODS
This study is a randomized controlled three-arm parallel trial performed on a group of patients who applied to the outpatient clinic of Orthodontics at the Faculty of Dentistry of Bulent Ecevit University on November 11 th , 2014. We collected a total of 90 patients (mean=14.73±2.63, 10-24 years old) who were undergoing fixed orthodontic treatment after meeting eligibility criteria  This study was conducted as a single-blind, randomized clinical trial. A computer program (research randomizer) was used to randomly allocate each patient to one of three groups.
To avoid bias, random sequencing was performed by one of the authors, who had not taken part in allocation or by the measurement statistician. Another author explained the study and introduced oral hygiene to the patients and their guardians according to random sequencing, which was provided in opaque, sealed envelopes during the first appointment. Also, the investigator who treated patients and collected data was blinded to all groups throughout the study.  (Table 1). 20 Ninety consecutive fixed orthodontic appliance treatment candidates in compliance with the above-mentioned criteria were randomly assigned to three groups (n = 30 in each): Learning objectives for oral hygiene education

Learning objectives for components of fixed appliance treatment
The equipment required for orthodontic oral care.
What are the components of oral fixed appliance therapy?
How do I use an orthodontic tooth brush?
The obligation for hygiene of the molar bands and molar tubes in every oral care episode.
How do I use an interspace brush? What are the names of the two fixed appliance components to be checked at the end of daily oral care?
How do I use an ordinary tooth brush? What should I do when my brackets are removed or my archwire is broken?
How do I use dental floss? What precaution should I take in case of irritation caused by the brackets and molar tubes?
How do I use fluorinated mouthwash? What are the basic rules when using elastics?
What are the names of the two fixed appliance components to be checked at the end of daily oral care?
What should I do in case of pain due to the appliance?
What kind of food do I have to avoid?
What is the duration of the therapy?
What is the frequency of orthodontic appointments?
Is it safe to attend sports activities?
Is it safe to play any musical instrument?  Study group 1 (S1): The patients in this study group received video-assisted information (Fig 2).
Study group 2 (S2): The patients in this study group received hands-on training.
Both video and hands-on assisted training sessions covered a set of knowledge and skills on fixed appliance therapeutic devices and oral hygiene, as stated in the educational booklet of BOS (Table 1). 20 The primary outcomes were the plaque and gingival indices.

RESULTS
All of the patients in the control and study groups were comparable regarding age, gender and initial plaque and gingival indices values (p > 0.05) ( Table 2 significantly shorter in the control group when compared with those of both study groups (p < 0.001) ( Table 3). The mean time for video-assisted education was significantly longer than that of the hands-on training group (p < 0.001) ( Table 4).
The two study groups did not show any significant intergroup or in-group deterioration regarding plaque and gingival indices at the initial eighth week examinations (p > 0.05) ( Table 4).   the control group patients significantly deteriorated when compared with the initial index values (p < 0.001) ( Table 3).

However, the eighth week plaque and gingival indices in
The eighth week plaque and gingival indices of the control group were also significantly poorer than those of the two study groups (p < 0.001) ( Table 3).
The time duration spent on patient education was found to be inversely and strongly correlated with the preservation rate The present study investigated the success and clinical efficacy of different educational interventions on oral hygiene motivation in individuals undergoing fixed orthodontic treatment. This is because fixed appliance treatment is known for its deleterious effects, such as gingivitis, white spots, decalcification and cavity formation unless oral hygiene is maintained by the patients themselves. [22][23][24][25] The institution of oral hygiene before the onset of orthodontic treatment is recommended as an effective means against development of the above-mentioned complications. 17 As it becomes more difficult to sustain oral hygiene following the application of therapeutic appliances, 26 the educational intervention for oral hygiene behaviour and the orthodontic treatment materials take priority in the beginning of the treatment. 17 The only known and successful way for achieving desired oral hygiene is both educating the patient prior to the treatment and building rapport between doctor and patient during the long-term treatment. The effectiveness of different methods in improving oral hygiene compliance of patients undergoing fixed orthodontic treatment to minimize these harmful effects has been investigated in previous studies. Since orthodontists worry that patients' compliance will decrease during the 4-6 week appointment intervals of the treatment, 19 the patients were motivated by a number of reminder messages or applications (text, WhatsApp, WeChat) that emphasized the importance of good oral hygiene, and the effectiveness of these reminders was investigated. In all of these studies, it was stated that the use of reminders in dentistry improved the patient's out-clinical management, regular attendance of appointments, positive behaviour changes and educational factors. 10,14,16,27 However, many smartphones have the ability to block messages and they can be easily blocked if they cause annoyance to patients. 19 In addition, it has been emphasized in studies that plaque disclosing tablets increase oral hygiene motivation through visualization of plaque accumulation. 11,12 Although it is easily accessible and practiced in orthodontic clinics, its use may be limited due to its price, especially in developing and underdeveloped countries. 19 Although the above-mentioned oral hygiene motivations Repetition of the topics related to oral hygiene during successive appointments is also recommended. 28 The first limitation of the study was the Hawthorne effect, 9 which resulted from the inability to blind patients. It was not possible to eliminate this because of the consent form obtained from patients and their parents for participation in the study.
The second limitation was that the follow-up period of the  20 patients was limited to eight weeks and long-term follow-up was not managed. However, this lack can be considered normal as we focus on training durations rather than the success of oral hygiene motivation in planning our study.

CONCLUSION
In a couple of previous studies, the provision of oral hygiene behaviour education by orthodontists or oral hygienists was emphasized. [9][10][11]13,14 However, the time and personnel constraints were not addressed in those studies. We found that
The authors report no commercial, proprietary or financial interest in the products or companies described in this article.