doi:10.31674/mjmr.2019.v03i03.

002

INCIDENCE OF DENTAL CARIES DURING FIXED ORTHODONTIC

TREATMENT IN PETRA JAYA DENTAL CLINIC: A RETROSPECTIVE
STUDY
Milton Hongli Tsai¹*, Nes Nawi²

Urban Transformation Centre (UTC) Dental Clinic, Kuching, Malaysia

Petra Jaya Orthodontic Specialist Clinic, Kuching, Malaysia

*Corresponding Author's Email: tsaimilton@yahoo.com

ABSTRACT

Objectives: The purpose of the present study was to investigate the incidence of dental caries during fixed
orthodontic treatment and the effect of gender, ethnicity, age at start of treatment, duration of treatment and
frequency of oral hygiene instructions on the incidence of dental caries. Materials and Method: The
retrospective study was conducted using selected orthodontic patient records (n=115) from 2017-2018.
Records of new carious lesions which developed during the treatment process were identified. Number of
caries and the teeth they are located were recorded. Independent variables were collected by chart abstraction.
Results: Gender, ethnicity, age at the start of treatment and duration of treatment were not significantly
associated with caries development. Conclusions: The incidence of dental caries in patients treated with fixed
orthodontic appliances were moderately high. This problem warrants significant attention from both patients
and providers that should result in increased emphasis on oral hygiene reinforcement and effective caries
preventive measures. The risk of developing caries lesions during orthodontic treatment should not be
underestimated by both orthodontists and patients.
Keywords: Dental Caries, Oral Health, Orthodontic Treatment

INTRODUCTION 97% of all orthodontic patients (Gontijo,Cruz Rde &

Dental caries is one of the complications of orthodontic Brando, 2007; Boersma, 2005). Orthodontic patients
treatment. Caries is a reversible multifactorial process of can find it difficult to maintain adequate oral hygiene
tooth demineralization and remineralization. It's also around fixed appliances. The decline in oral hygiene
known as tooth decay or disease where bacterial that often accompanies orthodontic treatment might
processes damage hard tooth structure. These tissues lead to an increased risk for development of caries
progressively break down, producing dental caries i.e. lesions. The severity of the resultant dental caries can
cavities. Two groups of bacteria are responsible for range from development of opaque WSL, or
initiating caries: Streptococcus mutans and Lactobacillus. decalcification, to loss of surface integrity of enamel
If they are left untreated, the disease can lead to pain, pulp and cavitation (Gorelick, Geiger & Gwinnett,1982;
necrosis and tooth loss. (Chang, Walsh & Freer, 1997 ; Mizrahi, 1982; Richter et al., 2011).
Sukhia, Ayub & Gandhi, 2006). Orthodontic appliances physically alter the microbial
Caries or enamel decalcification is a serious problem for environment (Balenseifen & Madonia, 1970; Bloom &
orthodontic patient as shown by previous records Brown,1964; Corbett et al., 1981; Mattingly et al., 1983;
suggested high prevalence of caries in patients Rosenbloom & Tinanoff, 1991; Scheie, Arneberg &
receiving fixed orthodontic treatment (FOT), with the Krogstad,1984).Increased proliferation of the facultative
cause being difficulty and negligence in oral hygiene bacterial population, including Streptococcus mutans,
maintenance (McGuinness, 1992). In orthodontics, leads to a decrease in pH that tips the demineralization-
caries usually occurs on smooth surfaces, affecting 2 to remineralization balance toward mineral loss

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 DENTAL CARIES DURING FIXED ORTHODONTIC TREATMENT

(demineralization), which in turn can lead to WSL limited phase 1 treatment before comprehensive
development and eventually to cavitation and caries treatment was not included in treatment-time
extending into the dentin (Chatterjee & Kleinberg, 1979; calculation. Frequency of oral-hygiene instructions after
Pinkham, 1989; Featherstone, 2003; Featherstone et al., the initial oral hygiene instructions was recorded from
2007). progress notes in the chart. From the patients' charts,
records of new carious lesions which developed during
The present study was designed to investigate the dental
the treatment process were identified. Number of caries
caries incidence during FOT and the effect of gender,
and the located teeth were recorded.
ethnicity, age at start of treatment, duration of treatment
and frequency of oral hygiene instructions on the Statistical analysis was done by using SPSS version 16.0.
incidence of dental caries. This study sought to aid The statistical analysis including frequency distribution,
orthodontists to be aware of the caries incidence and to cross tabulation and chi-square test was used to find the
decide whether current preventive therapy provided is association between dental caries and gender, race, age
adequate. The result of this study can help to emphasize group, treatment length and frequency of oral hygiene
the need for good oral hygiene instructions, motivation instructions, and the p-value was set at p<0.05.
and meticulous caries-prophylactic measures such as
RESULTS
professional tooth cleaning and topical fluoride
application during the FOT process. The present study comprised of 115 orthodontic patients
including 82 (71.3%) females and 33 (28.7%) males.
RESEARCH METHODOLOGY
The age of the subjects ranged from 12 to 30 years with
Ethical approval for this study was obtained from mean age 16.43 years. The frequency distribution of
Medical Review & Ethics Committee (MREC) subjects with respect to age group, gender and ethnicity
Malaysia (NMRR-19-541-46467). One hundred fifteen is given in Table 1.
patient records were selected by applying the inclusion
Table 1: Demographic profile of Subjects
and exclusion criteria from patients treated in the
Orthodontic Clinic in the Petrajaya Dental Clinic
between 2017 and 2018.
Inclusion criteria for record selection consist of patients
who (1) underwent comprehensive orthodontic treatment
with full fixed appliances on labial tooth surfaces; (2) had
all fixed orthodontic treatment completed (debonded) in
2017-2018; (3) had no dental structural abnormalities,
veneers, or other reconstructions; (4) had complete
treatment log information in their charts.
Exclusion criteria for record selection consist of
patients (a) with ongoing fixed orthodontic treatment;
(b) who underwent removable orthodontic appliance
treatment only; (c) whose appliances were removed
prematurely before completion of orthodontic
treatment; (d) who were transferred from other
orthodontic specialist clinic (transfer case).
Data collection from deidentified patient charts included
gender, race, age at initiation of orthodontic treatment
and treatment length. Treatment length was defined as
the period between the start of full fixed appliance The present study depicted the incidence of dental caries
therapy and the removal of all active fixed appliances. A as 34.8% (Table 2) with the mean 0.61 and standard

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deviation 1.19. (Table 3) Among 115 patients, 40 Occurrence of dental caries among male and female
patients (34.8%) had one or more carious tooth/teeth in patients was 30.0% and 70.0% respectively. However,
the oral cavity. there was no statistically significant association in caries
occurrence between gender groups (Table 4).
Table 2: Frequency according to presence of cavitated
lesions In a total of 115 orthodontic patients, the occurrence of
dental caries was 62.5% in Chinese, 27.5% in Malay,
5.0% in Iban, 2.5% in Bidayuh, 2.5% in Melanau and
0% in Indian patients. However, there was no significant
association between the ethnicity and caries occurrence
(Table 4).
Table 3: Frequency according to the number of The recorded number of oral-hygiene instructions
cavitated lesions between provider and patient was significantly
associated with development of cavitated lesions
(p=0.017). A decrease was shown for the number of
cavitated lesions for patients having more than 2 oral-
hygiene discussions (12.5%) versus those with whom
oral hygiene was not discussed after the initial oral
hygiene instructions (52.5%). (Table 4)
According to the duration of orthodontic treatment,
subjects undergoing treatment for less than 25 months
duration had 10.0%, 25-35 months had 50.0%, 36-45
The study showed that the distribution of caries months had 30.0%, and more than 45 months had 10.0%
occurrence was highest in age group 14-16 years i.e. occurrence of dental caries. However, there was no
60.0%. However, there was no association between the association between the duration of orthodontic
age group and occurrence of dental caries (Table 4). treatment and caries occurrence (Table 4).

Table 4: Determine associated factors towards dental caries during FOT.

Independent Carious teeth

variable No Yes p-value
a

n % n %
Age (years) <14 5 6.7% 2 5.0% 0.924
14-16 46 61.3% 24 60.0%
17-19 17 22.7% 11 27.5%
>19 7 9.3% 3 7.5%
Gender Male 21 28.0% 12 30.0% 0.821
Female 54 72.0% 28 70.0%

Ethnicity Malay 29 38.7% 11 27.5% 0.345

Chinese 36 48.0% 25 62.5%
Indian 3 4.0% 0 0.0%

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 RISK FACTORS FOR MEN WITH HIV INCIDENCE IN INDONESIA

Iban 4 5.3% 2 5.0%

Bidayuh 3 4.0% 1 2.5%
Melanau 0 0.0% 1 2.5%
Others 0 0.0% 0 0.0%
0 57 76.0% 21 52.5% 0.017
1-2 16 21.3% 14 35.0%
>2 2 2.7% 5 12.5%
Treatment length (months) <25 11 14.7% 4 10.0% 0.543
25-35 28 37.3% 20 50.0%
36-45 24 32.0% 12 30.0%
>45 12 16.0% 4 10.0%
a
P-value was derived from Pearson chi-square test

With regards to the quadrant involved, the first quadrant

was the most affected (17.4%) whereas the fourth
quadrant was the least affected (7.0%). The upper teeth
(1st and 2nd quadrants) were more affected than the lower
teeth (3rd and 4th quadrants). (Table 5)
Table 5: Frequency of dental caries according to the
quadrant involved

The maxillary right first molars (16) were the most

affected teeth (8.7%). The least affected teeth were the
maxillary right first premolars, mandibular anteriors,
mandibular right premolars, mandibular left first
premolars and mandibular third molars (0%). (Table 6)
Table 6: Frequency of dental caries according to type
of tooth

DISCUSSION
The present study indicates that carious lesions remains
a significant problem during fixed orthodontic

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treatment. The overall incidence found in the present the time period of orthodontic treatment (Tufekci et al.,
study was 34.8% which falls in the mid-range of the 2011; Chapman et al., 2010).
reported figures in the previous literature, which range
The number of times that orthodontic care providers
from 2 to 97% (McGuinness, 1992; Lovrov, Hertrich &
offered oral-hygiene instructions was significantly
Hirschfelder,2007;Gontijo, Cruz Rde & Brando, 2007).
associated with development of new cavitated lesions
Richter et al., (2011) reported the incidence of new
(p=0.017). The frequency of oral-hygiene discussions
white-spot lesions (WSL) during orthodontic treatment
was associated with lesser number of carious lesions.
in 72.9% subjects, and the incidence of new cavitated
The importance of repeating the instruction in order to
lesions in this population was 2.3%. The highest
increase the compliance was shown by Ashkenazi et al.,
incidence of WSLs reported in the previous literature
(2012) who showed that a significant positive co-
(97%) was probably due to the early identification of the
relation was found between compliance with preventive
presence of WSLs that were not clinically visible as the
measures and number and frequency of recall
study used Quantitative Light-induced Fluorescence
appointments in which patients receive reinforcement.
(QLF) to evaluate the presence of WSLs.
However, Richter et al. (2011) found that the number of
In the present study, we aimed at analysing the effect of oral hygiene conversations increased concurrently with
age at start of treatment, gender, ethnicity, frequency of the development of both WSL and cavitated lesions
oral hygiene instructions and treatment length on the (parameter estimate, 1.88).
incidence of dental caries.
With regards to the most affected teeth, it was found in
The results were non-significant in relation to gender the present study that the maxillary right first molars
while considering the incidence of carious lesions and were the most affected teeth. Similar findings were
this finding was similar to the results of Richter et al., found by some previous investigators who have reported
(2011). However, some studies reported significant the most affected teeth to be the maxillary first molars
gender differences and indicated that males were having [22]. However, some studies have reported different
greater risk of developing lesions (Boersma et al., 2005 ; results, with the most affected teeth reported to be either
Chapman et al., 2010). the maxillary canines or the maxillary lateral incisors
(Gorelick, Geiger & Gwinnett, 1982 ; Tufekci et al.,
As for the age group distribution, the present study 2011; Ogaard, 1989; Chapman et al., 2010).
reveals that there was no significant association between
age at the start of treatment and incidence of new carious This study accounted for only independent variables that
lesions, consistent with the results of Richter et al. were readily available in the patients' charts. It was by
(2011). However, Chapman et al., (2010) showed that nature limited due to a retrospective design. No
younger patients were at higher risk for caries information on patients' socio-economic status,
development than the adults. frequency of consulting the dental clinic, prophylactic
fluoride therapy, oral hygiene practices and diet habits
The results were non-significant in relation to ethnicity was available. The relation between new carious lesions
while considering the incidence of carious lesions. A and many other variables (e.g. oral hygiene & food
study by Chapman et al., (2011) showed that the white habits) were evaluated in other studies. Shrestha et al.,
ethnic group was at higher risk for caries development (2013) found that large proportion of orthodontic
during fixed orthodontic treatment. patients consume sweets foodstuff, junk food and snacks
in between meals and very few patients practice special
In the current study, duration of treatment was found to
oral hygiene measures (interdental brush, fluoride
have no significant association with the formation of
mouthwash).
carious lesions. Richter et al., (2011) found that longer
treatment duration was not significantly related to Unfortunately for this retrospective study, only cavitated
increase cavitated lesions. Lovrov, Hertrich & carious lesions were recorded. No information on
Hirschfelder (2007) were unable to find an impact of the reversible white spot lesions (WSL) was available from
treatment length on the prevalence of WSLs. However, the patients' charts. Previous retrospective studies used
some studies found increased prevalence of caries with pre-treatment and post treatment intraoral photographs

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 RISK FACTORS FOR MEN WITH HIV INCIDENCE IN INDONESIA

to determine the incidence of labial caries lesions in REFERENCES

patients who underwent comprehensive orthodontic
Ashkenazi, M., Bidoosi, M. & Levin, L. (2012). Factors
treatment with full fixed appliances. However, the
Associated with Reduced Compliance of Children
photographic method would result in underestimation of
to Dental Preventive Measures. Odontology,
reporting the WSL. Some have argued that it is relatively
100(2), pp 241-248
poor for assessing individual lesions longitudinally
(Lovrov, Hertrich & Hirschfelder, 2007; Richter et al., Balenseifen, J.W.& Madonia, J.V. (1970). Study of
2011). This is due to varying photographic conditions dental plaque in orthodontic patients. Journal of
and artefacts between that points: lighting, angulation, Dental Research, 49(2), pp 320-324
and magnification. Intraoral photographs can only Bloom, R.H.& Brown, L.R. Jr. (1964). A Study of The
provide partial view of the labial surfaces of teeth Effects of Orthodontic Appliances on The Oral
(Ellwood & O' Mullane, 1994). Microbial Flora. Oral Surgery, Oral Medicine and
Gorelick et al. (1982) compared orthodontically treated Oral Pathology, 17, pp 658-667.
patients with untreated controls. Tufekci et al. (2011) Boersma, J.G., van der Veen, M.H., Lagerweij, M.D.,
compared orthodontic patients in control and treatment Bokhout, B.& Prahl-Andersen, B.(2005). Caries
group at 6 and 12 months into treatment by control Prevalence Measured with QLF After Treatment
group. Although their study had the benefit of with Fixed Orthodontic Appliances: Influencing
comparisons with a control group, it was cross-sectional Factors. Caries Research, 39(1), pp 41-47.
in design. What was reported to be the “incidence” of
white-spot development was actually the “prevalence” Chang, H.S., Walsh, L.J.& Freer, T.J. (1997). Enamel
of lesions in the 2 or 3 groups. Demineralization During Orthodontic Treatment.
Aetiology and Prevention. Australian Dental
The high prevalence and incidence of carious lesions Journal. 42(5), pp 322-327.
during and after orthodontic treatment with fixed
Chapman, J.A., Roberts, W.E., Eckert, G.J., Kula,
appliances warrants a more detailed investigation of this K.S.& González-Cabezas, C. (2010). Risk Factors
phenomenon in a prospective randomized controlled for Incidence and Severity of White Spot Lesions
clinical trial by using a direct method of assessing early During Treatment with Fixed Orthodontic
caries lesions with well-documented charting. Appliances. American journal of orthodontics and
CONCLUSION dentofacial orthopaedics, 138(2), pp 188-194.
Chatterjee, R.& Kleinberg, I.(1979). Effect Of
Caries and decalcification continue to be a serious
Orthodontic Band Placement On The Chemical
problem as shown by a moderately-high incidence of
Composition Of Human Incisor Tooth Plaque.
new cavitated carious lesions (34.8%) in patients treated
Archives of Oral Biology, 24(2), pp 97-100
with fixed orthodontic treatment. Sex, age, ethnicity and
treatment length were not associated with lesion Corbett, J.A., Brown, L.R., Keene, H.J.& Horton, I. M.
development, but a significant association was evidenced (1981). Comparison of Streptococcus Mutans
with frequency of oral hygiene instructions. The Concentrations in Non-Banded and Banded
maxillary right first molars were the most affected teeth. Orthodontic Patients. Journal of Dental Research,
60(12), pp1936-1942.
This widespread problem of caries development is an
alarming challenge and warrants significant attention Ellwood, R.P.& O'Mullane, D.M. (1994). Association
from both patients and providers that should result in between dental enamel opacities and dental caries
greatly increased emphasis on oral hygiene in a north Wales population. Caries Research,
reinforcement and effective caries preventive 28(5), pp 383-387
measures. Orthodontists should be aware of the high Featherstone, J.D. (2003). The Caries Balance:
risk of dental caries and provide intensive oral hygiene Contributing Factors and Early Detection. Journal
instructions and monitoring. of California Dental Association, 31(2), pp 129-133

12 | Vol. 3 (3) JULY 2019 | Malaysian Journal of Medical Research

 RISK FACTORS FOR MEN WITH HIV INCIDENCE IN INDONESIA

Featherstone, J.D., Domejean-Orliaguet, S., Jenson, L., Journal of Orthodontics Orthopedics, 96(5), pp 423-
Wolff, M.& Young, D.A. (2007). Caries Risk 427
Assessment in Practice for Age 6 Through Adult.
Pinkham, J.R.(1989). Pediatric Dentistry: Infancy
Journal of California Dental Association, 35(10),
Through Adolescence, W. B. Saunders, Philadelphia
pp 710-713
Richter, A.E., Arruda, A.O., Peters, M.C.& Sohn, W.
Gontijo, L., Cruz Rde, A. & Brando, P.R. (2007).
(2011). Incidence of caries lesions among patients
Dental Enamel Around Fixed Orthodontic
treated with comprehensive orthodontics.
Appliances After Fluoride Varnish Application.
American Journal of Orthodontics and Dentofacial
Brazilian Dental Journal, 18(1), pp 49-53.
Orthopedics, 139(5), pp 657-664
Gorelick, L., Geiger, A.M. & Gwinnett, A.J. (1982).
Rosenbloom, R.G. & Tinanoff, N. (1991). Salivary
Incidence of White Spot Formation After Bonding
Streptococcus Mutans Levels In Patients Before,
And Banding. American Journal of Orthodontics,
During, And After Orthodontic Treatment.
81(2), pp 93–98.
American Journal of Orthodontics and Dentofacial
Lovrov, S., Hertrich, K. & Hirschfelder U. (2007). Orthopedics, 100(1), pp 35-37
Enamel Demineralization During Fixed Orthodontic
Scheie, A.A., Arneberg, P.& Krogstad, O. (1984).
Treatment-Incidence and Correlation to Various
Effect of Orthodontic Treatment On Prevalence Of
Oral-Hygiene Parameters. Journal of Orofacial
Streptococcus Mutans In Plaque And Saliva.
Orthopedics, 68(5), pp 353-363.
Scandinavian Journal of Dental Research, 92(3),
Mattingly, J.A., Sauer, G.J., Yancey, J.M.& Arnold, pp 211-217
R.R. (1983). Enhancement Of Streptococcus
Shrestha, S., Shrestha, L., Shrestha, N., & Shrestha,
Mutans Colonization By Direct Bonded
R.M. (2013). Effect of Orthodontic Treatment in
Orthodontic Appliances. Journal of Dental
Occurrence of Dental Caries. Orthodontic Journal
Research, 62(12), pp 1209-1211.
of Nepal, 3(1), pp 31-36.
McGuinness, N.J.(1992). Prevention in orthodontics-a
Sukhia, H.R., Ayub, M.A.& Gandhi, D. (2006). Enamel
review. Dental Update, 19(4), pp 168-170.
Decalcification in Orthodontic Patients; Prevalence
Mizrahi, E. (1982). Enamel Demineralization And Oral Distribution - A Cross-Sectional Study.
Following Orthodontic Treatment. American Pakistan Oral Dental Journal, 28(2),pp 193-197.
Journal of Orthodontics.82(1), pp 62–67.
Tufekci, E., Dixon, J.S., Gunselloy, J.C.& Lindauer, S.J.
Ogaard, B.(1989). Prevalence of white spot lesions in 19- (2011). Prevalence of White Spot Lesions During
year-olds: a study on untreated and orthodontically Orthodontic Treatment with Fixed Appliances. The
treated persons 5 years after treatment. American Angle Orthodontist, 81(2), pp 206–210.

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