|Year : 2018 | Volume
| Issue : 3 | Page : 301-307
The effect of fiber-reinforced composite versus band and loop space maintainers on oral Lactobacillus acidophilus and Streptococcus mutans levels in saliva
Mohamed Abd-Ellatif El-Patal1, Moshabab A Asiry2, Ibrahim AlShahrani3, Samy Youssef El Bayoumy4, Mohammed Abo-Elkasem Ahmed Wakwak5, Mona Abdelghafar Mohamed Khalil6
1 Department of Pediatric Dentistry, Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia; Department of Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Al-Azhar University, Cairo, Egypt
2 Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
3 Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Khalid University, Abha, Saudi Arabia
4 Department of Pedodontics and Dental Public Health, Faculty of Dental Medicine, Boys Section, Al-Azhar University, Cairo, Egypt
5 Department of Pedodontics and Dental Public Health (Assuit Branch), Al-Azhar University, Cairo, Egypt
6 Department of Biochemistry, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
|Date of Web Publication||24-Sep-2018|
Dr. Mohamed Abd-Ellatif El-Patal
Department of Pediatric Dentistry, Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Orthodontic bands have been shown to alter oral microbial flora that lead to convert caries-free patients to moderate or high caries risk individuals. Aim: This study aimed to evaluate the effect of conventional band and loop space maintainers versus fiber-reinforced composite (FRC) resin space maintainer on the salivary cariogenic microflora (Lactobacillus and Streptococcus mutans) in children over a period of 6 months. Materials and Methods: The study sample was divided equally into two groups: Group A: 25 patients received FRC (INFIBRA®: Reinforcing ribbon, Bioloren, Italy) space maintainer and Group B: 25 patients received band and loop space maintainers. The saliva samples were collected from the patients before the insertion of the space maintainer and at 2 weeks, 3 months, and 6 months postinsertion. Results and Conclusion: The Lactobacillus acidophilus isolated was 1.7 colony-forming unit (CFU) (×106) and 1.8 CFU (×106) in Group A and Group B, respectively, prior to the insertion of space maintainers. There was no significant increase in L. acidophilus over the follow-up of 6 months in both the groups (P > 0.05). However, the Streptococcus mutans isolated before insertion in both Group A and Group B was 2.6 CFU (×106), which over a period of 6 months showed significant increase to 3.13 CFU (×106) in Group B (P < 0.05) and no increase was seen in Group A. S. mutans level increased considerably in patients with band and loop space maintainer over the follow-up of 6 months. No significant increase in the L. acidophilus count was observed over the same period in both the groups.
Keywords: Band and loop, fiber-reinforced composite, Lactobacillus acidophilus, space maintainers, Streptococcus mutans
|How to cite this article:|
El-Patal MA, Asiry MA, AlShahrani I, El Bayoumy SY, Ahmed Wakwak MA, Mohamed Khalil MA. The effect of fiber-reinforced composite versus band and loop space maintainers on oral Lactobacillus acidophilus and Streptococcus mutans levels in saliva. J Indian Soc Pedod Prev Dent 2018;36:301-7
|How to cite this URL:|
El-Patal MA, Asiry MA, AlShahrani I, El Bayoumy SY, Ahmed Wakwak MA, Mohamed Khalil MA. The effect of fiber-reinforced composite versus band and loop space maintainers on oral Lactobacillus acidophilus and Streptococcus mutans levels in saliva. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2019 Feb 23];36:301-7. Available from: http://www.jisppd.com/text.asp?2018/36/3/301/241962
| Introduction|| |
Primary teeth play a critical role in the growth and development of a child. In addition to their role in esthetics, eating, speech, and to encourage normal function and resultant expected growth, the other main function of a primary tooth is to hold space for the permanent successor until it is ready to erupt., The hindrance in this normal physiologic process can occur due to early premature loss of primary molars, due to dental caries which may lead to mesial tipping or migration of large permanent molar teeth into the space created. This may result in loss of space leading to discrepancy of arch length, malocclusion, crowding of teeth, impaction of permanent premolars, and supra-eruption of opposing tooth. Therefore, one of the most important roles of primary molars is to maintain adequate space for the eruption of its predecessors.,
The premature extraction or loss of primary tooth is unavoidable due to extensive caries or other reasons; the safest option to maintain arch space is by placing a space maintainer. Space maintainer is an intraoral appliance used to preserve arch length following the premature loss of primary teeth/tooth. This allows the permanent teeth to erupt unhindered into proper alignment and occlusion., Space maintainer appliances may be unilateral or bilateral and fixed or removable. Band and loop space maintainer is the most common type of space maintainer used in the case of premature extraction of a primary molar because it can be produced easily and economically, requires little chair time for application, can be used bilaterally, and is well tolerated by children., Band and loop has been used since long as a space maintainer with high success rates, but in spite of disintegration of cement, solder failure, caries formation along the margins of the band, long construction time, the need for a cast or model, and the possibility of metal allergy are some of the disadvantages associated with them.,
Fiber-reinforced composite resin (FRCR) space maintainer seems to be a suitable alternative to the conventional fixed space maintainer. FRCR space maintainers are easy to apply and require only one visit. There is no need for making impressions and laboratory procedures are eliminated. Patients are satisfied because these space maintainers are esthetic, less bulky, occupy less space in the oral cavity, and feel natural. FRCR is a biocompatible material which consists of high-strength polyethylene or glass fibers with various advantages such as ease of adhesion to tooth surface, reduced chairside time, elimination of laboratory procedures, and high strength. FRCR is commercially available as INFIBRA®, Ribbond®, EverStick®, Supersplint®; which has been used as space maintainer with various designs.,
Dental caries is the most common chronic disease of childhood. The percentage of children found to be caries free with regard to primary teeth was 7%; however, this proportion would increase to 15.6% if the enamel lesions were excluded. Dental caries is a multifactorial chronic bacterial disease that causes demineralization and destruction of the hard tissues usually by production of acid by bacterial fermentation of the food debris accumulated on the tooth surface.,,
The role of Streptococcus mutans in caries initiation and lactobacilli in caries progression has been proven and therefore, the salivary count of these two bacteria predicts the caries susceptibility in the oral cavity. In addition, orthodontic bands can alter the dietary habits, which could increase the retention of dental plaque and/or reduced saliva-induced deglutition. Therefore, orthodontic patients with brackets or bands are at high risk of caries because the bacteria live well in the surrounding edges of these appliances. The study of the level of S. mutans in saliva is one of the most common methods for identifying individuals with risk of dental caries. Longitudinal studies have shown that groups of individuals with a large amount of S. mutans in their saliva have significantly higher caries activity than those who have lower numbers of these bacteria. A strong correlation has been established between the Lactobacillus count and caries; the higher the Decayed, Missing, Filled index, the higher is the Lactobacillus count.,
FRCRs have been used by various branches of dentistry such as removable prosthodontics, fixed partial dentures, periodontal splints, and certain orthodontic treatment as a retentive splint., Therefore, FRCRs are regarded as an excellent alternative to band and loop space maintainers with regard to esthetics and design. There is paucity in the dental literature to compare the caries susceptibility of conventional band and loop space maintainers versus FRCR. The salivary S. mutans and Lactobacilli counts can predict the risk for dental caries in individuals with bands and FRCRs. Hence, the present study was undertaken to assess the salivary S. mutans and Lactobacilli level before and after insertion of conventional band and loop and FRCR (INFIBRA®: Reinforcing ribbon, Bioloren, Italy) space maintainers over a period of 6 months.
| Materials And Methods|| |
Fifty selected Egyptian children (aged 4–9 years) from the Pediatric Dental Outpatient Clinic, Faculty of Dental Medicine, Al-Azhar University, were included after obtaining approval from local Ethical Committee. Informed consent was taken from the parents/guardians of all the children participating in the study. The inclusion and exclusion criteria for the study are shown in [Table 1].
All the children were found to have low-to-moderate caries activity after recording brief history and final diagnosis. The participants were given oral hygiene instructions, and full-mouth oral prophylaxis was done before banding or bonding of space maintainers. The study sample was divided equally into two groups according to the type of space maintainer as follows:
- Group A: twenty-five patients received fiber-reinforced composite (FRC) space maintainers
- Group B: twenty-five patients received band and loop space maintainers.
Construction of band and loop space maintainer
A brief history was recorded and a clinical examination was done. Intraoral periapical radiographs were taken in the area of tooth loss. Impressions were made by alginate impression material, study model was prepared, and a space analysis was done for each child. A prefabricated band was selected for the abutment tooth by measuring the mesiodistal diameter of abutment tooth with a caliper and correlating it with the internal diameter of the prefabricated band. The smallest stainless steel band that seats approximately 1 mm below the mesial and distal marginal ridge was selected. Impressions were made with alginate impression material. Each band was then gently removed with a band remover and stabilized in the impression material in the correct position. The impression was then casted using dental stone with the band in place within 30 min of impression making. The construction of band and loop space maintainer was done in the dental laboratory by a qualified dental technician. The loop was soldered to the band in its middle third. Band and loop space maintainers were cemented onto a clean, dry abutment tooth using glass ionomer cement (GIC) (Medicem, Promedica, Neumunster, Germany) mixed according to manufacturer's instructions. Excess cement was removed from the surface; the area was kept dry by low-volume suction and cotton roll isolation during cementation. Space maintainers were checked for gingival clearance and occlusal interference. Children were instructed not to eat for 30 min following cementation. In addition, parents were instructed to notify the clinician immediately if the band and loop space maintainer became loose, or if any discomfort was encountered. Regular follow-up appointments were scheduled at 4–6 months.
Technique for construction of fiber-reinforced composite space maintainer
A brief history was recorded and a clinical examination was done. Intraoral periapical radiographs were taken in the area of tooth loss. In order to determine the length of FRCR (INFIBRA®, Reinforcing ribbon, Bioloren, Italy) space maintainer required, the distance between the mesiobuccal line angle of the primary canine and distobuccal line angle of the second primary molar was measured using a digital vernier caliper. No grooves or slots were prepared on the abutment teeth in order to prevent unnecessary loss of tooth structure. After administration of adequate anesthesia, isolation was done using a rubber dam and suction. Both the abutment teeth (primary canine and second primary molar) were etched with 35% phosphoric acid for 40 s. The teeth were rinsed, air-dried, and wetted with an adhesive Adper Single Bond-2® (3M Unitek, Monrovia, California) that was light cured for 20 s. A thin layer of flowable composite VLC Flowable Filling composite (Prime Dent Manufacturing Inc., Chicago, USA) was applied to the buccal surfaces of the abutment teeth without light curing it. The cut length of FRCR was placed on this flowable composite, extending from the buccal aspect of primary second molar to the buccal aspect of primary canine. The ends of the fiber were adapted to the tooth surfaces with a plastic filling instrument. Preliminary curing was done individually at each end of the fiber framework for 40 s, during which the other end was protected from the light source. An additional layer of flowable composite was applied over the area where the fiber abutted the tooth surface and was light cured for 40 s. A similar procedure was repeated on the lingual aspect of the abutment teeth. Any uncovered fiber was further covered with flowable composite. The space maintainer was checked for gingival clearance and occlusal interference. Finishing was done using composite finishing burs. Instructions on oral hygiene and appliance maintenance were given to both children and parents.
The samples were collected before the insertion of the space maintainer and after 2 weeks, 3 months, and 6 months of postinsertion. A fresh unstimulated whole saliva sample was collected by asking each child to spit in a sterile container (either after getting up or at least 2 h after meal). 1 ml of the collected saliva sample was preserved in a tube containing 9-ml thioglycolate broth transfer medium. All specimens were transported as soon as possible to the microbiological laboratory for culture on selective media. For determining S. mutans salivary levels, Mitis salivarius with bacitracin agar was used according to the manufacturer's instructions: 1 mL of saliva was put in a sterilized tube and serially diluted from 101 to 106 with sterilized distilled water. After vortexing the tubes for 15 s, 1 mL of diluted saliva was spread onto the agar plates. The inoculated plates were then placed in anaerobic jar containing gas pack at 37°C for 48 h and 96 h intervals, respectively. The number of S. mutans per milliliter of saliva was estimated by comparing the colony density on the growth substrate. The same procedure was used to determine L. acidophilus salivary levels but using selective Man Rogosa Sharpe (MRS) Agar. After these processes, total viable S. mutans and Lactobacillus colonies were counted and the number of the viable microorganisms was calculated by means of colony-forming units per milliliter of volume.
Statistical analysis was performed with IBM® SPSS® (SPSS Inc., Chicago, IL, USA) Statistical software, Version 20 for Windows.
Data were explored for normality using Kolmogorov–Smirnov and Shapiro–Wilk tests and showed parametric (normal) distribution. Pair-wise t-test was used to compare between different variables (pre and post) in the same group, while independent sample t-test was used to compare between FRC and band and loop) groups. The significance level was set at P < 0.05.
| Results|| |
Identifications of the isolated bacterial strains
S. mutans were identified by their characteristic colonial morphology on M. salivarius agar medium. The colonies were raised, convex opaque of dark blue color with rough margins and granular frosted appearance. Smears prepared from those colonies were Gram stained and when examined microscopically demonstrated Gram-positive cocci arranged in short chains. The cocci were either spherical or slightly oval.
L. acidophilus were identified by the morphology of their colonies on MRS Agar medium. The colonies were raised, opaque of yellow color with smooth margins. Smears prepared from those colonies were Gram stained and when examined microscopically demonstrated the Gram-positive bacilli.
Effect of space maintainer material on bacterial count
L. acidophilus was detected in all the individuals before the insertion of space maintainers in both the groups (A – 1.73 and B – 1.8). The Lactobacillus isolated from samples collected 2 weeks after insertions of space maintainers in both the groups decreased but was not statistically significant (P > 0.05). The corresponding values of the samples collected from both the groups at different time intervals after 3 months and 6 months were Group A – 1.75 and 1.83 and in Group B – 1.93 and 1.98, respectively [Figure 1]. These values imply no significant difference between baseline and terminal values nor was there any difference between banded and bonded surfaces (P > 0.05) [Table 2].
|Figure 1: Graph represents salivary Lactobacillus counts before and after insertion of space maintainers. Samples collected at baseline, 2 weeks, 3 months, and 6 months have been pooled for Group A and Group B|
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|Table 2: Mean colony-forming units (×106) of the Streptococcus mutans and Acidophilus lactobacillus|
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S. mutans were also isolated from both the groups before insertion of space maintainers (Group A – 2.68, Group B – 2.6). The samples during the first 2 weeks after banding and bonding showed marginal decrease in S. mutans level similar to Lactobaccillus but were not significant (P > 0.05). In samples collected after 6 months of extensive banding (Group B), S. mutans levels were significantly increased. No such trend was seen after the same duration of treatment in the bonded surfaces (Group A), implying no significant difference between baseline and terminal values [Figure 2]. Thus, after 6 months of treatment, S. mutans levels showed significant difference between Groups A and B. It appeared that the Group B individuals were heavily infected with S. mutans as compared to their baseline values and Group A individuals [Table 2].
|Figure 2: Graph represents salivary Streptococcus mutans counts before and after insertion of space maintainers. Samples collected at baseline, 2 weeks, 3 months, and 6 months have been pooled for Group A and Group B|
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| Discussion|| |
Orthodontic bands used in band and loop space maintainer appliances are more susceptible to plaque accumulation and increased risk of dental caries in the abutment tooth. The oral ecological imbalance caused by xerostomia or low pH environment or changes in dietary intake may promote colonization and proliferation of cariogenic microorganisms. Several previous studies have emphasized that orthodontic appliances physically alter the oral environment that encourages the proliferation of caries-causing microorganisms such as S. mutans and Lactobacilli.
The study of the level of S. mutans in saliva is one of the most common methods for identifying individuals at risk of dental caries., A strong correlation has been established between the Lactobacillus count and caries; the higher the caries, the higher is the number of children harboring a high Lactobacillus count. In the present study, band and loop space maintainer was used because it is the conventional appliance which accommodates changing dentition. Band and loop has been used since long as a space maintainer with high success rates. Currently, GICs are more widely accepted for use in the cementation of band and loop. Not only do GICs adhere to both enamel and metal, they also provide fluoride release and uptake. Despite these advantages, the use of GICs has not eliminated the problem of failure at the stainless steel band–tooth interface. Resin-based materials have been developed with a stronger bond to tooth structure than GICs., According to Nayak et al., the fabrication of conventional band and loop space maintainer required more laboratory time and needed a minimum of two appointments. They concluded that this procedure was time-consuming and intensive, and therefore expensive. Furthermore, impression making was difficult in young and uncooperative children.
The benefits of space maintainers such as band and loop can be compromised by an increased incidence of caries in caries-free patients. Therefore, the teeth surrounded by orthodontic bands require constant prophylaxis and strict dietary restrictions to prevent dental caries compared to patients with FRCR space maintainers.
FRCR (INFIBRA®: Reinforcing ribbon, Bioloren, Italy) provides an excellent esthetic choice as a space maintainer with ultra-high-molecular-weight polyethylene fiber. It is well tolerated by the patient, is esthetic, and is less time-consuming. FRC's potential as a space maintainer in the primary or mixed dentition has gained popularity in the past years. Composites that are reinforced with fibers can result in materials with enhanced mechanical properties. Fibers produce a load-enhancing effect on brittle composite materials by acting as the stress-bearing component and by crack-stopping or crack-deflecting mechanisms.,
In the present study, there was no significant difference in the count of Lactobacillus and S. mutans before insertion and 2 weeks postinsertion. However, the results suggest that there was decrease in S. mutans and Lactobacillus level during the 2nd week after insertion of both types of space maintainers. This can be attributed to oral prophylaxis done before cementation or bonding of space maintainers and also pumicing of teeth before banding may also have contributed.
The main findings of the present study were the elevated salivary S. mutans levels in Group B with band and loop space maintainers compared to the FRCR Group A, which was statistically significant (P < 0.05). S. mutans is known to be the pioneer bacteria in caries formation and initiation; therefore, elevated levels of S. mutans suggest increased caries susceptibility of patients with band and loop space maintainers. The results in the present study were statistically significant when S. mutans count increased from baseline to terminal values in Group B; similar studies have concurred elevated levels of salivary S. mutans counts after extensive banding. The retentive areas at the margins of the bands may have favored the colonization and proliferation of S. mutans. The results were not significant in this study because the number of tooth banded was less compared to other studies, thereby decreasing retentive areas. The observed shift in the levels of S. mutans is due to the change in oral environment and low pH which support the growth of S. mutans.,
According to Setia et al., caries were examined visually and by tactile method in individuals with bands and FRCR space maintainers. An explorer was used to check for the presence of caries on the abutment tooth in the patients. Patients with neither band and loop nor FRCR space maintainer developed caries throughout the study over a period of 9 months. This study was contradicting to the results of the present study, but microbial aspect of the present study cannot be undermined.
Recently, studies have shown that orthodontic bands tend to jeopardize the oral environment and cause hindrance in maintaining proper oral hygiene. The S. mutans isolated in 50%–80% of orthodontic patients was due to the accumulation of dental plaque resulting in demineralization of dental surfaces of the abutment teeth. These findings are in accordance with the results of the present study.
According to previous long-term studies, extensive banding of teeth may have a negative effect on oral microbial flora and increase the risk for dental caries in such patients., The present study follow-up lasted for 6 months; a long-term microbial assay in patients with space maintainers until the eruption of permanent successors would be the scope for future research.
There was no marked increase in salivary Lactobacillus levels in the group of children with band and loop space maintainers over a period of 6 months as shown in the results. However, results contradicting this finding were observed in a study by Maret et al., who showed increased salivary S. mutans and Lactobacillus during 6-month period in patients with fixed orthodontic appliances.
Patients with band and loop space maintainer had higher salivary S. mutans count after 6 months compared to the patients with FRCR. This finding suggests that patients with orthodontic bands are more susceptible to dental caries in abutment tooth than the patients with FRCR. A study has shown the formation of enamel opacities after de-banding of appliance and their location was underneath the band and not at the margins of the band and tooth, contradicting some studies which suggest caries at the margins of the bands. Thus, from a microbial aspect, caries-free patients with band and loop space maintainers have an increased risk of developing clinically detectable dental caries lesions than the patients with FRCR.
Another important aspect to be noticed in the present study result is the negligible increase of salivary S. mutans and Lactobacilli levels in FRCR (INFIBRA®: Reinforcing ribbon, Bioloren, Italy) space maintainer group even after 6 months, which was very low compared to the increase of cariogenic microflora in band and loop space maintainer group. An in vitro study by Lassila et al., was done to evaluate the adhesion of S. mutans to a short glass fiber-reinforced semi-interpenetrating polymer network matrix composite resin (EverStick® and Ribbond®) in comparison with composite restorative materials. The results showed no difference in the adhesion of S. mutans on FRCR and composite restorative resins, despite different surface roughness. The authors concluded that FRCR can be used successfully as a posterior restorative adjunct to various restorative materials such as resin-modified GICs, composites, and amalgam.
The results in the FRCR Group A (INFIBRA®) may be attributed to good finishing and polishing of composite with finishing burs and sufficient clearance between space maintainer and gingiva, thereby reducing accumulation of cariogenic microflora. Due to paucity in the literature on the effect of FRCR on salivary cariogenic microflora, the results of the present study could not be compared to other studies. However, the present study provides baseline data for future research in the field of pediatric dentistry.
| Conclusion|| |
S. mutans level increased considerably in patients with band and loop space maintainer over the follow-up of 6 months. No significant increase in the L. acidophilus count was observed over the same period in both the groups. Therefore, FRCR (INFIBRA®: Reinforcing ribbon, Bioloren, Italy) space maintainers are the best short-term alternative to prevent caries and space loss in children.
Financial support and sponsorship
Conflict of interest
There is no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]