Therefore, the evaluation of the effects of orthodontic treatment on oral
Therefore, the aim of this review was to evaluate if orthodontic appliances induce changes in Does an orthodontic appliance affect the number and the composition of Are there any differences in
This systematic review was performed according to the PRISMA statement.11
According to Participants-Intervention-Comparison-Outcome-Study design schema (PICOS), the inclusion and exclusion criteria are summarised in Table I.
List of inclusion and exclusion criteria.
Field | Inclusion | Exclusion |
---|---|---|
Patients | Children, adolescents or young adults (<25 years) of any sex, ethnicity and malocclusion, in general good health | Adults (>25 years) |
Intervention (exposure) | Orthodontic treatment with any vestibular fixed appliance (metal or ceramic, conventionally-ligated or self-ligated) or any removable appliances | Patients not receiving orthodontic treatment |
Comparison | A. No comparison (For the descriptive analysis of Candida changes in treated patients) |
|
Outcome | Quantitative and qualitative analysis of |
No clear mention of the analysis or time-point |
Study design | Randomized clinical trials or non-randomized, prospective or retrospective, cohort studies |
Note: Tx, treatment; ROA, removable orthodontic appliance; FOA, fixed orthodontic appliance.
The search for articles was carried out using four electronic databases (Pubmed, Scopus, Web of Knowledge, CENTRAL), and included publications in the English language from inception up to September 2021. Human studies which featured the keywords “orthodontic” OR “orthodontics” OR “fixed appliance” OR “removable appliance” OR “bracket” OR “removable aligner” AND “Candida” OR “Candidiasis” OR “Candidosis”, were identified. In addition, the reference and citation lists of the included trials and relevant reviews were manually searched.
All titles identified from the literature were screened and selected by two independent authors (A.C.; E.L.M.). Duplicate studies were eliminated. The abstracts were examined and full texts were obtained if additional data were needed to fulfil the eligibility criteria. Conflicts were resolved by discussion with a third author (L.L.M.).
The characteristics of the included studies (study design, patients, age, orthodontic appliance, sample site, timing, analysis method, outcome, additional measures, quality of the study) were independently extracted by two authors (A.C.; E.L.M.). For further clarification, missing or unclear information was directly requested of the respective authors.
The methodological quality of the included studies was assessed according to the “Swedish Council on Technology Assessment in Health Care Criteria for Grading Assessed Studies” (SBU) method.12 Articles were ranked into three levels (A, B, C) of evidence (Table II) and, based on the score assigned to each study, the review level of available evidence was further scored into four grades (1,2,3,4) (Table III).
Swedish council on technology assessment in health-care (SBU) criteria for grading assessed studies.
Definitions of evidence level.
Level | Evidence | Definition |
---|---|---|
1 | Strong | At least two studies assessed with level “A” |
2 | Moderate | One study with level “A” and at least two studies with level “B” |
3 | Limited | At least two studies with level “B” |
4 | Inconclusive | Fewer than two studies with level “B” |
Due to the lack of homogeneity in the study setting (study design, sample site, sample collection time and methods), only a systematic review could be conducted rather than a meta-analysis.
The initial search identified 533 articles from Pubmed, Scopus and Web of Knowledge. After eliminating duplicates and ineligible studies by title and abstract, a total of 157 full texts were screened. Finally, a total of sixteen papers were identified according to the eligibility criteria.
The flow chart of the selection of eligible studies for this review is summarised in Figure 1.
Flow diagram of the included studies according to the PRISMA.
According to the SBU tool, the quality of evidence for nine studies was moderate (grade B) and for seven studies was low (grade C). As a result, the level of evidence for the conclusions of this review was considered limited (level 3).
The characteristics of the studies are presented in Table IV. Of the 16 included studies, all were prospective in nature and included four reports which described the changes in
Characteristics of the studies.
No. | Study ID/ | Design | Patients (M/F) | Agea | Appliance | Sample site | Timing | Analysis method | Outcome | Additional measures | Quality of the study |
---|---|---|---|---|---|---|---|---|---|---|---|
1 | Arendorf 198513 | Prospective | Exp: 33 (15/18) | 8–17 y | ROA | Six mucosal site (ant and post palate, ant and post tongue, r and l cheek) | T0 = before AppIns |
Imprint Culture (A |
Prevalence (%) Density | PI + saliv pH | C |
2 | Hägg 200414 | Prospective | Exp: 27 (13/14) | 15.5 + 2.3 y | FOA | Rinse Dorsum of the tongue Supra and subgingival plaque | T0=before AppIns |
Oral Rinse ( |
Prevalence (%) |
PI + count of |
B |
3 | Arslan 200815 | Prospective | Exp 1: 72 |
19.8 y | FOA (metal brackets) | Dorsum of the tongue (only for T0) |
T0 = before AppIns |
Swab Culture |
Prevalence (%) |
None | B |
4 | Lee 200816 | Prospective | Exp: 97 (38/59) | 17.7 y | FOA | Rinse | From T0 = before AppIns to T10 = 12 mos after T0 | Oral rinse technique ( |
Prevalence (%) |
None | C |
5 | Mahmoudadabi 200917 | Prospective | Exp 1: 34 |
13 y (Exp 1) |
ROA (upper) Cr | Saliva |
T0 = before AppIns |
Culture (Arendorf and Walker, Davenport techiques) ( |
Prevalence (%) |
None | C |
6 | Gonçalves e Silva 201418 | Prospective | Exp 1: 30 |
9.1+−1.7 (Exp 1) |
ROA Cr | Cheek and lateral surface of the tongue Saliva | T0 = before AppIns |
Culture ( |
Prevalence (%) |
Counts of Anti-C. |
B |
7 | Arab 20168 | Prospective | Exp 1: 30 (6/24) | 12–18 y | FOA | Saliva | T0 = before AppIns |
Culture |
Count (CFU) | Salivary flow and pH Microbial counts (S. |
C |
8 | Khanpayeh 201419 | Prospective | Exp 1: 40 |
7–18 y | FOA |
T0 = before AppIns |
Culture |
Frequency (%) |
None | B | |
9 | Kundu 201620 | Prospective | Exp 1: 10 |
6–15 y | ROA Fixed space maintainers (nc) | T0 = before AppIns |
Culture |
Count (CFU) | Bacterial count ( |
B | |
10 | Zheng 201621 | Prospective | Exp 1: 50 (23/27) | 10–18 (13.6 y) | FOA | Gargle | T0 = before AppIns |
Culture |
Incidence (%) |
None | B |
11 | Shukla 201722 | Prospective | Exp 1: 60 | 16–18 y | FOA | Buccal and labial Plaque of anterior teeth and U6 + L6 | T0 = before AppIns |
Swab Culture ( |
Count (CFU) | B | |
12 | Grzegocka 202023 | Prospective | Exp 1: 17 (6M/11) | 17+−7 y | FOA | Oral rinse Elastomeric rings (nc) | T0 = before AppIns |
Culture |
Prevalence (%) |
API |
C |
13 | Sanz-Orrio-Soler 202024 | Prospective Controlled Trial | Exp 1: 124 (43/80) | 19.5 y | FOA (metal or ceramic) | U and L vestibule | T0 = before AppIns |
Swab Culture |
Frequency (%) |
Questionnaire about hygiene habits | B |
14 | Pellissari 202125 | Prospective | Exp 1: 23 (7/10) |
20.7+− 8.7 y (Exp 1) |
FOA |
Biofilm around bck | From 3 to 6 mos after AppIns | Culture Biochemical tests ( |
Prevalence (%) |
Fungal strains and resistance to Antifungals Bacterial strains and resistance to Antimicrobials | B |
15 | Rodríguez Rentería 202126 | Prospective | Exp 1: 55 (34/21) | 8.4 y | ROA | Support oral mucosa Surface of ROA (not considered) | T0 = before AppIns |
Chromogenic culture |
Frequency (%) |
Microbial species |
C |
16 | Kouvelis 202127 | Prospective | Exp 1: 30 (17/13) | 13.97 +− 2.07 | FOA | Saliva | T0 = before AppIns |
Culture | Count | Salivary pH, flow rate, buffering capacity |
C |
Note:
Patient ages are reported as means (one value) or if no mean is available as range (two values in parentheses). Exp, experimental group; Cr, control group; ROA, removable orthodontic appliance; FOA, fixed orthodontic; nc, not considered in this study; %, percentage; CFU, colony forming unit; PI, plaque index; saliv pH, salivary pH; API, Approximal Plaque Index; GBI, Gingival Bleeding Index; We, week; mo, month; y, years; AppIns, appliance insertion; AppRem, appliance removal; bck, brackets; Ant, anterior; post, posterior; r, right; l, left; U, upper; L, lower; U5, upper second premolar; L5, lower second premolar; U1, upper central incisors, L1, lower central incisors; U6, upper first molars; L6, lower first molars; SDA, Sabouraud's dextrose agar; PCR, Polimerase Chain Reaction; RAPD, Random Amplification of Polymorphic DNA.
The results are summarised in Figure 1.
Two studies20,26 described the short-term changes occurring during ROA treatment; eight studies8,14,15,21,22,23,24,27 analysed the effects related to FOA therapy. From baseline to one month of ROA therapy, a significant increase (
One study20 reported the mid-term effects of ROA treatment and found a significant increase (
One study20 investigated the long-term
Two studies evaluated the differences in
Eleven studies described the changes in the frequency of the different candida strains during orthodontic treatment using a ROA17,18,19,26 and FOA.14,15,16,21,23,24,25 Mahmoudabi et al.17 observed that
Arendorf et al.13 suggested that ROA may initiate a
Several studies8,15,21,22 reported a significant increase in candida colonies during the early stages of FOA treatment, compared to pre-treatment levels. However, contrasting results were reported by earlier studies16,23,24 in which FOA did not increase the number of
It is accepted that the most common aetiological contributor of oral candidiasis is
The assessment of candida colonies in orthodontic patients compared to untreated controls showed that
The analysis of the
Furthermore, differences in the oral yeasts of patients with or without orthodontic appliances have demonstrated a higher
A higher colonisation of non-
The increase in
This situation may be explained by the opportunistic pathogenic character of these micro-organisms, that may cause infection in cases of immuno-suppression. Therefore, clinicians should be cautious when providing orthodontic treatment in immuno-compromised children because of an increased risk of candida infection. This is especially valid during FOA treatment because traumatic mucositis often occurs to the oral mucosa due to FOA irritation throughout treatment.15
Additional host-dependent variables, such as sialometric variations,8,13 immuno-deficiency, a diet rich in sugar and deficient oral hygiene,14,23 should also be considered as contributors to the formation of a
The oral prevention, correct hygiene habits and a greater awareness of children under orthodontic treatment and their parents, not only guarantees the success of treatment, but can also decrease the risk of systemic and/or local diseases, especially in immuno-compromised patients.14,19,21,22,23,24,26
Considering the clinical heterogeneity of the reviewed studies, as well as the differences between the sample sites, the analytical methods and, in the quantitative assessment (the number composition was expressed as counts of CFU or as a percentage of frequency), the present review reflects only the changing trend in the colonisation of oral
According to the SBU tool, the present review may draw conclusions reflecting a limited level of evidence.
ROA induced a temporary increase of
Contrasting and conflicting results have been reported for FOA treatment.
FOA therapy seemed to increase the frequency of
Orthodontic treatment (especially with FOA) promoted oral