<%BANNER%>

Clinical evaluation of the Prophy-Jet in routine plaque debridement of orthodontic patients

University of Florida Institutional Repository

PAGE 1

CLINICAL EVALUATION OF THE PR OPHY-JET™ IN ROUTINE PLAQUE DEBRIDEMENT OF ORTHODONTIC PATIENTS By JEREMY M. ALBERT A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2003

PAGE 2

ii ACKNOWLEDGMENTS I thank my wife Jacque for all of her s upport, patience, and s acrifices through my many years in school. I look forward to our fu ture together and all that it will bring. I thank my daughter Alyssa, who alone is worth all the hard work and effort. I thank my family for guiding me into the person that I am today and for giving me the ability to be excellent. I would like to thank the me mbers of my committee—Dr. Wheeler, Dr. Dolce, Dr. Towle, and Dr. McGorray. I would also like to thank all of the pati ents who participated in the study; and the staff at the Graduate Orthodontic Clinic— Marie Taylor, Debbie Walls, April Heritage, and JoAnn Ridge ll—for their help in this project.

PAGE 3

iii TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................ii ABSTRACT....................................................................................................................iv INTRODUCTION............................................................................................................1 MATERIALS AND METHODS......................................................................................4 RESULTS........................................................................................................................ .8 DISCUSSION.................................................................................................................14 CONCLUSIONS.............................................................................................................18 REFERENCES...............................................................................................................19 BIOGRAPHICAL SKETCH..........................................................................................21

PAGE 4

iv Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science CLINICAL EVALUATION OF THE PR OPHY-JET™ IN ROUTINE PLAQUE DEBRIDEMENT OF ORTHODONTIC PATIENTS By Jeremy M. Albert May 2003 Chair: Timothy T. Wheeler Major Department: Orthodontics Orthodontic appliances, specifically br ackets bonded to teeth, can accumulate plaque, leading to gingivitis, enamel decalcifi cation, and dental decay. Currently, plaque removal in the orthodontic office is limited to tooth-brushing after wire removal. A prospective randomized clinical tr ial was conducted to compare the effectiveness of the Prophy-Jet™ to that of tooth-brushing for re moving dental plaque and for maintaining oral health. We r ecruited 40 orthodontic patients with fixed appliances showing poor oral hygiene to par ticipate in the 6-month study. Patients were randomly assigned to have one side of thei r mouth to be cleaned monthly with the Prophy-Jet™; the contralateral side was brus hed by the patient. Plaque Index (PI), Papillary Bleeding Score (PBS), and Decalci fication Index (DI) were assessed throughout the study. Significantly lower mean PI scores after cleaning were found for the Prophy-Jet™ (0.41 maxillary posterior, 0.08 maxillary anterior, 0.23 mandibular posterior, 0.05

PAGE 5

v mandibular anterior) versus tooth-brushing (1.85 maxillary poster ior, 2.08 maxillary anterior, 1.64 mandibular poste rior, 1.78 mandibular anterior ). Monthly PI and PBS scores were not significantly di fferent. However, changes in DI scores were significantly less for the Prophy-Jet™ teeth (mean di fference= 0.27 mandibular posterior, 0.37 maxillary anterior, 0.18 mandibular anterior). Results show that the Prophy-Jet™ was mo re effective than tooth-brushing at removing dental plaque for a single session. In addition, monthly cleanings with the Prophy-Jet™ were found to decrease the pr ogression of enamel decalcifications in patients with inadequate oral hyg iene practices between visits.

PAGE 6

1 INTRODUCTION Dental plaque has long been associated w ith dental decay and periodontal disease. Fixed orthodontic appliances, specifically brackets bonded to teeth, can accumulate plaque along their margins with teeth; and ma y interfere with effective plaque removal. In addition, proper oral hygiene by these patien ts, while crucial to successful treatment, can be difficult to maintain. Accumulated dent al plaque in orthodontic patients has been associated with enamel decalcification, enamel scarring, dental decay, and gingivitis. In a study of decalcification incidence, 50% of or thodontic patients experienced an increase in decalcification during treatment, with th e highest incidence in the maxillary incisor region and lowest incidence in the maxillary posterior region.1 Professional dental prophylaxis over the years has traditionally involved the use of a rubber cup and abrasive paste for cor onal polishing. The ultimate goal of this procedure is complete removal of supragingi val plaque and stain. However, the use of rubber cup and abrasive past e is often laborious, time-c onsuming, and ineffective in completely removing supragingival depos its, particularly around bonded orthodontic appliances. Since its introduction to the dental marketplace in 1977, air-powder polishing systems have been effective at removing stain and plaque.2 The design of the various air-powder polishing systems, such as Dent sply’s Prophy-Jet™, use a mixture of air, water, and sodium bicarbonate to deliver a controlled stream of sodium bicarbonate particles to the tooth surface. This slurry of powder and water debr ides tooth surfaces of

PAGE 7

2 plaque and stain by abrasion. Advantages of air polishers are rapid removal of tooth deposits, less invoked hypersensitivity;3,4 less operator fatigue;5 and improved access to pits and fissures.6 In a survey of 140 stain patien ts, 94% preferred the Prophy-Jet™ compared to hand instrument ation or ultrasonic scaling.7 Reasons cited by the patients were that the Prophy-Jet™ was more thor ough, it required less chair time, and it was more comfortable because no heat, scratching, or pressure were generated during the prophylaxis. Currently, plaque removal in the orth odontic office is limited for mainly to tooth-brushing after wire removal. This me thod of plaque removal requires wire removal and often relies on the patient’s ability to effectively rem ove the plaque with a manual tooth-brush. While the Prophy-Jet™ has been shown to be effective in general dental patients, its long-term effectiveness on or thodontic patients has never been studied. By designing a study that includes lo ng-term follow-up on the periodontal and dental health of orthodontic patients, the potential benefits of routine Prophy-Jet™ cleanings could be explored not only for a si ngle visit, but as a re gimen for oral health maintenance for orthodontic patient s with oral hygiene concerns. The purposes of this clinical trial were as follows: To evaluate the efficacy of the Prophy-Jet™ in removing dental plaque in orthodontic patients with arch-wires in place; To evaluate the long-term effects of mont hly debridements with the Prophy-Jet™ in orthodontic patients with poor oral hygiene on gingivitis, decalcification, and plaque accumulation;

PAGE 8

3 To compare the effectiveness of the Pr ophy-Jet™ to currently used method of tooth-brushing.

PAGE 9

4 MATERIALS AND METHODS This study was designed as a prospective randomized controlled clinical trial. Patients undergoing orthodontic treatment with brackets and wires in the maxillary and mandibular arches were recruite d from the Graduate Orthodontic Clinic at the University of Florida College of Dentistry. Other selecti on criteria for inclusion in the trial were the presence of extensive amounts of visually detectable plaque around the orthodontic appliances as identified by the operator, good health with no current medications, and willingness to sign informed consent. Patients were instructed to restrict home care to floss and manual tooth-brushe s; and were not allowed the use of any electric tooth-brushes. The Institutional Review Boar d for research at the University of Florida approved the study protocol before the study was begun. Participants in the study were randomly a ssigned a side of the mouth that would be cleaned monthly by the De ntsply Prophy-Jet™ instrument for the duration of the 6-month study. The contralateral side was manually brushed by the patient at each clinical visit. This randomization was crea ted from a computer-generated sequence that was followed for patient assignment. A mouth tray was placed on the tooth-brush side of the mouth while using the Prophy-Jet™ to prev ent crossover spray. For participation in the trial, patients were financially compen sated and received a full mouth debridement with the Prophy-Jet™ at co mpletion of the study. The protocol for each clinical visit wa s designed based on a pilot study that was conducted in 1999 at the University of Florida. This pilot study showed the effectiveness

PAGE 10

5 of debridement with the ProphyJet™ with arch-wires in pl ace; therefore, arch-wires were not removed for the present study. Patient s were seen for a tota l of seven clinical visits, the first consisting of a baseline examin ation of dental health parameters including the collection of clinical indices. At th is initial visit, Pr ophy-Jet™ cleaning on the assigned side and manual tooth-brushing on the contralateral side were performed, with 30 seconds allotted per arch for each met hod to make procedure time comparable. Patients were then seen at monthly intervals for 6 months, at which times clinical indices were recorded and the split-m outh cleaning was performed. The labial surfaces of teeth bonded with brackets from the 2nd premolars forward were included in this assessment. The following clinical indices were measured for this study. Plaque. Plaque levels were assessed usi ng the Turesky modification of the Quigley-Hein Plaque Index (PI).8 0 = No plaque visible 1 = Separate flecks of plaque visible at the gingival margin 2 = A thin continuous band of plaque (up to 1 mm) at the gingival margin 3 = A band of plaque wider than 1 mm but covering less than one-third of the tooth surface 4 = Plaque covering at least one-third but less than two-thirds of the surface 5 = Plaque covering more than two-thirds of the surface The PI was recorded at each monthly vis it. In addition, the PI before and after cleaning was scored at the base line visit to compare mechani cal cleaning effectiveness of the Prophy-Jet™ to that of ma nual tooth-brushing under the clinical conditions of the study.

PAGE 11

6 Decalcifications. Decalcifications were assessed visually and tactilely with a dental explorer and scored by using a modified version of th e white spot lesion index of Gorelick et al.1 0 = No white spot present 1 = Visible white spots without surf ace interruption (mild decalcification) 2 = Visible white spot lesi on having a roughened surface but not requiring a restoration (moderate decalcification) 3 = Visible white spot lesion with surf ace interruption (severe decalcification) 4 = Cavitation The decalcification index (DI) was measured at baseline, 3 months, and 6 months due to the slow, progressive nature of decalcifications. Gingivitis. Gingivitis was assessed at each m onthly visit using the Papillary Bleeding Score (PBS) of Loesche.9 A Stimu-dent™ was used to stimulate the interdental papilla, which is a common site of gingi val inflammation for orthodontic patients. Subsequent gingival bleeding was used as a measure of gingival health. 1 = No bleeding 2 = Slight bleeding 3 = Bleeding with flow 4 = Intermediate bleeding (copious) 5 = Spontaneous bleeding A single operator performed all measurem ents and cleanings; thus, blinding was not possible for the decalcification index, wh ich was recorded after cleanings. Before recruitment of patients for the Prophy-Je t™ study, the operator was calibrated by a calibrated dental hygienist on the three clinical indices (DI, PI, and PBS) and use of the Prophy-Jet™ to ensure consistency of results Five orthodontic patients meeting the inclusion criteria of the planned study we re examined by operator and hygienist and standardization and reproducibility of indices were demonstrated. These patients were not included in the clinical trial.

PAGE 12

7 Forty patients were recruited to part icipate in the study. The mean age was 18.1 9 y (range 11 to 56 y). The group was composed equally of 20 males and 20 females. In reference to use of a domi nant hand, 35 patients were right-handed and 5 patients were left-handed. The assignment of sides of the mouth to be cleaned with the Prophy-Jet™ was 20 for the right side and 20 for the left side. For the right-handed subjects, 17 had Prophy-Jet™ on the left and 18 had Prophy-Jet™ on the right; for left-handed subjects, 3 had Prophy-Jet™ on the left, and 2 had Prophy-Jet™ on the right. Over the course of the 6-month study, 5 patients were eliminated for missing appointments or discontinuing or thodontic treatment. Thirty -five patients successfully completed the study and were seen at all seven clinical visits. Each patient served as a control: one a ssigned side of the mouth was cleaned by the Prophy-Jet™ for the duration of the 6 months. Changes that occurred during treatment for PI, DI, and PBS on the two treatment sides were evaluated with the paired t-test and the 2-sample t-test. Pearson correlation coefficients were used to evaluate for relationships within the data set.

PAGE 13

8 RESULTS The difference in mean reduction in PI sc ores at the baseline visit (Figure 1) between the Prophy-Jet™ and tooth-brush wa s statistically significant for all four quadrants, with the Prophy-Jet™ having gr eater PI reduction (p < 0.0001). A sample comparison of the cleaning effectiveness between the Prophy-Jet™ and manual toothbrushing at the baseline visit is illustrated in Figure 2. Change in DI scores from baseline to 6 months were significantly lower for the Prophy-Jet™ for the mandibular anterior and posterior, and the maxillary anterior (p < 0.05). The maxillary posterior did not reach statistical signi ficance (p = 0.26). The mean DI scores are shown in Figure 3, and th e differences between the two sides (with a positive number indicating less decalcifica tion increase for the Prophy-Jet™) are shown in Figure 4. Figure 5 shows a sample photo co mparison of both sides. Mean DI score change did not differ significantly by gender or side of mouth selected for Prophy-Jet™ use. Plaque index (PI) changes from baseline to 6 months are shown in Figure 6 and did not reach statistical signi ficance (p = 0.07). Patient ge nder did not influence PI scores; however, patients who received the Pr ophy-Jet™ cleanings on the left side of their mouth had a significantly greater difference in plaque levels between the two sides (mean = 0.46 0.52) than those assigned to the right side (mean = 0.00 0.80).

PAGE 14

9 Papillary Bleeding Score (PBS) changes fr om baseline to 6 months were not significantly different (p = 0.46) and are shown in Figure 7. Mean PBS score change did not differ by gender or side of mout h selected for Prophy-Jet™ use. Analysis via Pearson correlation coeffici ents (Table 1) indicated statistically significant correlations of the changes in cl inical indices between the Prophy-Jet™ and tooth-brush sides. DI, PI, and PBS were positively correl ated between the two sides (p < 0.005). In addition, for the Prophy-Je t™ side, changes in DI were positively correlated with changes in PI (p < 0.05). 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0PI Before Cleaning After Cleaning PJ TB PJ TB PJ TB PJ TB Posterior Anterior Posterior Anterior Maxilla Mandible Figure 1. Plaque Index scores (mean SE, n = 40) before and afte r cleaning at baseline visit, by region. (PJ = Prophy-Je t™, TB = tooth-brush). Significant at p < 0.0001

PAGE 15

10 Figure 2. Study subject after cl eaning at baseline visit. A) With Prophy-Jet™. B) With tooth-brush. Disclosing solution has been used to reveal plaque. 0.00 0.25 0.50 0.75 1.00 1.25 1.50DI Baseline 6 months PJ TB PJ TB PJ TB PJ TB Posterior Anterior Posterior Anterior Maxilla Mandible Figure 3. Decalcification Index scores (mean SE) at baseline and 6 months, by region. (PJ = Prophy-Jet™, TB = tooth-brush). A B

PAGE 16

11 0.00 0.10 0.20 0.30 0.40 0.50 Maxillary posterior *Mandibular posterior *Maxillary anterior *Mandibular anteriorDI Difference Figure 4. Difference in Decalcification Inde x change (mean SE, n = 35) by region. Positive DI difference indicates less increase for Prophy-Jet™. *Significant at p < 0.05 Figure 5. Study subject at comp letion of the six month tria l. This illustrates the decreased decalcification on the (A) Pr ophy-Jet™ side compared to the (B) tooth-brush side. A B

PAGE 17

12 2.75 3.00 3.25 3.50 3.75 4.00Baseline Month 1 Month 2 Month 3 Month 4 Month 5 Month 6PI PJ Maxillary posterior PJ Maxillary anterior PJ Mandibular posterior PJ Mandibular anterior TB Maxillary posterior TB Maxillary anterior TB Mandibular posterior TB Mandibular anterior Figure 6. Monthly mean Plaque Index scores (n = 35) from base line to 6 months, by region. (PJ = Prophy-Jet™, TB = tooth-brush) *Not significant at p = 0.07 0.50 0.70 0.90 1.10 1.30 1.50 1.70Baseline Month 1 Month 2 Month 3 Month 4 Month 5 Month 6PBS PJ Maxillary posterior PJ Maxillary anterior PJ Mandibular posterior PJ Mandibular anterior TB Maxillary posterior TB Maxillary anterior TB Mandibular posterior TB Mandibular anterior Figure 7. Monthly mean Papillary Bleeding Scor e from baseline to 6 months, by region. (PJ = Prophy-Jet, TB = Tooth-brush) *Not significant, p = 0.46

PAGE 18

13 Table 1. Pearson Correlation Coefficients (R values) for Decalcification Index (DI), Plaque Index (PI), and Papill ary Bleeding Score (PBS). DI TB DI PJ PI TB PI PJ PBS TB PBS PJ DI TB 1.00000 0.56192 (p=0.0004) 0.19013 (p=0.2739) 0.25993 (p=0.1316) -0.00457 (p=0.9792) -0.03324 (p=0.8497) DI PJ 1.00000 0.22428 (p=0.1952) 0.36608 (p=0.0306) -0.10785 (p=0.5374) -0.06599 (p=0.7065) PI TB 1.00000 0.82883 (p<0.0001) -0.06343 (p=0.7174) -0.15548 (p=0.3725) PI PJ 1.00000 -0.08753 (p=0.6171) -0.21230 (p=0.2208) PBS TB 1.00000 0.55921 (p=0.0005) PBS PJ 1.00000 (PJ = Prophy-Jet™, TB = Tooth-brush, = change from baseline to visit 6)

PAGE 19

14 DISCUSSION The present study was conducted as a pros pective randomized c ontrolled clinical trial on 40 orthodontic patients with full fi xed appliances dem onstrating visible supragingival plaque. By selecting patient s in orthodontic treatment with poor oral hygiene, it was hoped that monthly Pr ophy-Jet™ cleanings would minimize the deleterious effects of plaque accumulation due to inadequate brushing or flossing at home. However, this patient group may not be representative of orthodontic patients as a whole. Other potential limitations include ge ographic sampling bias, lack of blinding due to the single operator for decalcification inde x, effect of extraneous factors such as manual dexterity for the patients, an d selection of clinical indices Previous studies investigated the use of the Prophy-Jet™ on orthodontic patients. Two studies by Barnes and Gerbo et al.10,11 investigated the app lication of air-powder polishing systems in the orthodontic setting. The first study was conducted in two parts with both using the Prophy-Jet™ device. Pa rt 1 showed that the Prophy-Jet™ was more effective in removing plaque around orthodontic appliances; and required less time than traditional rubber cup/pumice prophylaxis. The investigators noted the clinical advantage of lack of disturbance of orthodontic wires and elastic ba nds with the Prophy-Jet™. Part 2 of the study was performed by the bonding of brackets with composite to ten extracted maxillary central incisors and cem enting of molar bands with zinc phosphate cement to ten extracted mandibular first molars. The results indicated that, while both the composite and zinc phosphate cement were e xposed to the air powde r spray, the surface

PAGE 20

15 of the two materials maintained their integr ity and their margins remained intact. The authors concluded that use of air-powder sp ray had no detrimental effects on orthodontic brackets or bands or their cementing agents. Other studies have suggested roughening and/or wear of dent al restorative materials such as amalgam, composite, and gold foil;7,12,13,14 thus, it has been recommended to avoi d prolonged direct exposure of these materials to the compressed spray of slurry. In the present study, the effectiveness of plaque debridement in a single visit by the Prophy-Jet™ was far superior to that of tooth-br ushing. While PI scores were similar on both sides before cleaning, the PI scores after cleaning on the Prophy-Jet™ side were less than the tooth-brush in all areas of the m outh (Figure 1). This portion of the study was to verify previous reports of Prophy-Jet™ cleaning efficiency and to give a statistical comparison of the effectiveness of the selected cleaning methods under orthodontic clinical conditions. The lack of any effect by the Prophy-Jet ™ cleanings on monthly plaque levels and gingival inflammation can be explained by the pathogenesis of periodontal disease and the design of the study. The salivary pe llicle forms within minutes to hours after professional dental cleaning, and the initial co lonizers are gram positive bacteria such as Streptococcus and Actinomyces species.15 Over the following days, the plaque increases in thickness and quantity as gram-negative cocci and gram-positive and gram-negative rods and filaments increase their presence. The patients included in this study were identified as having poor oral hygiene and the duration of time between monthly appointments was more than enough time for pla que levels and gingivi tis to return to baseline levels. Any potential benefits of a professional cleaning would have to be

PAGE 21

16 maintained by the patients in their home car e in order to minimize the damaging effects of plaque accumulation on the teeth and surr ounding periodontium. However, poor oral hygiene patients are the ones that would most benefit from additional hygiene measures. Therefore, we chose to study this group. Th e interval of one month between cleanings was selected as the minimum amount of time be tween most clinical visits for orthodontic patients. Over the 6-month study, it was shown that the Prophy-Jet™ significantly decreased the formation and/or progression of decalcifications. It should be noted, however, that the decalcification process was not entirely avoided. From baseline to 6 months, the mean DI scores for the Pr ophy-Jet™ increased from 0.71 to 0.74 in the maxilla and 0.56 to 0.66 in the mandible. Howe ver, the tooth-brush side experienced a significantly greater increase over the six months from 0.65 to 0.95 in the maxilla and 0.44 to 0.79 in the mandible. Thus, wh ile formation and/or progression of decalcifications was not entirely prev ented, the thoroughness of the Prophy-Jet™ cleaning at monthly visits in some manner significantly disrupted the decalcification process. Possibilities for this include interfer ence in the colonizati on of certain bacteria into the developing plaque on the tooth surface. Although there are more than 300 species of bacteria in plaque, most have no cariogenic potential.16 Primary etiologic bacteria in dental caries include Streptococcus mutans and Streptococcus sobrinus with Lactobacilli as a secondary invader involved in caries progression in enamel.17 Thus, even in the presence of unalte red plaque levels and gingiv itis, the monthly debridement by the Prophy-Jet™ may have altered the ba cterial load by physical disruption and

PAGE 22

17 prevent more deleterious organisms from co lonizing and promoting the decalcification process. The correlation of the changes in the thr ee clinical indices from baseline to 6 months reinforces the importance of the patient’s involvement in oral health maintenance. The R values of 0.56 for Decalcification Index, 0.83 for Plaque Index, and 0.56 for Papillary Bleeding Score indicate positive correlation between the changes that occurred on the Prophy-Jet™ and tooth-brus h sides. Any changes for th e indices on one side were paralleled by the contralateral side. This is not unexpected since this was a split-mouth study. Additionally, the positive correlation between PI changes and DI changes for the Prophy-Jet™ side demonstrates that if the pa tients were able to maintain the decreased plaque levels by the Prophy-Jet™ cleaning, th ose patients experien ced less increases in decalcifications on that side. Obviously, ade quate home care is critical in maintaining oral hygiene and preventing decalcifications. For the present study, the Prophy-Jet™ proved to be useful on patients that were poorly compliant with oral hygiene in preventing the excessive formation of decalcifications.

PAGE 23

18 CONCLUSIONS This prospective clinical trial was designe d to evaluate the effects of Prophy-Jet™ cleanings as compared to conventional toot h-brushing during office visits on orthodontic patients with poor oral hygiene. Based on the findings of this study, the following conclusions were reached: The Prophy-Jet™ is more effective than the tooth-brush at removing plaque in orthodontic patients for a single visit setting. Over the course of six m onths, the monthly Prophy-Jet™ cleanings significantly reduced the progression and/or formation of enamel decalcifications, even in the presence of unaltered monthly pl aque levels and gingivitis. Maintenance of adequate oral hygiene at home is essential to minimizing the deleterious effects of plaque accumu lation, including decalcifications. The Prophy-Jet™ is an effective suppleme nt to oral health maintenance during orthodontic treatment for poor oral hygiene patients. The mechanism for the decalcification re duction remains unclear, but could be attributed to interference in th e colonization of certain bacter ia by the monthly cleanings. Future studies may be designed to inve stigate this hypothesis by examining the differences in bacterial strains present on each side. Other factors may also be explored to minimize decalcifications and gingivitis, such as fluoride supplements, mechanical tooth-brushes, or increased fr equency of professional cleaning.

PAGE 24

19 REFERENCES 1. Gorelick L, Geiger AM, Gwinnett AJ. Inci dence of white spot formation after banding and bonding. Am J Orthod 1982;81:93. 2. Brown DM, Barnhart RC. A scientific f oundation for clinical use of air polishing systems. J Pract Hyg 1995;4:36-40. 3. Atkinson DR, Cobb CM, and Killoy WJ. The effect of an air-powder abrasive system on in vitro root surfaces. J Periodontol 1984;55:13-18. 4. Galloway SE, Pashley DH. Rate of remova l of root structure by the use of the Prophy-jet device. J Pe riodontol 1987;7:464-469. 5. Weaks LM, Lescher NB, Barnes CM, Holroyd SV. Clinical evaluation of the Prophy-jet as an instrument for routine removal of tooth stain and plaque. J Periodontol 1984;3:486-488. 6. Strand GV, Randal M. Efficiency of clean ing fissures with an air-polishing instrument. Acm Odontol Scand 1988;46:113-117. 7. Clinical Research Associates. Oral prophylaxis: Prophy-Jet. Clin Res Assoc 1981;5:1-4. 8. Quigley GA, Hein JW. Comparative cl eaning efficiency of manual and power brushing. J Am Dent Assoc 1962;65:26. 9. Loesche, W. J. Clinical and microbiologi cal aspects of chemotherapeutic agents used according to the specific plaq ue hypothesis. J Dent Res 1979;58:2402-2412. 10. Barnes CM, Russell CM, Gerbo LR, Barnes DW. Effects of an air-polishing system on orthodontically bracketed and banded teeth. Am J Orthodont Dentofacial Orthop 1990;97:74-91. 11. Gerbo LR, Barnes CM, Leinfelder KF. App lications of the ai r-powder polisher in clinical orthodontics. Am J Orthodont Dentofacial Orthop 1993;103:71-73. 12. Gorfil C, Nordenberg D, Liberman R, Ben-Amar A. The effect of ultrasonic cleaning and air polishing on the marginal integrity of radicular amalgam and composite resin restorations. J Clin Periodontol 1989;16(3):137-139.

PAGE 25

20 13. Cooley RL, Lubow RM, Patrissi BA. Th e effect of an air-powder abrasive instrument on composite resin. J Am Dent Assoc 1986;112:362-364. 14. Gutmann MS, Marker VA, Gutmann JL. Restoration surface roughness after airpowder polishing. Am J Dent 1993;6:99-102. 15. Rateitschak KH, Wolf HF, Hassell TM. Color Atlas of Dental Medicine: Periodontology. Thieme Medical Publishers,1989:13-19. 16. Schwartz RS, Summitt JB, Robbins JW. F undamentals of Operative Dentistry: A Contemporary Approach. Quintessence Publishing Co,1996:51-57. 17. Matthewson RJ, Primosch RE. Fundam entals of Pediatric Dentistry 3rd Ed. Quintessence Publishing Co,1995:80-115.

PAGE 26

21 BIOGRAPHICAL SKETCH Jeremy Matthew Albert was born in Hunt sville, Alabama, and raised in Tarpon Springs, Florida. He attended the University of Florida for his undergraduate study, with a B.S. in nutritional science. He was then admitted to the University of Florida College of Dentistry for his dental education and graduated with honors from dental school in 2000, obtaining a Doctor of Dental Medicine degree. After gr aduation, Dr. Albert continued his dental education at the University of Florida earning a Master of Science degree with a certificate in orthodontics in May 2003.


Permanent Link: http://ufdc.ufl.edu/UFE0000627/00001

Material Information

Title: Clinical evaluation of the Prophy-Jet in routine plaque debridement of orthodontic patients
Physical Description: Mixed Material
Creator: Albert, Jeremy M. ( Author, Primary )
Publication Date: 2002
Copyright Date: 2002

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0000627:00001

Permanent Link: http://ufdc.ufl.edu/UFE0000627/00001

Material Information

Title: Clinical evaluation of the Prophy-Jet in routine plaque debridement of orthodontic patients
Physical Description: Mixed Material
Creator: Albert, Jeremy M. ( Author, Primary )
Publication Date: 2002
Copyright Date: 2002

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0000627:00001


This item has the following downloads:


Full Text











CLINICAL EVALUATION OF THE PROPHY-JETTM IN ROUTINE PLAQUE
DEBRIDEMENT OF ORTHODONTIC PATIENTS













By

JEREMY M. ALBERT


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA


2003















ACKNOWLEDGMENTS

I thank my wife Jacque for all of her support, patience, and sacrifices through my

many years in school. I look forward to our future together and all that it will bring.

I thank my daughter Alyssa, who alone is worth all the hard work and effort.

I thank my family for guiding me into the person that I am today and for giving me

the ability to be excellent.

I would like to thank the members of my committee-Dr. Wheeler, Dr. Dolce, Dr.

Towle, and Dr. McGorray. I would also like to thank all of the patients who participated

in the study; and the staff at the Graduate Orthodontic Clinic- Marie Taylor, Debbie

Walls, April Heritage, and JoAnn Ridgell-for their help in this project.















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ............................................................................................... ii

ABSTRACT ..................................... ...... .............. iv

IN TR O D U C TIO N ............................................................................... ......... .

M A TERIALS AN D M ETH OD S............................................................. ............... 4

R E SU L T S ............................................................................... . 8

D ISC U S SIO N ...................................................... 14

CON CLU SION S...... ...... .......................... .............. ........ ........... 18

REFEREN CES ..................... ...... ............ .. .. .. ....... .......19

BIOGRAPH ICAL SKETCH ................................................. ..............21















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

CLINICAL EVALUATION OF THE PROPHY-JETTM IN ROUTINE PLAQUE
DEBRIDEMENT OF ORTHODONTIC PATIENTS

By

Jeremy M. Albert

May 2003

Chair: Timothy T. Wheeler
Major Department: Orthodontics

Orthodontic appliances, specifically brackets bonded to teeth, can accumulate

plaque, leading to gingivitis, enamel decalcification, and dental decay. Currently, plaque

removal in the orthodontic office is limited to tooth-brushing after wire removal.

A prospective randomized clinical trial was conducted to compare the

effectiveness of the Prophy-JetTM to that of tooth-brushing for removing dental plaque

and for maintaining oral health. We recruited 40 orthodontic patients with fixed

appliances showing poor oral hygiene to participate in the 6-month study. Patients were

randomly assigned to have one side of their mouth to be cleaned monthly with the

Prophy-JetTM; the contralateral side was brushed by the patient. Plaque Index (PI),

Papillary Bleeding Score (PBS), and Decalcification Index (DI) were assessed throughout

the study.

Significantly lower mean PI scores after cleaning were found for the Prophy-JetTM

(0.41 maxillary posterior, 0.08 maxillary anterior, 0.23 mandibular posterior, 0.05









mandibular anterior) versus tooth-brushing (1.85 maxillary posterior, 2.08 maxillary

anterior, 1.64 mandibular posterior, 1.78 mandibular anterior). Monthly PI and PBS

scores were not significantly different. However, changes in DI scores were significantly

less for the Prophy-JetTM teeth (mean difference= 0.27 mandibular posterior, 0.37

maxillary anterior, 0.18 mandibular anterior).

Results show that the Prophy-JetTM was more effective than tooth-brushing at

removing dental plaque for a single session. In addition, monthly cleaning with the

Prophy-JetTM were found to decrease the progression of enamel decalcifications in

patients with inadequate oral hygiene practices between visits.














INTRODUCTION

Dental plaque has long been associated with dental decay and periodontal disease.

Fixed orthodontic appliances, specifically brackets bonded to teeth, can accumulate

plaque along their margins with teeth; and may interfere with effective plaque removal.

In addition, proper oral hygiene by these patients, while crucial to successful treatment,

can be difficult to maintain. Accumulated dental plaque in orthodontic patients has been

associated with enamel decalcification, enamel scarring, dental decay, and gingivitis. In

a study of decalcification incidence, 50% of orthodontic patients experienced an increase

in decalcification during treatment, with the highest incidence in the maxillary incisor

region and lowest incidence in the maxillary posterior region.1

Professional dental prophylaxis over the years has traditionally involved the use

of a rubber cup and abrasive paste for coronal polishing. The ultimate goal of this

procedure is complete removal of supragingival plaque and stain. However, the use of

rubber cup and abrasive paste is often laborious, time-consuming, and ineffective in

completely removing supragingival deposits, particularly around bonded orthodontic

appliances.

Since its introduction to the dental marketplace in 1977, air-powder polishing

systems have been effective at removing stain and plaque.2 The design of the various

air-powder polishing systems, such as Dentsply's Prophy-JetTM, use a mixture of air,

water, and sodium bicarbonate to deliver a controlled stream of sodium bicarbonate

particles to the tooth surface. This slurry of powder and water debrides tooth surfaces of






2


plaque and stain by abrasion. Advantages of air polishers are rapid removal of tooth

deposits, less invoked hypersensitivity;3'4 less operator fatigue;5 and improved access to

pits and fissures.6 In a survey of 140 stain patients, 94% preferred the Prophy-JetTM

compared to hand instrumentation or ultrasonic scaling. Reasons cited by the patients

were that the Prophy-JetTM was more thorough, it required less chair time, and it was

more comfortable because no heat, scratching, or pressure were generated during the

prophylaxis.

Currently, plaque removal in the orthodontic office is limited for mainly to

tooth-brushing after wire removal. This method of plaque removal requires wire removal

and often relies on the patient's ability to effectively remove the plaque with a manual

tooth-brush. While the Prophy-JetTM has been shown to be effective in general dental

patients, its long-term effectiveness on orthodontic patients has never been studied.

By designing a study that includes long-term follow-up on the periodontal and

dental health of orthodontic patients, the potential benefits of routine Prophy-JetTM

cleaning could be explored not only for a single visit, but as a regimen for oral health

maintenance for orthodontic patients with oral hygiene concerns.

The purposes of this clinical trial were as follows:

* To evaluate the efficacy of the Prophy-JetTM in removing dental plaque in orthodontic

patients with arch-wires in place;

* To evaluate the long-term effects of monthly debridements with the Prophy-JetTM in

orthodontic patients with poor oral hygiene on gingivitis, decalcification, and plaque

accumulation;









* To compare the effectiveness of the Prophy-JetTM to currently used method of

tooth-brushing.














MATERIALS AND METHODS

This study was designed as a prospective randomized controlled clinical trial.

Patients undergoing orthodontic treatment with brackets and wires in the maxillary and

mandibular arches were recruited from the Graduate Orthodontic Clinic at the University

of Florida College of Dentistry. Other selection criteria for inclusion in the trial were the

presence of extensive amounts of visually detectable plaque around the orthodontic

appliances as identified by the operator, good health with no current medications, and

willingness to sign informed consent. Patients were instructed to restrict home care to

floss and manual tooth-brushes; and were not allowed the use of any electric

tooth-brushes. The Institutional Review Board for research at the University of Florida

approved the study protocol before the study was begun.

Participants in the study were randomly assigned a side of the mouth that would

be cleaned monthly by the Dentsply Prophy-JetTM instrument for the duration of the

6-month study. The contralateral side was manually brushed by the patient at each

clinical visit. This randomization was created from a computer-generated sequence that

was followed for patient assignment. A mouth tray was placed on the tooth-brush side of

the mouth while using the Prophy-JetTM to prevent crossover spray. For participation in

the trial, patients were financially compensated and received a full mouth debridement

with the Prophy-JetTM at completion of the study.

The protocol for each clinical visit was designed based on a pilot study that was

conducted in 1999 at the University of Florida. This pilot study showed the effectiveness









of debridement with the Prophy-JetTM with arch-wires in place; therefore, arch-wires

were not removed for the present study. Patients were seen for a total of seven clinical

visits, the first consisting of a baseline examination of dental health parameters including

the collection of clinical indices. At this initial visit, Prophy-JetTM cleaning on the

assigned side and manual tooth-brushing on the contralateral side were performed, with

30 seconds allotted per arch for each method to make procedure time comparable.

Patients were then seen at monthly intervals for 6 months, at which times clinical indices

were recorded and the split-mouth cleaning was performed.

The labial surfaces of teeth bonded with brackets from the 2nd premolars forward

were included in this assessment. The following clinical indices were measured for this

study.

Plaque. Plaque levels were assessed using the Turesky modification of the

Quigley-Hein Plaque Index (PI).8

0 = No plaque visible
1 = Separate flecks of plaque visible at the gingival margin
2 = A thin continuous band of plaque (up to 1 mm) at the gingival margin
3 = A band of plaque wider than 1 mm but covering less than one-third of the tooth
surface
4 = Plaque covering at least one-third but less than two-thirds of the surface
5 = Plaque covering more than two-thirds of the surface

The PI was recorded at each monthly visit. In addition, the PI before and after

cleaning was scored at the baseline visit to compare mechanical cleaning effectiveness of

the Prophy-JetTM to that of manual tooth-brushing under the clinical conditions of the

study.









Decalcifications. Decalcifications were assessed visually and tactilely with a

dental explorer and scored by using a modified version of the white spot lesion index of

Gorelick et al.1

0 = No white spot present
1 = Visible white spots without surface interruption (mild decalcification)
2 = Visible white spot lesion having a roughened surface but not requiring a restoration
(moderate decalcification)
3 = Visible white spot lesion with surface interruption (severe decalcification)
4 = Cavitation

The decalcification index (DI) was measured at baseline, 3 months, and 6 months

due to the slow, progressive nature of decalcifications.

Gingivitis. Gingivitis was assessed at each monthly visit using the Papillary

Bleeding Score (PBS) of Loesche.9 A Stimu-dentTM was used to stimulate the interdental

papilla, which is a common site of gingival inflammation for orthodontic patients.

Subsequent gingival bleeding was used as a measure of gingival health.

1 = No bleeding
2 = Slight bleeding
3 = Bleeding with flow
4 = Intermediate bleeding (copious)
5 = Spontaneous bleeding

A single operator performed all measurements and cleaning; thus, blinding was

not possible for the decalcification index, which was recorded after cleaning. Before

recruitment of patients for the Prophy-JetTM study, the operator was calibrated by a

calibrated dental hygienist on the three clinical indices (DI, PI, and PBS) and use of the

Prophy-JetTM to ensure consistency of results. Five orthodontic patients meeting the

inclusion criteria of the planned study were examined by operator and hygienist and

standardization and reproducibility of indices were demonstrated. These patients were

not included in the clinical trial.









Forty patients were recruited to participate in the study. The mean age was

18.1 + 9 y (range 11 to 56 y). The group was composed equally of 20 males and

20 females. In reference to use of a dominant hand, 35 patients were right-handed and

5 patients were left-handed. The assignment of sides of the mouth to be cleaned with the

Prophy-JetTM was 20 for the right side and 20 for the left side. For the right-handed

subjects, 17 had Prophy-JetTM on the left and 18 had Prophy-JetTM on the right; for

left-handed subjects, 3 had Prophy-JetTM on the left, and 2 had Prophy-JetTM on the right.

Over the course of the 6-month study, 5 patients were eliminated for missing

appointments or discontinuing orthodontic treatment. Thirty-five patients successfully

completed the study and were seen at all seven clinical visits.

Each patient served as a control: one assigned side of the mouth was cleaned by

the Prophy-JetTM for the duration of the 6 months. Changes that occurred during

treatment for PI, DI, and PBS on the two treatment sides were evaluated with the paired

t-test and the 2-sample t-test. Pearson correlation coefficients were used to evaluate for

relationships within the data set.















RESULTS

The difference in mean reduction in PI scores at the baseline visit (Figure 1)

between the Prophy-JetTM and tooth-brush was statistically significant for all four

quadrants, with the Prophy-JetTM having greater PI reduction (p < 0.0001). A sample

comparison of the cleaning effectiveness between the Prophy-JetTM and manual tooth-

brushing at the baseline visit is illustrated in Figure 2.

Change in DI scores from baseline to 6 months were significantly lower for the

Prophy-JetTM for the mandibular anterior and posterior, and the maxillary anterior

(p < 0.05). The maxillary posterior did not reach statistical significance (p = 0.26). The

mean DI scores are shown in Figure 3, and the differences between the two sides (with a

positive number indicating less decalcification increase for the Prophy-JetTM) are shown

in Figure 4. Figure 5 shows a sample photo comparison of both sides. Mean DI score

change did not differ significantly by gender or side of mouth selected for Prophy-JetTM

use.

Plaque index (PI) changes from baseline to 6 months are shown in Figure 6 and

did not reach statistical significance (p = 0.07). Patient gender did not influence PI

scores; however, patients who received the Prophy-JetTM cleaning on the left side of

their mouth had a significantly greater difference in plaque levels between the two sides

(mean = 0.46 0.52) than those assigned to the right side (mean = 0.00 + 0.80).









Papillary Bleeding Score (PBS) changes from baseline to 6 months were not

significantly different (p = 0.46) and are shown in Figure 7. Mean PBS score change did

not differ by gender or side of mouth selected for Prophy-JetTM use.

Analysis via Pearson correlation coefficients (Table 1) indicated statistically

significant correlations of the changes in clinical indices between the Prophy-JetTM and

tooth-brush sides. DI, PI, and PBS were positively correlated between the two sides

(p < 0.005). In addition, for the Prophy-JetTM side, changes in DI were positively

correlated with changes in PI (p < 0.05).


4.0

3.5

3.0

2.5
M Before Cleaning
2.0 -
F After Cleaning
1.5

1.0

0.5 -

0.0 "
PJ TB PJ TB PJ TB PJ TB
Posterior Anterior Posterior Anterior
Maxilla Mandible


Figure 1. Plaque Index scores (mean + SE, n = 40) before and after cleaning at baseline
visit, by region. (PJ = Prophy-JetTM, TB = tooth-brush).
Significant at p < 0.0001
















A








Figure 2. Study subject after cleaning at baseline visit. A) With Prophy-JetTM. B) With
tooth-brush. Disclosing solution has been used to reveal plaque.


* Baseline
* 6 months


PJ TB PJ TB
Posterior Anterior
Maxilla


PJ TB PJ TB
Posterior Anterior
Mandible


Figure 3. Decalcification Index scores (mean + SE) at baseline and 6 months, by region.
(PJ = Prophy-JetTM, TB = tooth-brush).


1.50

1.25

1.00

Q 0.75

0.50

0.25

0.00










0.50

0.40


0.30

0.20

0.10

0.00


Maxillary *Mandibular


posterior


posterior


*Maxillary *Mandibular


anterior


anterior


Figure 4. Difference in Decalcification Index change (mean + SE, n = 35) by region.
Positive DI difference indicates less increase for Prophy-JetTM.
*Significant at p < 0.05


Figure 5. Study subject at completion of the six month trial. This illustrates the
decreased decalcification on the (A) Prophy-JetTM side compared to the (B)
tooth-brush side.


I T


I











4.00

7 -*- PJ Maxillary posterior
-3 PJ Maxillary anterior

3.50 -A- PJ Mandibular posterior
S-*-PJ Mandibular anterior
/ -e- TB Maxillary posterior
3.25 -
/ -- TB Maxillary anterior

3.00 -A- TB Mandibular posterior
--- TB Mandibular anterior

2.75






Figure 6. Monthly mean Plaque Index scores (n = 35) from baseline to 6 months, by
region. (PJ = Prophy-JetTM, TB = tooth-brush)
*Not significant at p = 0.07


1.70

1.50- -- PJ Maxillary posterior
-- PJ Maxillary anterior
1.30 -A- PJ Mandibular posterior

v -- PJ Mandibular anterior
a 1.10 -
S-- TB Maxillary posterior
0.90 -- TB Maxillary anterior
A- TB Mandibular posterior
0.70 -- TB Mandibular anterior

0.50






Figure 7. Monthly mean Papillary Bleeding Score from baseline to 6 months, by region.
(PJ = Prophy-Jet, TB = Tooth-brush)
*Not significant, p = 0.46









Table 1. Pearson Correlation Coefficients (R values) for Decalcification Index (DI),
Plaque Index (PI), and Papillary Bleeding Score (PBS).

ADITB ADIPJ A PITB A PI PJ APBSTB A PBS PJ
ADITB 1.00000 0.56192 0.19013 0.25993 -0.00457 -0.03324
(p=0.0004) (p=0.2739) (p=0.1316) (p=0.9792) (p=0.8497)
A DIPJ 1.00000 0.22428 0.36608 -0.10785 -0.06599
(p=0.1952) (p=0.0306) (p=0.5374) (p=0.7065)
A PI TB 1.00000 0.82883 -0.06343 -0.15548
(p<0.0001) (p=0.7174) (p=0.3725)
A PI PJ 1.00000 -0.08753 -0.21230
(p=0.6171) (p=0.2208)
APBSTB 1.00000 0.55921
(p=0.0005)
A PBS PJ 1.00000


(PJ = Prophy-JetTM, TB = Tooth-brush, A = change from baseline to visit 6)














DISCUSSION

The present study was conducted as a prospective randomized controlled clinical

trial on 40 orthodontic patients with full fixed appliances demonstrating visible

supragingival plaque. By selecting patients in orthodontic treatment with poor oral

hygiene, it was hoped that monthly Prophy-JetTM cleaning would minimize the

deleterious effects of plaque accumulation due to inadequate brushing or flossing at

home. However, this patient group may not be representative of orthodontic patients as a

whole. Other potential limitations include geographic sampling bias, lack of blinding due

to the single operator for decalcification index, effect of extraneous factors such as

manual dexterity for the patients, and selection of clinical indices

Previous studies investigated the use of the Prophy-JetTM on orthodontic patients.

Two studies by Barnes and Gerbo et al.10'11 investigated the application of air-powder

polishing systems in the orthodontic setting. The first study was conducted in two parts

with both using the Prophy-JetTM device. Part 1 showed that the Prophy-JetTM was more

effective in removing plaque around orthodontic appliances; and required less time than

traditional rubber cup/pumice prophylaxis. The investigators noted the clinical advantage

of lack of disturbance of orthodontic wires and elastic bands with the Prophy-JetTM.

Part 2 of the study was performed by the bonding of brackets with composite to ten

extracted maxillary central incisors and cementing of molar bands with zinc phosphate

cement to ten extracted mandibular first molars. The results indicated that, while both the

composite and zinc phosphate cement were exposed to the air powder spray, the surface









of the two materials maintained their integrity and their margins remained intact. The

authors concluded that use of air-powder spray had no detrimental effects on orthodontic

brackets or bands or their cementing agents. Other studies have suggested roughening

and/or wear of dental restorative materials such as amalgam, composite, and gold

foil;7'12'13'14 thus, it has been recommended to avoid prolonged direct exposure of these

materials to the compressed spray of slurry.

In the present study, the effectiveness of plaque debridement in a single visit by

the Prophy-JetTM was far superior to that of tooth-brushing. While PI scores were similar

on both sides before cleaning, the PI scores after cleaning on the Prophy-JetTM side were

less than the tooth-brush in all areas of the mouth (Figure 1). This portion of the study

was to verify previous reports of Prophy-JetTM cleaning efficiency and to give a statistical

comparison of the effectiveness of the selected cleaning methods under orthodontic

clinical conditions.

The lack of any effect by the Prophy-JetTM cleaning on monthly plaque levels

and gingival inflammation can be explained by the pathogenesis of periodontal disease

and the design of the study. The salivary pellicle forms within minutes to hours after

professional dental cleaning, and the initial colonizers are gram positive bacteria such as

Streptococcus and Actinomyces species.15 Over the following days, the plaque increases

in thickness and quantity as gram-negative cocci and gram-positive and gram-negative

rods and filaments increase their presence. The patients included in this study were

identified as having poor oral hygiene and the duration of time between monthly

appointments was more than enough time for plaque levels and gingivitis to return to

baseline levels. Any potential benefits of a professional cleaning would have to be









maintained by the patients in their home care in order to minimize the damaging effects

of plaque accumulation on the teeth and surrounding periodontium. However, poor oral

hygiene patients are the ones that would most benefit from additional hygiene measures.

Therefore, we chose to study this group. The interval of one month between cleaning

was selected as the minimum amount of time between most clinical visits for orthodontic

patients.

Over the 6-month study, it was shown that the Prophy-JetTM significantly

decreased the formation and/or progression of decalcifications. It should be noted,

however, that the decalcification process was not entirely avoided. From baseline to

6 months, the mean DI scores for the Prophy-JetTM increased from 0.71 to 0.74 in the

maxilla and 0.56 to 0.66 in the mandible. However, the tooth-brush side experienced a

significantly greater increase over the six months from 0.65 to 0.95 in the maxilla and

0.44 to 0.79 in the mandible. Thus, while formation and/or progression of

decalcifications was not entirely prevented, the thoroughness of the Prophy-JetTM

cleaning at monthly visits in some manner significantly disrupted the decalcification

process. Possibilities for this include interference in the colonization of certain bacteria

into the developing plaque on the tooth surface. Although there are more than 300

species of bacteria in plaque, most have no cariogenic potential.16 Primary etiologic

bacteria in dental caries include Streptococcus mutans and Streptococcus sobrinus, with

Lactobacilli as a secondary invader involved in caries progression in enamel.17 Thus,

even in the presence of unaltered plaque levels and gingivitis, the monthly debridement

by the Prophy-JetTM may have altered the bacterial load by physical disruption and









prevent more deleterious organisms from colonizing and promoting the decalcification

process.

The correlation of the changes in the three clinical indices from baseline to 6

months reinforces the importance of the patient's involvement in oral health maintenance.

The R values of 0.56 for Decalcification Index, 0.83 for Plaque Index, and 0.56 for

Papillary Bleeding Score indicate positive correlation between the changes that occurred

on the Prophy-JetTM and tooth-brush sides. Any changes for the indices on one side were

paralleled by the contralateral side. This is not unexpected since this was a split-mouth

study. Additionally, the positive correlation between PI changes and DI changes for the

Prophy-JetTM side demonstrates that if the patients were able to maintain the decreased

plaque levels by the Prophy-JetTM cleaning, those patients experienced less increases in

decalcifications on that side. Obviously, adequate home care is critical in maintaining

oral hygiene and preventing decalcifications. For the present study, the Prophy-JetTM

proved to be useful on patients that were poorly compliant with oral hygiene in

preventing the excessive formation of decalcifications.















CONCLUSIONS

This prospective clinical trial was designed to evaluate the effects of Prophy-JetTM

cleaning as compared to conventional tooth-brushing during office visits on orthodontic

patients with poor oral hygiene. Based on the findings of this study, the following

conclusions were reached:

* The Prophy-JetTM is more effective than the tooth-brush at removing plaque in
orthodontic patients for a single visit setting.
* Over the course of six months, the monthly Prophy-JetTM cleaning significantly
reduced the progression and/or formation of enamel decalcifications, even in the
presence of unaltered monthly plaque levels and gingivitis.
* Maintenance of adequate oral hygiene at home is essential to minimizing the
deleterious effects of plaque accumulation, including decalcifications.
* The Prophy-JetTM is an effective supplement to oral health maintenance during
orthodontic treatment for poor oral hygiene patients.

The mechanism for the decalcification reduction remains unclear, but could be

attributed to interference in the colonization of certain bacteria by the monthly cleaning.

Future studies may be designed to investigate this hypothesis by examining the

differences in bacterial strains present on each side. Other factors may also be explored

to minimize decalcifications and gingivitis, such as fluoride supplements, mechanical

tooth-brushes, or increased frequency of professional cleaning.















REFERENCES


1. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after
banding and bonding. Am J Orthod 1982;81:93.

2. Brown DM, Barnhart RC. A scientific foundation for clinical use of air polishing
systems. J Pract Hyg 1995;4:36-40.

3. Atkinson DR, Cobb CM, and Killoy WJ. The effect of an air-powder abrasive
system on in vitro root surfaces. J Periodontol 1984;55:13-18.

4. Galloway SE, Pashley DH. Rate of removal of root structure by the use of the
Prophy-jet device. J Periodontol 1987;7:464-469.

5. Weaks LM, Lescher NB, Barnes CM, Holroyd SV. Clinical evaluation of the
Prophy-jet as an instrument for routine removal of tooth stain and plaque. J
Periodontol 1984;3:486-488.

6. Strand GV, Randal M. Efficiency of cleaning fissures with an air-polishing
instrument. Acm Odontol Scand 1988;46:113-117.

7. Clinical Research Associates. Oral prophylaxis: Prophy-Jet. Clin Res Assoc
1981;5:1-4.

8. Quigley GA, Hein JW. Comparative cleaning efficiency of manual and power
brushing. J Am Dent Assoc 1962;65:26.

9. Loesche, W. J. Clinical and microbiological aspects of chemotherapeutic agents
used according to the specific plaque hypothesis. J Dent Res 1979;58:2402-2412.

10. Barnes CM, Russell CM, Gerbo LR, Barnes DW. Effects of an air-polishing
system on orthodontically bracketed and banded teeth. Am J Orthodont
Dentofacial Orthop 1990;97:74-91.

11. Gerbo LR, Barnes CM, Leinfelder KF. Applications of the air-powder polisher in
clinical orthodontics. Am J Orthodont Dentofacial Orthop 1993;103:71-73.

12. Gorfil C, Nordenberg D, Liberman R, Ben-Amar A. The effect of ultrasonic
cleaning and air polishing on the marginal integrity of radicular amalgam and
composite resin restorations. J Clin Periodontol 1989; 16(3): 137-139.






20


13. Cooley RL, Lubow RM, Patrissi BA. The effect of an air-powder abrasive
instrument on composite resin. J Am Dent Assoc 1986; 112:362-364.

14. Gutmann MS, Marker VA, Gutmann JL. Restoration surface roughness after air-
powder polishing. Am J Dent 1993;6:99-102.

15. Rateitschak KH, Wolf HF, Hassell TM. Color Atlas of Dental Medicine:
Periodontology. Thieme Medical Publishers,1989:13-19.

16. Schwartz RS, Summitt JB, Robbins JW. Fundamentals of Operative Dentistry: A
Contemporary Approach. Quintessence Publishing Co,1996:51-57.

17. Matthewson RJ, Primosch RE. Fundamentals of Pediatric Dentistry 3rd Ed.
Quintessence Publishing Co, 1995:80-115.















BIOGRAPHICAL SKETCH

Jeremy Matthew Albert was born in Huntsville, Alabama, and raised in Tarpon

Springs, Florida. He attended the University of Florida for his undergraduate study, with

a B.S. in nutritional science. He was then admitted to the University of Florida College

of Dentistry for his dental education and graduated with honors from dental school in

2000, obtaining a Doctor of Dental Medicine degree. After graduation, Dr. Albert

continued his dental education at the University of Florida earning a Master of Science

degree with a certificate in orthodontics in May 2003.