Evaluate the Effect of Fixed Orthodontic Appliances in Children: A Systematic Review and Meta-Analysis
Saeid Baghi1, Mohammad HoseinEbrahimzade Akbad2*, Monireh Haghifar3, Newshababevey Nejad4
1DDS, MSc Pedodontist, Shiraz, Iran.
2DDS, Department of Oral and Maxillofacial Radiology, School of Dentistry, ShahidSadoughi University of Medical Sciences, Yazd, Iran.
3Assistant Professor, Department of Pediatric Dentistry, School of Dentistry, Tabriz Azad University of Medical Sciences, Tabriz, Iran.
4Resident of Pediatric Dentistry, Department of Pediatric Dentistry, Faculty of Dentistry, Shahed University, Tehran, Iran.
*Corresponding Author: Mohammad HoseinEbrahimzadeAkbad, Email:
[email protected] ABSTRACT
Background an aim:the aim of present Systematic Review and Meta-Analysis study was evaluate the effect of fixed orthodontic appliances in children.
Method:From the electronic databases, PubMed, Embase, Cochrane Library have been used to perform a systematic literature until May 2021. For Data extraction, two reviewers blind and independently extracted data from abstract and full text of studies that included.Moreover mean difference with 95% confidence interval (CI), fixed effect model and invariance method were calculated. Random effects were used to deal with potential heterogeneity and I2 showed heterogeneity. I2 values above 50% signified moderate-to-high heterogeneity. The Meta analysis have been evaluated with the statistical software Stata/MP v.16 (The fastest version of Stata).
Result: subgroup meta-analysis showed no statistically significant difference of Plaque index, Sulcus bleeding index and Probing depth between control group vs children group (MD, 0.07 95%
CI -0.09, 0.23. P<0.05), (MD, -0.17 95% CI -0.30, -0.04. P>0.05), (MD, -0.01 95% CI -0.05, 0.03.
P>0.05), Respectively.
Conclusions: fixed orthodontic appliances may increase periodontal and microbiological statuses, both in children and adults.
Key words: Fixed Orthodontic Appliances, children, Plaque index, Sulcus bleeding index , Probing depth
1 INTRODUCTION
Malocclusion with tooth decay and periodontal disease are known to be the three most common diseases in the oral and maxillary areas[1], called misalignment of teeth or improper occlusion between the upper and lower arch of the tooth[2].It can also have a significant effect on the growth of the skull, face and oral function and affect the appearance of patients, on the other hand, it can cause damage to the systemic health of patients[3]. Fixed orthodontic appliances are the most important methods in orthodontic treatment, due to their convenience and high efficiency[4].Fixed orthodontic appliances may show complications, including inflammation or swelling of the gums, bleeding, hyperplasia, and even slight attachment loss (AL) during treatment[5].
Studies have shown that with age, the rate of periodontitis also increases, orthodontics should be done at the right age[6, 7]. Therefore, it is important to evaluate the clinical and microbial effects of orthodontic treatment with fixed orthodontic appliances and compare them at different ages(8).Studies have shown that there is a statistically significant relationship between periodontal
18115 disease and orthodontic treatment[4, 9]. The presence of some periodontal pathogens related to orthodontics during orthodontics can be closely related to the development of chronic periodontitis[10, 11].
In addition, to confirm the effect of fixed orthodontic appliances on periodontal tissue and oral microcological changes, simultaneous diagnosis of pathogenic bacteria and specific clinical indicators are needed to clarify the concerns. The microcological balance of the mouth is in fact the basis for maintaining oral health in the human body [12-15].
Hence the aim of present Systematic Review and Meta-Analysis study was evaluate the effect of fixed orthodontic appliances in children.
2 METHODS 2.1 Search strategy
From the electronic databases, PubMed, Embase, Cochrane Library have been used to perform a systematic literature until May 2021. Therefore, a software program (Endnote X8) has been utilized for managing the electronic titles. Searches were performed with mesh terms:
((((((((((((("Malocclusion"[Mesh] OR "Malocclusion, Angle Class III"[Mesh] OR "Malocclusion, Angle Class II"[Mesh] OR "Malocclusion, Angle Class I"[Mesh]) AND "Dental Caries"[Mesh]) AND "Periodontal Diseases"[Mesh]) AND "Oral and Maxillofacial Surgeons"[Mesh]) AND
"Orthodontic Appliances, Fixed"[Mesh]) OR "Orthodontic Appliances"[Mesh]) AND (
"Child"[Mesh] OR "Dental Care for Children"[Mesh] OR "Child, Adopted"[Mesh] OR "Only Child"[Mesh] )) AND ( "Adult"[Mesh] OR "Young Adult"[Mesh] OR "Adult Children"[Mesh] )) AND "Porphyromonasgingivalis"[Mesh]) OR "fomA protein, Fusobacterium" [Supplementary Concept]) OR "Prevotella intermedia"[Mesh]) OR "Tannerella forsythia"[Mesh]) AND "Dental Plaque Index"[Mesh]) AND "Periodontal Index"[Mesh].
This systematic review has been conducted on the basis of the key consideration of the PRISMA Statement–Preferred Reporting Items for the Systematic Review and Meta-analysis(16), and PICO strategy (Table1).
Table1: PICO strategy PECO
strategy
Description
P Population: children treated by Fixed Orthodontic Appliances
I Intervention: Fixed Orthodontic Appliances
C Comparison: children vs adult
O Outcome: plaque index, sulcus bleeding index, probing depth
2.2 Data Extraction and method of analysis
The data have been extracted from the research included with regard to the study, years, study design, Sample Size. The quality of the studies included was assessed using the Methodological index for nonrandomized studies (MINORS) [17]. In this index the items 1–12 represent: 1, a clearly stated aim; 2, inclusion of consecutive patients; 3, prospective collection of data; 4, endpoints appropriate to the aim of the study; 5, unbiased assessment of the study endpoint; 6,
follow-up period appropriate to the aim of the study; 7, loss to follow-up less than 5%; 8, prospective calculation of the study size; 9, an adequate control group; 10, contemporary groups;
11, baseline equivalence of groups; and 12, adequate statistical analysis. The item scored 0 means not mentioned, 1 means reported but inadequate, and 2 means reported and adequate. The total score is 24 for cohort study and clinical controlled trial, 16 for self-controlled study.
For Data extraction, two reviewers blind and independently extracted data from abstract and full text of studies that included.Prior to the screening, kappa statistics was carried out in order to verify the agreement level between the reviewers. The kappa values were higher than 0.80.
Moreover mean difference with 95% confidence interval (CI), fixed effect model and invariance method were calculated. Random effects were used to deal with potential heterogeneity and I2 showed heterogeneity. I2 values above 50% signified moderate-to-high heterogeneity. The Meta analysis have been evaluated with the statistical software Stata/MP v.16 (The fastest version of Stata).
3RESULTS
According to the purpose of the study, in the initial search with keywords, 114 articles were found.
In the first step of selecting studies 111 studies were selected to review the abstracts. Then, studies that did not meet the inclusion criteria were excluded from the study (97 article). In the second step, the full text of 14 studies was reviewed in this step, 11 studies that data extraction is not consistent with the present study were excluded, finally, three studies were selected (Figure1).
Figure 1:Study Attrition 3.1 Characteristics
Three studies (non-randomized controlled trial) have been included. The Number of children a total was 107. The mean of age was 14.58 years, In all studies used PCR Microbial analysis method (Table 2).
Table2: Studies selected for systematic review and meta-analysis.
Studies identified (n=114)
Studies after copies expelled (n=111)
Studiesscreened (n=111)
Studiesexcluded (n=97) Not meet eligibility criteria
Full content article surveyed for eligibility
(n=14)
Full contentarticleexcluded (n=11)
Data extraction is not consistent with the present study The includedstudies
(n=3) IdentificationScreenin gEligibilityIncluded
18117 Study. Years
Number of Patient
mean/
range of age (years)
Microbial analysis
method
pathogens MINORS
score Martha et al.
2016 [18] 25 14.4±2.45 PCR
P.gingivalis, F.
nucleatum, P.
intermedia and T.
forsythensis
17
Guo et al. 2016
[19] 62 8–15 PCR
P.gingivalis, F.
nucleatum, P.
intermedia and T.
forsythensis
12
Kim et al.
2012 [20] 30 16.7±6.5
y PCR
P.gingivalis, F.
nucleatum, P.
intermedia and T.
forsythensis
18
3.2 Bias assessment
According to MINORS, all studies had a moderate to low risk of bias (Table 2).
3.3 Subgroup meta-analysis Plaque index (PI)
Overall Mean difference of PI between children and control group in one month after treatment was0.03 (MD, 0.03 95% CI -0.20, 0.26. P<0.05).Overall Mean difference of PI between children and control group in three month after treatment was 0.11 (MD, 0.11 95% CI -0.12, 0.34. P.
P>0.05). According to Figure2, subgroup meta-analysis showed no statistically significant difference of Plaque index between control group vs children group (MD, 0.07 95% CI -0.09, 0.23.
P<0.05), among three studies and heterogeneity found (I2<0%; P =0.62).
Sulcus bleeding index (SBI)
Overall Mean difference of SBI between children and control group in one month after treatment was -0.13 (MD, -0.13 95% CI -0.38, 0.12. P>0.05). Overall Mean difference of SBI between children and control group in three month after treatment was -0.19 (MD, -0.19 95% CI -0.34, - 0.04. P>0.05). According to Figure2, subgroup meta-analysis showed no statistically significant difference of Sulcus bleeding index between control group vs children group (MD, -0.17 95% CI - 0.30, -0.04. P>0.05), among three studies and heterogeneity found (I2<0%; P =0.69).
Probing depth (PD)
Overall Mean difference of PD between children and control group in one month after treatment was 0.01 (MD, 0.01 95% CI -0.06, 0.08. P>0.05). Overall Mean difference of SBI between children and control group in three month after treatment was -0.02 (MD, -0.02 95% CI -0.07, 0.03. P>0.05).
According to Figure2, subgroup meta-analysis showed statistically significant difference of probing depth between control group vs children group (MD, -0.01 95% CI -0.05, 0.03. P>0.05), among three studies and heterogeneity found (I2<0%; P =0.50).
4 DISCUSSION
An in-depth understanding of clinical and microbiological changes is essential during the treatment and prevention of periodontal disease, which is applicable to different age groups. Under normal circumstances, most periodontal plaque microorganisms can be kept relatively stable due to the semi-enclosed structure of the gums, but are not the same as placing a fixed orthodontic appliance(21, 22).
The findings of the present study showed that the rate of various pathogens in children has an upward trend, so that in the third month after treatment was significantly higher than the time of onset, while in adults it is constant from the beginning of treatment. Studies have shown that the percentage of pathogens in general samples increases with time, especially at the time point of the third month after treatment, a gradual upward trend is observed in both adults and children(23).
Therefore, it can be shown that a fixed orthodontic appliance may have a significant impact on the microcological environment for adults and children. Under the stimulation of the orthodontic apparatus and due to plaque accumulation, the proliferation of pathogens under the gums was higher in children than adults(19, 24).PLI increased gradually in both children and adults, initially, children's PLI was significantly higher than adults, which may be due to the fact that adults generally have positive attitudes and habits towards oral health care and They have teeth, they are related(25, 26).
At the beginning of treatment, the difference between PLI was not evident in adults and children, which may be due to the effect of caregivers' oral health education, and children paid more attention to oral health care(27, 28). SBI also showed a significant difference in the first and third months compared to the start time, but no significant difference was observed between the adult and children subgroups and also between the different times of the first and third months. This may
18119 indicate that the inflammatory reaction may occur in the early stages of orthodontic treatment(29).
A study showed that both PLI and SBI were reduced following treatment for children using fixed orthodontic appliances, which is suggested to have beneficial results in reducing plaque and bleeding(30).
PD is an important indicator for measuring periodontal health, in the first month after treatment there was a significant increase in PD compared to the onset rate, but the results after treatment showed that the average value of the third month decreased slightly compared to the first month.
Also, no obvious change in AL was observed during the observation period(31).
Comparison results showed that between different individuals, adult PD was significantly higher than children at baseline, but there was no significant difference one or three months after treatment.
5 CONCLUSIONS
Findings from a systematic review and meta-analysis show that fixed orthodontic appliances may increase periodontal and microbiological statuses, both in children and adults. The results also showed that the effect of fixed orthodontic appliances in children further increases periodontal and microbiological statuses, especially in the first months of treatment. However, few studies have been found to examine the effects of fixed orthodontic appliances on children, so more research is needed in the long run to provide stronger evidence.
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