Abst ract
Submitted: June 28, 2016 0RGL¿FDWLRQ2FWREHU Accepted: December 06, 2016
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of
St rept ococcus m ut ans
in saliva and
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rem ains a problem . Whit e spot lesions are observed in nearly 50% of
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orthodontic m aterials has shown inconclusive results on their ability to reduce
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ORTHO LC) and a light cured com posit e resin ( Transbond XT) , and t o analyze
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( APF) on SM count s. I n a parallel st udy design, t wo groups ( n= 14/ 15) were used wit h random allocat ion and high salivary SM count s before t reat m ent .
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DQG%RWKVDOLYDDQGELR¿OPZHUHFROOHFWHGRQWKHt h, 21st, 35t h, and
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out on t he 35t h day. Bonding wit h RMGI C did not alt er SM count s in saliva
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SM count s along t he t rial period. Topical applicat ion of 1.23% APF did not
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SM. The use of RMGI C as bonding m at erials allowed a bet t er cont rol of
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adj acent t o t he com posit e m at erial.
Ke yw or ds: Orthodontics. Glass ionom er cem ents. St rept ococcus m ut ans.
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Marcela Cristina Damião ANDRUCIOLI1
Gisele FARIA2 Paulo NELSON-FILHO1 Fábio Lourenço ROMANO1 Mírian Aiko Nakane MATSUMOTO1
1Universidade de São Paulo, Faculdade de Odontologia de Ribeirão Preto, Departamento de Clínica
Infantil, Ribeirão Preto, SP, Brasil.
2Universidade Estadual Paulista, Faculdade de Odontologia de Araraquara, Departamento de
Odontologia Restauradora, Araraquara, SP, Brasil.
Corresponding address: Dr. Marcela Cristina Damião Andrucioli Departamento de Clínica Infantil - Faculdade de
Odontologia de Ribeirão Preto Universidade de São Paulo Avenida do Café, S/N, Monte Alegre - 14040-904
Ribeirão Preto - SP - Brazil Phone: +55-16-3602-4099 - Fax: +55-16-3633-0999
I nt roduct ion
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com m on problem and a pot ent ial risk of ort hodont ic t r eat m en t , especially in pat ien t s w it h poor or al
hygiene13,237KHUHLVDVLJQL¿FDQWLQFUHDVHLQVDOLYDU\
DQG ELR¿OP OHYHOV RISt rept ococcus m ut ans ( SM) in
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t r eat m ent , concom it ant w it h an incr eased r isk t o dental caries2,14,17. Fixed orthodontic appliances induce
int raoral changes, such as a low- pH environm ent , which increase enam el suscept ibilit y t o t he form at ion of w h it e sp ot lesion s ( WSL) cau sed b y or g an ic
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potentially irreversible and can be observed as early as 1 m ont h aft er t he beginning of ort hodont ic t reat m ent , causing aest het ic problem s1,3,11,12.
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but it depends on pat ient com pliance4 and t hus, ot her SUHYHQWLYHPHDVXUHVVXFKDVWRSLFDOÀXRULGHVKRXOGEH
associat ed2,8,17. There are several form s of delivering WRSLFDOÀXRULGHGXULQJRUWKRGRQWLFWUHDWPHQWZKLFK
include t oot hpast es, m out hr inses, gel, var nishes,
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and elast ics1,3,4,24.
Th e u se of g lass ion om er cem en t ( GI C) f or b r ack et b on d in g is a m ean t o r elease f lu or id e from a rechargeable source t o sit es at higher risk for dev elopin g den t al car ies1 , 3 , 4 , 9 , 1 1 , 1 2 , 1 9 , 2 4 , 2 5. Resin
m odif ied GI C ( RMGI C) is a good alt er n at iv e f or ort hodont ic bonding as t hey offer prot ect ion against
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resist ance t o bracket debonding t han convent ional GI C1,5,6,14,15,21,22,24,30.
Th e an t im icr obial act iv it y of GI C is du e t o a
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and decr ease of pH dur ing t he set t ing r eact ion, which increases t he sensit ivit y of m icroorganism s t o
ÀXRULGH7,14,28. Furt herm ore, t he lit erat ure shows t hat ÀXRULGHUHFKDUJLQJUHVWRUHWKHDQWLEDFWHULDOSURSHUWLHV RIWKHUHVLQPRGL¿HGJODVVLRQRPHUFHPHQWV27.
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clinical t rials. However, t hese st udies have em ployed t he split - m out h design w hereby t he t est m at erial is allocat ed t o t wo quadrant s of t he m out h and t he control m aterial is allocated to the other two quadrants at t he sam e t im e11,16,18,29. This t rial design can lead t o
sam e cross- over effect ont o t he cont rol side.
The aim s of t his parallel designed clinical t rial was t o com pare t he effect of t wo ort hodont ic bonding m at erials ( RMGI C and com posit e resin) on t he levels
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br ack et s an d t o ev alu at e if a 1 . 2 3 % acidu lat ed
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reduct ion of SM count s.
Mat erial and m et hods
Eligible participants were screened am ong patients
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appliances, who had com plet e perm anent dent it ion, were free of caries, had good general healt h, and had not used antibiotics and/ or antim icrobial m outhwashes in t he previous 3 m ont hs. The m inim um sam ple size
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difference of 30% bet ween t he groups. Twenty- nine 12- 20-year- old pat ient s who m et t he inclusion crit eria and present ed high salivary SM count s were enrolled in t he st udy. Following t he approval of t he research proj ect by t he inst it ut ional Et hics Com m it t ee ( process # 2005.1.1013.58.7) , all subj ect s or t heir parent s/ caregivers received verbal and writ t en inform at ion about t he st udy purposes and procedures and signed an inform ed consent form for participation. All patients
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wit h m et iculous rubber cup/ pum ice prophylaxis, and pat ient s received general oral hygiene inst ruct ions and were orient ed t o brush t heir t eet h 3 t im es a day aft er m eals using a t oot hbrush ( Professional®,
Colgat e- Palm olive I ndúst ria and Com ércio Lt da., São
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( Colgat e Máx im a Pr ot eção An t icar ies®, Colgat
e-Palm olive I ndúst ria and Com ércio Lt da., São Paulo, SP, Brazil) supplied by t he researchers t hroughout
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were used.
saliva sam ples were seeded on SB- 20M solid cult ure m edium , pr epar ed accor ding t o Sarav ia, et al.2 6
( 2013) . The num ber of colony form ing unit s ( cfu) per m illiliter of saliva was counted under aseptic conditions under a st ereom icroscope ( Nikon, Tokyo, Japan) wit h
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t ransferred t o t ubes cont aining t hioglycollat e ( Difco Laborat ories I nc., Det roit , MI , USA) and incubat ed at 37oC during 24 h for biot yping. The growt h of 06FIXZDVYHUL¿HGDIWHUWKHLQFXEDWLRQSHULRGDQG
t he following t est s were perform ed for biochem ical
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hydrolysis of arginine and sculin, product ion of H2O2, and sensit ivit y t o 2.0 I U bacit racin.
I n all pat ient s, st er ile new Edgew ise m et allic o r t h o d o n t i c b r a ck e t s ( 0 . 0 2 2 x 0 . 0 2 8 - i n ch sl o t ) ( Generus, GAC I nt ernat ional I nc., Bohem ia, NY, USA) were bonded in all t eet h wit h a RMGI C ( Fuj i Ort ho LC; CG Corporat ion, Tokyo, Japan - experim ent al group, n= 14) or an ort hodont ic light- cured com posit e resin ( Transbond XT, 3M Unitek, Monrovia, CA, USA - control group, n= 15) . The 29 pat ient s were random ized t o t he t wo groups using t he SAS ( St at ist ical Analysis Syst em s) version 9.1.3 for Windows ( SAS I nst it ut e I nc., Cary, NC, USA) st at ist ical soft ware.
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bot h groups at 7 ( T7d) , 21 ( T21d) , 35( T35d) , and 49 ( T49d) days aft er ort hodont ic appliance placem ent . On t he 35t h day, 1.23% APF gel was t opically applied for PLQDIWHUFROOHFWLRQRIVDOLYDDQGELR¿OPVDPSOHV$W HDFKFROOHFWLRQWLPHELR¿OPZDVUHPRYHGZLWKDVWHULOH
probe in a single and cont inuous m ovem ent around bracket s of t he m axillary right canine ( 13) , m axillary left lat eral incisor ( 22) , m andibular left canine ( 33) and m andibular right cent ral incisor ( 41) t o verify t he
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on SM levels.
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t est t ubes cont aining 4 t o 5 glass beads and 2.0 m L
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sam ples were vort exed for 2 and 1 m in, respect ively, for m icrobial desorpt ion, and subm it t ed t o t en- fold serial dilutions (10-5). After that, 50 m L of each dilution
was plat ed equidist ant ly on SB- 20M cult ure m edium and incubat ed under candle j ar syst em at 37° C for 48 t o 72 hours. The num ber of colony form ing unit s
( cfu) perPLOOLOLWHURIVDOLYDDQGELR¿OPZDVFRXQWHG
and biot yping of colonies wit h MS charact erist ics were
perform ed, as describe before for saliva ( T0) .
St at ist ical analysis
The original data m easured in cfu were transform ed in log10 for st at ist ical analysis and are report ed as log( cfu) / m L. The SM log( cfu) / m L m eans in saliva before ort hodont ic t reat m ent ( T0) and in saliva and
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t im e ( T7d, T21d, T35d, and T49d) were com pared using t he St udent ’s t t est for independent sam ples and t he Levene t est was used t o evaluat e t he hom ogeneit y of variances. The hypot hesis of equalit y of SMlog( cfu) / m L m eans in saliva before t reat m ent ( T0) and in saliva
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T35d, and T49d) was t est ed using repeat ed m easures ANOVA and Tukey’s t est . Dat a were analyzed using a GraphPad Pr ism st at ist ical soft w ar e ( GraphPad
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level of 5% was set for all analyses.
Result s
Analysis of t he SMlog( cfu) / m L m eans in salivaat T0 by t he St udent ’s t t est for pairwise com parisons ( p = 0 . 4 2 ) an d t h e Lev en e t est f or h om og en eit y ( p= 0.27) showed t hat t he groups were sim ilar.
Regarding t he effect of t he t est ed m at erials on SM log( cfu ) / m L m ean s in saliva, n o st at ist ically
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t im es wit hin t he Fuj i- Ort ho ( p= 0.09) and Transbond XT ( p= 0.25) gr oups ( Figur e 1) . Fur t her m or e, no
VLJQL¿FDQWGLIIHUHQFHVZHUHIRXQGLQWKH60log( cfu) / m L m eans in saliva bet w een t he Fuj i- Or t ho and Transbond XT groups at any of t he collect ion t im es ( Table 1) . The 1.23% APF gel applicat ion at T35d r educed t he num ber of SM log( cfu) / m L in saliva,
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Regarding t he effect of t he t est ed m at erials on SM
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si g n i f i ca n t d i f f er en ces w er e f o u n d a m o n g t h e collect ion t im es wit hin t he Fuj i- Ort ho group ( p= 0.08) alt hough it could be observed a t rend of a gradual increase in cfu levels over t im e ( T7d t o T35d) ( Figure 2) . I n addit ion, t he SM log( cfu) / m L m eans in dent al
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applicat ion ( T49d - Table 2) . This gradual increase was also observed in t he Transbond XT group, but
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num eric increase occurred in SM log( cfu) / m L m eans
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bonded wit h t his m at erial. Com paring t he ort hodont ic
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in t he SMORJFIXP/PHDQVLQELR¿OPEHWZHHQWKH
Fuj i- Ort ho and Transbond XT groups at any of t he collect ion t im es ( Table 2) .
Discussion
I n t his clinical t rial, com parisons bet w een t w o ort hodont ic bonding m at erials ( RMGI C and com posit e
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bracket s at any collect ion t im e. The m ain difference bet w een t h e m at er ials w as t h at RMGI C at least allowed a bet t er cont rol of SM cfu count s in dent al
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m icr oor gan ism s alon g t h e t r ial per iod t h at w as
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A parallel st udy design was used t o exam ine t he
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em ployed a split- m outh design11,17,29. When exam ining
t h e cap acit y of f lu or id e- con t ain in g m at er ials t o
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which t he t est m at erial has been placed and t here would inevit ably be som e crossover effect ont o t he
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been r epor t ed t o hav e m ost ly a local effect20, a VOLJKWFURVVRYHURIÀXRULGHYLDVDOLYDKDVDOVREHHQ
suggest ed10. This w ould r educe t he differ ence in
effect bet ween t he t est m at erials and t he power of
WKH H[SHULPHQW WR ¿QG GLIIHUHQFH3,4. Accor ding t o
Rogers, Chadwick and Treasure23 ( 2010) , unt il bet t er XQGHUVWDQGLQJKRZÀXRULGHUHOHDVHGRQRQHVLGHRI WKHPRXWKLQÀXHQFHVWKHRWKHUVLGHDSDUDOOHOVWXG\
design seem s t o be t he m ost appropriat e.
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Figure 1- Means and standard deviations [log(cfu)/mL] of Streptococcus mutans in saliva for experimental (Fuji ORTHO LC) and control (Transbond XT) groups at different times of collection
Fuji-Ortho (n=15)
Transbond XT (n=14)
Collection time Mean (S.D.) Mean (S.D.) p value T0 4.35 (1.03) 4.69 (1.23) 0.42 T7d 4.77 (0.85) 5.28 (0.66) 0.08
T21d 4.98 (1.13) 5.19 (1.19) 0.62 T35d 5.18 (1.09) 5.20 (1.42) 0.97
T49d 4.77 (1.47) 4.79 (1.73) 0.97
T0 = before bracket bonding. T7d, T21d, T35d, T49d = 7, 21, 35, and 49 days after bracket bonding, respectively. The p values express the
results of the Student’s t-test for comparison of the materials at each collection time.
in SM log( cfu) / m L m eans in t he saliva of t he pat ient s with brackets bonded with RMGI C and com posite resin,
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These result s m ean t hat t he use of RMGI C t o ret ain ort hodont ic bracket s did not reduce t he num ber of SM cfucount sin saliva. According t o Øgaard, et al.17
( 1997) , it could be explained by t he fact t hat t he
ÀXRULGHUHOHDVHGE\WKHRUWKRGRQWLFERQGLQJDGKHVLYH GLGQRWLQFUHDVHWKHÀXRULGHOHYHOVLQVDOLYDHYHQZKHQ LWZDVDVVRFLDWHGZLWKDÀXRULGHGHQWLIULFH,QWKHVDPH
way, Gorton and Featherstone9GLGQRW¿QGDQ\
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Regarding t he SM log( cfu) / m L m eans in dent al
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wit h RMGI C, a slight increase was observed from T7d t o T35d WKRXJK ZLWKRXW VWDWLVWLFDO VLJQL¿FDQFH
I n addit ion, pract ically no change occurred in SM
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ÀXRULGH DSSOLFDWLRQ DW 735d com par ed w it h T49d. I t
can be assum ed t hat RMGI C was not effect ive in
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ort hodont ic bracket s, but no increase in t he num ber of m icroorganism s was observed eit her. On t he ot her hand, regarding t he SM log( cfu) / m L m eans in dent al
ELR¿OPGHSRVLWVDGMDFHQWWRWKHEUDFNHWVERQGHGZLWK FRPSRVLWHUHVLQDVWDWLVWLFDOO\VLJQL¿FDQWLQFUHDVHZDV
observed from T7d t o T49d HYHQ DIWHU WRSLF ÀXRULGH
applicat ion at T35d.
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t he num ber of SM along t he t im e of or t hodont ic t reat m ent , regardless of t he m at erial used t o ret ain t he bracket s, alt hough RMGI C allowed a bet t er cont rol in SM count s t han t he com posit e. According t o Ahn, et
al.1ÀXRULGHUHOHDVLQJPDWHULDOVFDQDFWDVD
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Figure 2- Means and standard deviations [log(cfu)/mL] of Streptococcus mutansLQELR¿OPIRUH[SHULPHQWDO)XML257+2/&DQGFRQWURO
(Transbond XT) groups at different times of collection
Fuji-Ortho (n=15)
Transbond XT (n=14)
Collection time Mean (S.D.) Mean (S.D.) p value T7d 2.70 (1.38) 2.13 (0.94) 0.13 T21d 3.27 (1.04) 2.61 (1.05) 0.10
T35d 3.35 (1.25) 2.75 (1.14) 0.36 T49d 3.31 (1.03) 3.13 (1.30) 0.72
T0 = before bracket bonding. T7d, T21d, T35d, T49d = 7, 21, 35, and 49 days after bracket bonding, respectively. The p values express the results of the Student’s t-test for comparison of the materials at each collection time.
Table 2- Means of Streptococcus mutans>ORJFIXP/@LQGHQWDOELR¿OPDGMDFHQWWRWKHEUDFNHWVDFFRUGLQJWRWKHRUWKRGRQWLFERQGLQJ
PLFURRUJDQLVPVLQWKHELR¿OPDURXQGWKHEUDFNHWVZDV
expect ed for t he group t hat used RMGI C in our st udy. The r esult s of t his st udy differ fr om t hose of p r ev i o u s i n v est i g at i o n s. Hal l g r en , Ol i v eb y an d
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wit h com posit e ( Concise) com pared wit h GI C ( Aqua-Cem ) 1 m ont h aft er t he beginning of ort hodont ic treatm ent. Wright, et al.29 ( 1996) found sim ilar results ZLWK VLJQL¿FDQWO\ ORZHU 60 FRXQWV LQ GHQWDO ELR¿OP
adj acent t o GI C ( Gerist ore) t han t o com posit e resin (Phase I I ) 1 week after bracket bonding. After 5 weeks, however, t his difference was not det ect ed.
7KH HI¿FDF\ RI *,& LQ FRQWUROOLQJ 60 FRXQWV LQ GHQWDOELR¿OPLVDWWULEXWHGWRWKHDQWLPLFURELDODFWLYLW\ RIÀXRULGHUHOHDVHGIURPWKHVHPDWHULDOV22,28, alt hough ÀXRULGHUHOHDVHDQGEDFWHULDOLQKLELWLRQDUHJUHDWHULQ
convent ional GI C t han in RMGI C7.
I n agreem ent t o t his st udy, Ört hendahl, Thilander an d Sv an b er g1 8 ( 1 9 9 7 ) d id n ot f in d sig n if ican t
differences in SMcfu count sLQGHQWDOELR¿OPDGMDFHQW
t o b r ack et s b on d ed w it h GI C ( Ket ac- Cem ) an d com posite resin (Concise). This result can be attributed
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m ont hs aft er bracket bonding. This is an im port ant
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week, dim inishing considerably aft er t his t im e1,14. I n
t he sam e way, Gillgrass, et al.7 ( 1999) observed t hat *,&DQWLEDFWHULDODFWLYLW\ZDVVLJQL¿FDQWO\KLJKHULQ WKH¿UVWK
6HYHUDOÀXRULGDWHGPDWHULDOVUHOHDVHKLJKOHYHOVRI ÀXRULGHLQLWLDOO\EXWWKHUHOHDVLQJUDWHGURSVUDSLGO\ DQGPLJKWQRWEHVXI¿FLHQWWRSUHYHQWFDULHVRYHUWKH
whole course of ort hodont ic t reat m ent2,6,8,9. However,
Hallgren, Oliveby and Twetm an12 ( 1993) observed that
aft er six m ont hs from t he beginning of ort hodont ic
WUHDWPHQWWKHÀXRULGHOHYHOVZHUHKLJKHULQWKHELR¿OP
adj acent t o GI C t han t o com posit e resin.
$PDWHULDO¶VDELOLW\WREHUHFKDUJHGZLWKÀXRULGH
or ot her ant ibact erial com ponent s m ight ext end it s antibacterial activity for the duration of the orthodontic t reat m ent . The furt her developm ent of ort hodont ic cem ents to exhibit long-lasting antibacterial properties
ZLWKÀXRULGHUHOHDVHZLOOPLQLPL]HWKHULVNRIHQDPHO
dem ineralizat ion around bracket s1,6,14. I t has been UHSRUWHGWKDWÀXRULGHUHOHDVHIURP)XML2UWKR/&DORQH
fell t o m inim al values, but wit h t he associat ion of an
H[WULQVLF ÀXRULGH VRXUFH WKH OHYHOV IHOO LQLWLDOO\ DQG
t hen followed an upward t rend5,13,23,24. These result s PD\ EH FRQ¿UPHG LQ WKLV VWXG\ LQ ZKLFK WKH 60
cfu count s did not increase aft er 1.23% APF t opical applicat ion in t he RMGI C group, as it occurred in t he com posit e group.
Conclusion
Considering t he result s obt ained in t his st udy, we m ay conclude t hat t opical applicat ion 1.23% APF gel did not alt er SMFIXFRXQWVLQVDOLYDDQGGHQWDOELR¿OP
adj acent t o t he ort hodont ic bracket s for bot h groups; t he m at erial used for ort hodont ic bracket bonding ( RMGI C or com posit e resin) did not alt er t he SM cfu count s in saliva along t he t rial period, and t he SMcfu
FRXQWVLQGHQWDOELR¿OPDGMDFHQWWREUDFNHWVERQGHG
with RMGI C practically did not change, while there was
DVLJQL¿FDQWLQFUHDVHLQWKH60 cfu count s adj acent t o bracket s bonded wit h com posit e resin during t he t rial period.
Acknowledgem ent s
The aut hors are indebt ed t o Dr. I zabel Yoko I t o ( in m em oriam ) of Depart m ent of Clinical Analysis, Toxicology and Brom atology, School of Pharm aceutical Sciences of Ribeirão Pret o, Universit y of São Paulo, for helpful assist ance during m icrobiological processing and analysis.
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$KQ6-/HH6-/HH'</LP%6(IIHFWVRIGLIIHUHQWÀXRULGHUHFKDUJLQJ SURWRFROVRQÀXRULGHLRQUHOHDVHIURPYDULRXVRUWKRGRQWLFDGKHVLYHV J Dent . 2011; 39( 3) : 196- 201.
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![Table 1- Means of Streptococcus mutans [log(cfu)/mL] in saliva according to the orthodontic bonding material and sample collection time](https://thumb-eu.123doks.com/thumbv2/123dok_br/14984590.511578/4.892.252.636.90.404/table-means-streptococcus-according-orthodontic-bonding-material-collection.webp)
