The influence of orthodontic fixed appliances on the oral
               microbiota: A systematic review

Freitas, Amanda Osório Ayres de; Marquezan, Mariana; Nojima, Matilde da Cunha Gonçalves; Alviano, Daniela Sales; Maia, Lucianne Cople

doi:10.1590/2176-9451.19.2.046-055.oar

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Original Article • Dental Press J. Orthod. 19 (02) • Mar-Apr 2014 • https://doi.org/10.1590/2176-9451.19.2.046-055.oar copy

The influence of orthodontic fixed appliances on the oral microbiota: A systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

To investigate whether there is scientific evidence to support the hypothesis that the presence of orthodontic fixed appliances influences the oral microbiota.

Methods:

The search for articles was conducted in PubMed; ISI Web of Knowledge and Ovid databases, including articles published in English until May 17^th, 2012. They should report human observational studies presenting the following keywords: "fixed orthodontic appliance" AND "microbiological colonization"; OR "periodontal pathogens"; OR "Streptococcus"; OR "Lactobacillus"; OR "Candida"; OR "Tannerella forsythia"; OR "Treponema denticola"; OR "Fusobacterium nucleatum"; OR "Actimomyces actinomycetemcomitans"; OR "Prevotella intermedia", OR "Prevotella nigrescens"; OR "Porphyromonas gingivalis". Articles were previously selected by title and abstract. Articles that met the inclusion criteria were analyzed and classified as having low, moderate or high methodology quality. A new detailed checklist for quality assessment was developed based on the information required for applicable data extraction for reviews. The study design, sample, follow-up period, collection and microbial analysis methods, statistical treatment, results and discussion were assessed.

Results:

The initial search retrieved 305 articles of which 33 articles were selected by title and abstract. After full-text reading, 8 articles met the inclusion criteria, out of which 4 articles were classified as having low and 4 as moderate methodological quality. The moderate methodological quality studies were included in the systematic review.

Conclusions:

The literature revealed moderate evidence that the presence of fixed appliances influences the quantity and quality of oral microbiota.

Orthodontic appliances; Periodontics; Attachment sites; Microbiological; Microbiological analysis

Score protocol	Maximum score (10 points)
1. Study design: description of the study design	0.2
2. Participants	1.2
Sample standards: participant’s inclusion and exclusion criteria.	0.2
Sample characterization: number and characteristic of participants.	0.2
Calculation of sample size	0.6
Ethics: evidence of ethical factors	0.2
3. Study follow-up period	2.0
3 a 5 months	0.5
≥ 6 months	1.5
Month collections	0.5
4. Collection methods	3.0
Control of factors influencing collection: collection under dry conditions, removal of supragingival plaque and debris	-
5. Microbial analysis methods	3.0
Culture methods	1.0
Molecular biology	1.5
Mean standard deviation	0.5
6. Statistical analysis: adequate (indication of the test applied and significance level)	0.2
7. Results: adequate presentation of results (presentation of all proposed results; comparison between results considering time and microorganism; participant dropout with justification)	0.2
8. Discussion: consideration and possible explanation for the findings presented; comparison with previous published results	0.2

Author/ Year	Study design	Participants				Study follow-up period			Collection methods	Microbial analysis methods			Statistical analysis	Results	Discussion	Total points/ quality
		Sample Standards	Sample Characterization	Calculation of sample size	Ethics	3-5 month follow-up	≥ 6 month follow-up	1 month interval time	Control of factors influencing collection	Culture methods	Molecular biology
Sinclair et al,²⁰ 1987	0	0.2	0.2	0	0	0	1.5	0	3.0	1.0	0	0	0.2	0.2	0.2	6.5 / Moderate
Paolantonio et al,²³ 1997	0	0.2	0.2	0	0	0	1.5	0	3.0	1.0	0	0	0.2	0.2	0.2	6.5 / Moderate
Paolantonio et al,²² 1999	0	0.2	0.2	0	0	1.0	0	0.5	3.0	1.0	0	0	0.2	0.2	0.2	6.0 / Moderate
Jordan et al,²⁷ 2002	0	0.2	0.2	0	0	1.0	0	0.5	0	0	1.5	0	0	0	0.2	3.6 / Low
Hagg et al,⁵ 2004	0.2	0.2	0.2	0	0	1.0	0	0	0	1.0	0	0	0.2	0.2	0.2	3.2 / Low
Turkkahraman et al,¹¹ 2005	0	0.2	0.2	0	0.2	0	0	0.5	0	1.0	0	0	0.2	0.2	0.2	2.7 / Low
Ristic et al,²¹ 2007	0.2	0.2	0.2	0	0.2	0	1.5	0	3.0	1.0	0	0	0.2	0.2	0.2	6.9 / Moderate
Andrucioli et al,²⁸ 2012	0	0.5	0.5	0	0.2	0	0	0.5	0	0	1.5	0	0.2	0.2	0.2	3.8/ Low

Author/ Year	Study design	Participant		Material collection time	Collection methods	Microbial analysis methods	Statistical analysis	Conclusion
		Sample Standards	General sample description	Total study time/ interval times	Control of factors influencing collection	Culture methods/ molecular biology/ SEM
Sinclair et al,²⁰ 1987	Not mentioned.	No history of orthodontic treatment, systemic disease or use of antibiotic therapy within the preceding 6 months; no fluoride rinse or gel was used before or during the study.	13 subjects, 8 males and 5 females, aged between 12 and 16 years old.	Collection at baseline and 1 year after placement of orthodontic appliance / Material from maxillary and mandibular central incisors, maxillary and mandibular right first permanent molars.	Plaque collected with 0.016’ stainless steel orthodontic wire 20 mm in length inserted in the gingival cervices/ Under dry field conditions with cheek retractors, cotton rolls and aspiration.	Culture methods.	Two- way ANOVA for comparison between the sampling periods and Student’s- t test for unmatched data.	Increase in the percentage of Streptococci and decrease in the percentage of Aa in the subgingival plaque; no increase in the percentage of potentially pathogenic Gram-negative organisms.
Paolantonio et al,²³ 1997	Longitudinal study.	Subjects were not affected by systemic diseases, nor had taken antibiotics during the 3 months preceding each microbiological examination.	70 subjects, 27 males and 43 females, aged between 12 and 20 years old.	Collection before placement of fixed orthodontic appliance and 3 years after/ Sampling was performed at mesio-buccal sites of 1^st molars and disto-buccal sites of lateral incisors.	Plaque samples: insertion of 3 sterile paper points at the deepest part of each gingival sulcus/ Removal of supragingival plaque by a sterile curette, gingival surface dried by gentle air flow.	Culture methods.	Mean % of Aa * in the total anaerobic flora from sampled sites was calculated for each individual; c² analysis to test the statistical significance of differences in the number of Aa * in orthodontic and control subjects.	The presence of orthodontic appliances significantly increases subgingival colonization by Aa among individuals presenting initial healthy periodontium.
Paolantonio et al,²² 1999	Not mentioned.	No loss of periodontal attachment, no systemic disease, no antibiotics taken during the 3 months before study or during it, and no mouthwash rinse.	24 subjects, 11 males and 13 females, aged between 18 and 22 years old.	Collection at baseline, 4, 8 and 12 weeks after bonding/ Material from mesiobuccal sites of the first molars and distobuccal sites of lateral incisors.	Plaque obtained by insertion of 3 sterile paper points at gingival sulcus/ Collected after removal of supragingival plaque with a sterile curette, gingival surface dried with air flow.	Culture methods.	Percentage of sites with positive results for Aa * mean values.	Placement of orthodontic appliance favors subgingival growth of Aa.

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