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ORIGINAL ARTICLE
Year : 2017  |  Volume : 35  |  Issue : 1  |  Page : 34-40
 

Evaluation of role of fixed orthodontics in changing oral ecological flora of opportunistic microbes in children and adolescent


1 Department of Orthodontics, Peoples College of Dental Sciences, Bhopal, Madhya Pradesh, India
2 Department of Orthodontics, Corps Dental Unit, Bhopal, Madhya Pradesh, India
3 Department of Microbiology, Barkatullah University, Bhopal, Madhya Pradesh, India
4 Department of Pathology, Peoples College of Dental Sciences, Bhopal, Madhya Pradesh, India

Date of Web Publication31-Jan-2017

Correspondence Address:
Rajkumar Maurya
Corps Dental Unit, Bhopal - 462 001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.199226

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   Abstract 

Objective: To determine the prevalence and counts of Streptococcus mutans and Candida species in orthodontic fixed appliance therapy patients and comparison of the efficiency of manual and electronic toothbrushes on minimizing plaque by reducing S. mutans and Candida species in above-mentioned patients. Materials and Methods: The study was carried out on total number of sixty patients scheduled for orthodontic treatment (age group: 13–18). Plaque samples were collected to determine oral carriage of S. mutans and Candida of these patients, and readings were noted at T0 (before appliance placement), 2nd and 3rd month after the placement of appliances (T1 and T2). Counts of S. mutans were determined using Dentocult SM kit. Candida was cultured on Sabouraud's dextrose agar. The participants in the study group (orthodontic patients) were then divided into two groups each of 30: Group 1 (manual toothbrush), Group 2 (electronic toothbrush), and plaque samples were taken at the end of 1st, 2nd, and 3rd month to determine the efficacy of manual versus electronic toothbrushes. Results: After orthodontic treatment, colonization of S. mutans and Candida increased dramatically. Results for S. mutans counts and Candida clearly showed superiority of electronic tooth brushing over manual tooth brushing during orthodontic treatment. Conclusion: Results clearly showed that orthodontic appliances increase colonization of S. mutans and Candida albicans in oral cavity over the period of treatment time which can be controlled with proper timely brushing. The study also concludes superiority of electronic tooth brushing over manual tooth brushing.


Keywords: Fixed appliances, oral microflora, tooth brushing


How to cite this article:
Shukla C, Maurya R, Singh V, Tijare M. Evaluation of role of fixed orthodontics in changing oral ecological flora of opportunistic microbes in children and adolescent. J Indian Soc Pedod Prev Dent 2017;35:34-40

How to cite this URL:
Shukla C, Maurya R, Singh V, Tijare M. Evaluation of role of fixed orthodontics in changing oral ecological flora of opportunistic microbes in children and adolescent. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2017 Jul 22];35:34-40. Available from: http://www.jisppd.com/text.asp?2017/35/1/34/199226



   Introduction Top


The accumulation of dental plaque (biofilm) at gingival margins is most important etiologic factor in periodontal disease. Fixed or removable orthodontic appliances also impede the maintenance of oral hygiene, resulting in plaque accumulation.[1],[2] Thus, the combination of orthodontic therapy and poor oral hygiene can cause serious damage to the periodontium.[3],[4],[5]

The component of fixed orthodontic appliances creates new retention areas that are suitable for bacterial colonization and lead to an increase in the number and change in the nature of microorganisms.[6],[7]

The absolute number and percentage of Streptococcus mutans and lactobacilli increases during orthodontic therapy.[8] The periodontal pathogens such as Actinobacillus actinomycetemcomitans[5],[9],[10] and Tannerella forsythia fungal pathogen Candida[9] have also been significantly associated with gingival inflammation during orthodontic therapy.[9]

S. mutans is a part of normal flora of oral cavity. They become pathogenic only under conditions that lead to frequent and prolonged acidification of the dental plaque.[11] Patients undergoing orthodontic therapy have oral ecological changes that lead to increased numbers of mutans streptococci in saliva and plaque.

Candida species is a commensal yeast which colonizes the oropharyngeal region of up to 60% of all healthy immune-competent individuals.[12] The ability of Candida to become a pathogenic microorganism capable of causing infections is attributed to a number of factors.[13] Local oral factors may also influence oral Candida carriage, and these mainly include wearing removable dentures, fixed and removable orthodontic appliances, dry mouth, high sugar diet, and poor oral hygiene.[12]

Daily brushing and flossing is a preventive care and must be taken by orthodontic patients for good oral health.[15] In these contexts, many types of toothbrushes both manual and powered options have been promoted for orthodontic patients.[14] The purpose of this study is to estimate the counts and colonization pattern of S. mutans and Candida after application of fixed orthodontic appliances and to compare the efficacy of electric and manual toothbrushes on reducing the levels of oral microflora.


   Materials and Methods Top


A total number of sixty patients scheduled for orthodontic treatment in the age group of 13–18 years were selected for the study. The inclusion criteria were (1) patients with permanent dentition, (2) no clinical sign of periodontitis, and (3) no history of any systemic illness. Patients having smoking habit, poor systemic health, having a history of periodontal treatment, pregnant patients, and undergoing antibiotic administration were excluded from the study.

Plaque samples were collected from buccal and labial aspects of the anterior teeth and four first molars to determine oral carriage of S. mutans and Candida of these patients, and readings were noted as T0[Figure 1]a and [Figure 1]b. Second and third month after the placement of appliances (0.22 MBT preadjusted Gemini), plaque samples were collected again from the same site, and readings were noted as T1 and T2[Figure 2]a and [Figure 2]b. Counts of S. mutans were determined using Dentocult SM kit (Orion Diagnostica, Espoo, Finland) [Figure 3]a. The presence of mutans streptococci was evidenced by light blue to dark blue raised colonies on the inoculated surface of the strip. Results were interpreted by comparing the strip with the manufacturer's model chart scores [Figure 3]b. Swabs were also collected from the same site and cultured on Sabouraud's dextrose agar (SDA) for Candida counts [Figure 4]a. Candida was identified by growth characteristics, Gram stain and germ tube test, and Candida counts as colony-forming units (CFU)/mm 2.
Figure 1: (a) Plaque sample collected from sterile cotton swab before starting treatment from incisors area. (b) Plaque sample collected from sterile cotton swab before starting treatment from molars area

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Figure 2: (a) Plaque sample collected from sterile cotton swab after starting treatment from incisors area. (b) Plaque sample collected from sterile cotton swab after starting treatment from molar area

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Figure 3: (a) Dentocult SM strip mutans kit. (b) Results were interpreted by comparing the strip with the manufacturer's model chart scores for Streptococcus mutans in CFU/ml

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Figure 4: (a) Sabouraud's dextrose agar plate. (b) Sabouraud's dextrose agar plate showing Candida growth colonies. (c) Gram-stains showing Candida colonies. (d) Fresh normal pooled human sera collection for Germ tube test of Candida. (e) Germ tube represented the initiation of a hypha directly from the yeast cell colonies

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  • Score 0: <10,000 CFU/ml
  • Score 1: <100000 CFU/ml
  • Score 2: 100,000–1,000,000 CFU/ml
  • Score 3: >1,000,000 CFU/ml.


Second plaque sample collected by sterile cotton swab was cultured on SDA plate. Inoculated culture plates were incubated at 37°C for 48 h. After 48 h of incubation colonies on SDA were small to medium sized, becomes large on further incubation, round, entire margin cream colored, pasty, and easily emulsifiable [Figure 4]b. Gram-staining was done to determine the morphology of Candida [Figure 4]c. For species identification of Candida, Germ tube test is performed [Figure 4]d. Of all the species of Candida, Candida albicans forms germ tube [Figure 4]e. On the basis of germ tube formation, it can be differentiated from non-C. albicans.

The participants in the study group (orthodontic patients) were then divided into two groups each of thirty, and after giving proper brushing instructions, they were assigned sequences of brush use as follows:

  • Group 1: Manual toothbrush
  • Group 2: Electronic toothbrush.


The subjects were advised to use their assigned toothbrushes three times a day for 2 min with designated toothpaste (Colgate). They were then evaluated in the afternoon periods after 3–5 h of brushing at the end of 1st month, 2nd, and 3rd month period. Modified bass technique method of brushing was explained and demonstrated to patients. These patients of both the groups were invited for taking plaque samples at the end of 1st month. They were evaluated at the end of morning or afternoon periods with 3–5 h of plaque accumulation. Plaque samples were collected from the patients of both the groups in the same manner as in their first visit and evaluated for the counts of S. mutans and Candida. This whole procedure was repeated till the end of the 3rd month of the study.


   Results Top


The counts of S. mutans were evaluated using Dentocult SM kit, and the results were interpreted according to the model chart as Class 0, Class 1, Class 2, and Class 3.

When Kruskal–Wallis test was applied it showed a significant difference between different time interval Dentocult score for S. mutans in orthodontic patients (P = 0.000). Mann–Whitney U-test showed a significant difference between T0 and T1; T0 and T2; and T1 and T2 during pairwise comparison as shown in [Table 1].
Table 1: Comparison of Dentocult score for Streptococcus mutans in orthodontic patients

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Kruskal–Wallis test was applied which showed a significant difference between different time interval for CFU for Candida in orthodontic patients (P = 0.000). Mann–Whitney U-test showed a significant difference between T0 and T1; T0 and T2; and T1 and T2 as shown in [Table 2].
Table 2: Comparison of colony forming units for Candida in orthodontic patients

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In the Group 1 patients using manual toothbrushes, assessment of S. mutans scores showed twenty-nine patients (96.7%) at M1 with moderate colonization, and only one patient showed mild colonization. Further improvement after manual brushing at M2 was noted with reduction in S. mutans colonies to mild colonization in all patients and negligent colonization at M3 in 25 patients (85%). Kruskal–Wallis test showed significant difference between different time interval for Dentocult score for S. mutans in orthodontic patients (P = 0.000). Similarly, Mann–Whitney U-test applied for pair-wise comparison showed significant difference between M1 and M2; M1 and M3; M2 and M3 (P = 0.000) as depicted in [Table 3].
Table 3: Comparison of Dentocult score for Streptococcus mutans in manual brushing orthodontic patients

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Similarly, assessment of Candida in manual brushing group showed improvement in oral hygiene after manual brushing from M1 with mean value 5000.00 for Candida colonization to none at M3. Further, Kruskal–Wallis test showed a significant difference between different time intervals for CFUs for Candida in manual brushing orthodontic patients (P = 0.035) and Mann–Whitney U-test applied for pair-wise comparison showed a significant difference between M1 and M2; M1 and M3; M2 and M3 as depicted in [Table 4]. In Group 2 patients, S. mutans scores in electronic brushing group showed drastic improvement in oral hygiene from E1 to E3. Kruskal–Wallis test showed a significant difference between different time interval for Dentocult score for S. mutans in electronic brushing orthodontic patients and Mann–Whitney U-test applied for pair-wise comparison showed a significant difference between E1 and E2; E1 and E3; E2 and E3 (P = 0.000) as depicted in [Table 5].
Table 4: Comparison of colony-forming units for Candida in manual brushing orthodontic patients

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Table 5: Comparison of Dentocult score for Streptococcus mutans in electronic brushing orthodontic patients

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Similarly, colonization of Candida in electronic tooth brushing group showed tremendous improvement in oral hygiene starting from E1 to E3. When Kruskal–Wallis test was applied for Candida showed a significant difference between different time intervals for CFUs for Candida in electronic brushing orthodontic patients, and Mann–Whitney U-test applied for pair-wise comparison for Candida showed significant difference between E1 and E2; E1 and E3 as depicted in [Table 6].
Table 6: Comparison of colony-forming units for Candida in electronic brushing orthodontic patients

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Comparison of Dentocult Score for S. mutans in manual and electronic brushing orthodontic showed the superiority of electronic tooth brushing over manual tooth brushing during orthodontic treatment as early as 1st month of brushing which later went on to be statistically significant after M3/T3. Descriptive statistics for comparison of Candida colonization in manual and electronic tooth brushing in orthodontic patients showed clear superiority of electronic tooth brushing starting from M1/E1 which further increased in superiority over the periods of M2/E2. Mann–Whitney U-test comparison of Dentocult score for S. mutans and similarly for Candida in Manual and electronic brushing orthodontic patients for M1/E1 and M2/E2 showed a significant difference. Mann–Whitney U-test comparison of Dentocult score for S. mutans in manual and electronic brushing orthodontic patients for M3/E3 showed significant difference but for comparison of colonization for Candida in manual and electronic brushing orthodontic patients for M3/E3 showed no significant difference.


   Discussion Top


Fixed orthodontic appliances are considered to jeopardize dental health due to the accumulation of microorganisms that may cause enamel demineralization, clinically visible as white spot lesions.[15] Biofilm formation on dentures results from complex interactions among yeast, bacteria, nutrients, and saliva or even serum proteins.[16],[17]

S. mutans is isolated in 50%–80% of orthodontic patients as a common cause of decalcification due to the accumulation of cariogenic plaque around the brackets progressing into carious lesions in such patients. In addition, C. albicans may also be isolated from the mouth of patients using orthodontic devices.[18],[19],[20] Chronic atrophic candidiasis or (denture-induced stomatitis) is the most common clinical manifestation of oral candidiasis and occur in up to 60% of denture wearers.[21]

In our study, although the sample size was relatively small, the crossover design enabled meaningful statistical results to be achieved. The study showed that of the 60 patients, before starting orthodontic treatment 46 patients (76%) showed mild, and 14 patients (24%) showed moderate colonizations of S. mutans. In addition, very few of the patients before starting treatment showed colonization with Candida, which is in contrast to a study by Dar-Odeh et al.[13] and Brawner and Cutler et al.[12]

In the present study, after orthodontic treatment severity of colonization increased dramatically with fifty patients showing (84%) moderate and six patients (10%) showing severe colonization of S. mutans at T1 which further increased in severity at T2 with 54 patients (90%) showing severe colonization with S. mutans. These findings correlates with a similar study by Jordan Corbett et al.[2] Our study showed that counts of S. mutans were higher in plaque samples of patient with orthodontic appliances as compared to patients without orthodontic appliances. Our finding also correlates with an investigation by Attin et al.[22] In comparing CFU for Candida in orthodontic patients before starting treatment showed mean value of 166.67 that increased in severity after orthodontic treatment at T1 mean value 3833.33 and T2 mean value 7333.33. A similar study showed the association of these appliances with important related factors, namely, nutritional, dietary, and other local oral factors (salivary flow rate, salivary pH, and smoking), in which it was found that orthodontic appliances did not encourage Candida colonization.[13]

It was observed that in the Group 1 patients using manual toothbrushes, S. mutans scores showed reduction in colonization from M1 to M3. Similarly assessment of Candida in manual brushing group showed improvement in oral hygiene after manual brushing from M1 to M3. All species of Candida were identified as C. albicans in all the positive cases, which were confirmed by Gram-stain and germ, tube formation. This supports the finding that C. albicans is the single most predominant candidal species in the oral cavity.[23]

In the Group 2 patients, S. mutans scores in electronic brushing group showed drastic improvement in oral hygiene with mild colonization at E1 to negligent at E2 and E3. This shows that electronic brushes were better in removing plaque as well reducing counts of S. mutans in orthodontic patients. Similarly, colonization of Candida in electronic tooth brushing group showed tremendous improvement in oral hygiene starting from E1 to E3 in all patients. The isolation was not significant, but counts did get reduced in Group 2 patients. The electronic brushes progressively reduced the counts of S. mutans as well as Candida in patients with fixed orthodontic appliances. Comparison of Dentocult score for S. mutans in Manual and electronic brushing orthodontic patients showed in 96% patients moderate colonization at M1 and mild colonization at E1 in all cases of electronic tooth brushing group. At M2 manual brushing group showed mild colonization for S. mutans in all patients while electronic tooth brushing group showed as high as 84% patient having negligent colonization for S mutans. The results clearly showed the superiority of electronic tooth brushing over manual tooth brushing during orthodontic treatment as early as 1st month of brushing which later went on to be statistically significant after M3/T3. Comparison of Candida colonization in manual and electronic tooth brushing in orthodontic patients showed clear superiority of electronic tooth brushing starting from M1/E1 with further increased in superiority over the periods of M2/E2.

In particular, studies comparing manual with electric toothbrushes have presented conflicting results in orthodontic patients. While some studies suggest that electric toothbrushes are superior to manual toothbrushes, others report equal effectiveness in plaque removal.[24],[25]

There are few in vivo studies comparing brushes using microbiological techniques. In our study, electronic brushes were found to be more efficient on reducing visible plaque from the teeth of the patients as well as reducing the counts of S. mutans and Candida.

Shukla et al. analyzed the colonization of S. mutans in orthodontic patients in the Indian populations. They showed that orthodontic appliance increased colonies of S. mutans over the period of 3 months. The present study by same authors reaffirmed the same findings along with increase in Candida. It also showed that electric brushing was quiet effective in reducing bacterial and fungal colonies than manual tooth brushing.[26]

In contrast to the present study, Haffajee et al. analyzed the presence and quantity of various bacteria, including S. mutans in patients with chronic periodontitis. They found no differences in the levels of S. mutans among the patients who had used an electric brush for 6 months.[24] Electronic brushes due to their rotating, oscillating, and counter directional action clear more plaque.[24]


   Conclusion Top


  • Results clearly showed that orthodontic appliances increase colonization of S. mutans and C. albicans in the oral cavity over the period of treatment time which can be controlled with proper timely brushing
  • The study also concludes superiority of electronic tooth brushing over manual tooth brushing during orthodontic treatment as early as 1st month of brushing which later went on to be statically significant after M3/T3.


 
   References Top

1.
Batoni G, Pardini M, Giannotti A, Ota F, Giuca MR, Gabriele M, et al. Effect of removable orthodontic appliances on oral colonisation by mutans streptococci in children. Eur J Oral Sci 2001;109:388-92.  Back to cited text no. 1
    
2.
Jordan C, LeBlanc DJ. Influences of orthodontic appliances on oral populations of mutans streptococci. Oral Microbiol Immunol 2002;17:65-71.  Back to cited text no. 2
    
3.
Lundström F, Hamp SE, Nyman S. Systematic plaque control in children undergoing long-term orthodontic treatment. Eur J Orthod 1980;2:27-39.  Back to cited text no. 3
    
4.
Huber SJ, Vernino AR, Nanda RS. Professional prophylaxis and its effect on the periodontium of full-banded orthodontic patients. Am J Orthod Dentofacial Orthop 1987;91:321-7.  Back to cited text no. 4
    
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Huser MC, Baehni PC, Lang R. Effects of orthodontic bands on microbiologic and clinical parameters. Am J Orthod Dentofacial Orthop 1990;97:213-8.  Back to cited text no. 5
    
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Forsberg CM, Brattström V, Malmberg E, Nord CE. Ligature wires and elastomeric rings: Two methods of ligation, and their association with microbial colonization of Streptococcus mutans and lactobacilli. Eur J Orthod 1991;13:416-20.  Back to cited text no. 6
    
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Türkkahraman H, Sayin MO, Bozkurt FY, Yetkin Z, Kaya S, Onal S. Archwire ligation techniques, microbial colonization, and periodontal status in orthodontically treated patients. Angle Orthod 2005;75:231-6.  Back to cited text no. 7
    
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Sakamaki ST, Bahn AN. Effect of orthodontic banding on localized oral lactobacilli. J Dent Res 1968;47:275-9.  Back to cited text no. 8
    
9.
Sallum EJ, Nouer DF, Klein MI, Gonçalves RB, Machion L, Wilson Sallum A, et al. Clinical and microbiologic changes after removal of orthodontic appliances. Am J Orthod Dentofacial Orthop 2004;126:363-6.  Back to cited text no. 9
    
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Paolantonio M, Festa F, di Placido G, D'Attilio M, Catamo G, Piccolomini R. Site-specific subgingival colonization by Actinobacillus actinomycetemcomitans in orthodontic patients. Am J Orthod Dentofacial Orthop 1999;115:423-8.  Back to cited text no. 10
    
11.
Jeevarathan J, Deepti A, Muthu MS, Rathna Prabhu V, Chamundeeswari GS. Effect of fluoride varnish on Streptococcus mutans counts in plaque of caries-free children using Dentocult SM strip mutans test: A randomized controlled triple blind study. J Indian Soc Pedod Prev Dent 2007;25:157-63.  Back to cited text no. 11
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12.
Brawner DL, Cutler JE. Oral Candida albicans isolates from nonhospitalized normal carriers, immunocompetent hospitalized patients, and immunocompromised patients with or without acquired immunodeficiency syndrome. J Clin Microbiol 1989;27:1335-41.  Back to cited text no. 12
    
13.
Dar-Odeh N, Shehabi A, Al-Bitar Z, Al-Omari I, Badran S, Al-Omiri M, et al. Oral Candida colonization in patients with fixed orthodontic appliances: The importance of some nutritional and salivary factors. Afr J Microbiol Res 2011;5:2150-4.  Back to cited text no. 13
    
14.
Oral and Dental Health Research Centre. Available from: http://www.colgate.compara. 4. [Last accessed on 2011 Sept 03].  Back to cited text no. 14
    
15.
Costa MR, Silva VC, Miqui MN, Sakima T, Spolidorio DM, Cirelli JA. Efficacy of ultrasonic, electric and manual toothbrushes in patients with fixed orthodontic appliances. Angle Orthod 2007;77:361-6.  Back to cited text no. 15
    
16.
Collee JG, Fraser AG, Marmion BP, Simmons A. Mackey and McCartney. Practical Medical Microbiology. 14th ed. Churchill Livingstone, New york: Elsevier; 1996. p. 796-9.  Back to cited text no. 16
    
17.
Nikawa H, Nishimura H, Hamada T, Kumagai H, Samaranayake LP. Effects of dietary sugars and, saliva and serum on Candida biofilm formation on acrylic surfaces. Mycopathologia 1997;139:87-91.  Back to cited text no. 17
    
18.
Nikawa H, Nishimura H, Makihira S, Hamada T, Sadamori S, Samaranayake LP. Effect of serum concentration on Candida biofilm formation on acrylic surfaces. Mycoses 2000;43:139-43.  Back to cited text no. 18
    
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Addy M, Shaw WC, Hansford P, Hopkins M. The effect of orthodontic appliances on the distribution of Candida and plaque in adolescents. Br J Orthod 1982;9:158-63.  Back to cited text no. 19
    
20.
Odds FC. Candida and Candidosis: A Review and Bibliography. London: Bailliere Tindall; 1988.  Back to cited text no. 20
    
21.
Ogaard B, Arends J, Helseth H, Dijkman G, van der Kuijl M. Fluoride level in saliva after bonding orthodontic brackets with a fluoride containing adhesive. Am J Orthod Dentofacial Orthop 1997;111:199-202.  Back to cited text no. 21
    
22.
Attin R, Thon C, Schlagenhauf U, Werner C, Wiegand A, Hannig C, et al. Recolonization of mutans steptococci on teeth with orthodontic appliances after antimicrobial therapy. Eur J Orthod 2005;27:489-93.  Back to cited text no. 22
    
23.
White LW. Efficacy of a sonic toothbrush in reducing plaque and gingivitis in adolescent patients. J Clin Orthod 1996;30:85-90.  Back to cited text no. 23
    
24.
Haffajee AD, Smith C, Torresyap G, Thompson M, Guerrero D, Socransky SS. Efficacy of manual and powered toothbrushes (II). Effect on microbiological parameters. J Clin Periodontol 2001;28:947-54.  Back to cited text no. 24
    
25.
Baker K. Mouthrinses in the prevention and treatment of periodontal disease. Curr Opin Periodontol 1993;3:89-96.  Back to cited text no. 25
    
26.
Shukla C, Maurya RK, Singh V, Tijare M. Evaluation of changes in Streptococcus mutans colonies in microflora of the Indian population with fixed orthodontics appliances. Dent Res J (Isfahan) 2016;13:309-14.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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