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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 23
| Issue : 10 | Page : 1395-1400 |
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The effects of using phase-contrast microscopy on oral hygiene training of patients receiving orthodontic treatment: A randomized controlled study
MF Koca1, G Acikgöz1, C Dundar2, T Kirtiloglu1
1 Department of Periodontology, Faculty of Dentistry, Ondokuz Mayıs University, Samsun, Turkey
2 Department of Public Health, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| Date of Submission | 16-Jul-2019 |
| Date of Acceptance | 02-Jun-2020 |
| Date of Web Publication | 12-Oct-2020 |
Correspondence Address:
Prof. C Dundar
Department of Public Health, Faculty of Medicine, Ondokuz Mayis University, Samsun
Turkey
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njcp.njcp_365_19
 Abstract | | |
Objective: To investigate of effects of using phase-contrast video technique on education in oral hygiene training. This one blind, parallel randomized controlled trial was conducted in a tertiary clinic. Fifty-three patients who presented to the orthodontics department aged 12–20 years were divided into two groups randomly by computer-generated assigned codes to receive oral hygiene education. The participants were blinded to type of education method. Before orthodontic therapy, the control group was trained only by the conventional method, while the test group was trained by phase-contrast video microscopy method in addition to conventional method. Some images and videos of moving microorganisms in dental plaque were shown to the patients in test group on a computer monitor. Subjects and Methods: The bacterial count, plaque index, and gingival index scores were compared. Measurements were obtained in baseline and follow-ups which were repeated with 1-month intervals after the training. Results: The plaque index scores (1.05 ± 0.1 vs. 1.43 ± 0.2; P < 0.001) and gingival index scores (0.90 ± 0.1 vs. 1.14 ± 0.2; P < 0.001) in test group was statistically lower than those in control group at the end of the study. The gingival index scores reduced by 39% in test group vs. 14% in control group. The number of bacteria significantly decreased in the group trained with phase-contrast video microscope technique (8,059,133 ± 3016 vs. 10,830,600 ± 4919; 0.018). Conclusions: The training with phase-contrast microscopy has a more positive effect than the traditional method in oral hygiene education.
Keywords: Dental plaque index, oral hygiene, orthodontics, training activities
How to cite this article:
Koca M F, Acikgöz G, Dundar C, Kirtiloglu T. The effects of using phase-contrast microscopy on oral hygiene training of patients receiving orthodontic treatment: A randomized controlled study. Niger J Clin Pract 2020;23:1395-400 |
How to cite this URL:
Koca M F, Acikgöz G, Dundar C, Kirtiloglu T. The effects of using phase-contrast microscopy on oral hygiene training of patients receiving orthodontic treatment: A randomized controlled study. Niger J Clin Pract [serial online] 2020 [cited 2022 Mar 7];23:1395-400. Available from: https://www.njcponline.com/text.asp?2020/23/10/1395/297922 |
| Introduction | |  |
Because the oral cavity contains a large number of microorganisms that vary widely, gingivitis and tooth decay continue to be one of the problems people face in certain phases of their lives. Many studies have attempted to reduce microorganism colonies in the oral cavity and different brushes, brushing methods, and various chemicals are the leading efforts to accomplish this.[1],[2],[3] Oral hygiene maintenance is an essential part of orthodontic therapy. Education and motivation are key to achieve good oral hygiene performance by the patients.[4] It aims to promote oral health primarily by providing information to improve awareness, leading to adoption of a healthier lifestyle, positive attitudes, and good oral health behavior. Videos provide a practical and entertaining audiovisual medium for health education that is suitable for both group and individual learning and also offer a standardized level of teaching, and information on the video can be repeated according to the viewers' needs.[5]
In today's patient-physician relationship, a verbal explanation with aid of models may not be sufficient. With the introduction of modern technology, visual education has reached the top level. In leading clinics, showing the bacteria plaque to the patient by using phase-contrast video techniques has provided significant contributions to patient education on the subject.[6]
The goal of dentists is to communicate consistent and persistent oral hygiene practice techniques to the patient in the most effective and successful way. Studies in psychology, education, and behavior therapy show the success of psychological approaches to behavior change.[7] A number of techniques have been explored in the training of patients about the presence of microbial dental plaque in oral tissues, the diseases it may cause, and how it should be removed. It has been shown in several studies that only recommending good oral hygiene practices is extremely limited in its ability to affect individual oral health.[1],[8],[9]
Gum disease and tooth decay continue to be one of the problems people face in certain phases of their lives. The oral cavity contains a large number of microorganisms that vary widely. Many studies have attempted to reduce microorganism colonies in the oral cavity. Different brushes, brushing methods, and various chemicals are the leading efforts to accomplish this. The brushing habits should start with prenatal mothers' education and continue to early childhood, preschool, school, and finally adulthood and should be monitored continuously. Visualization, models, slideshows, and video recordings are the methods used for explaining brushing techniques and their importance.[10] The colony counting method was used in patient training, by showing the morphological structures and numerical abundances of microorganisms using video. These images were compared to the preimages in order to show the effectiveness of brushing activities in the follow-up and shared with the patients for educational purposes. This training method is compared to the conventional method which is verbal explanation through the model. Our main hypothesis was training with phase-contrast microscopy video technique is more effective than the conventional technique in oral hygiene education.
| Material and Methods | | |
This single blind, parallel randomized controlled trial was conducted in the Orthodontics Department of Faculty of Dentistry at Ondokuz Mayis University in Samsun, Turkey. The study population consisted of 54 patients, who presented to orthodontics clinic between February and April 2014. The inclusion criteria for the patients were (1) with no history of previous orthodontic treatment, (2) decided to bracket installation, (3) age at adolescent, and (4) resident in Samsun. Patients who is younger or older age than adolescent age, having dental treatment affecting gingival health or oral hygiene, could not remove dental plaque by self-performed or mentally incompetent, and patients not willing to participate in the study were excluded. The sample size was determined using G* Power 3.1 computer program.[11] The sample size was calculated 54 patients with 27 subjects in each group. The statistical power was calculated as 0.80 for total group size of 54 with an expected large effect size (Cohen's d = 0.7) and alpha error probability = 0.05.
The participants were blinded to type of training. Regardless of their gender, patients were randomized into two groups by computer-generated assigned codes to receive oral hygiene education. One patient was lost to follow up, due to moving out of the Samsun province. Therefore, our study was carried out with 53 patients in total (Control group = 26, Test group = 27). The number of patients in the phases of the trial is displayed in the CONSORT diagram [Figure 1]. All participants and minor patient's parents provided written informed consent.
While the control group got only conventional oral hygiene education, the test group was trained by using phase-contrast video microscope technique in addition to the conventional verbal education, before the start of orthodontic treatment. Some images and videos of moving microorganisms in dental plaque taken from their mouth were shown to the patients in test group on a computer monitor [Figure 2]a and [Figure 2]b. | Figure 2: (a) Phase-contrast microscopy image of microorganisms in dental plaque before treatment. (b) Phase-contrast microscopy image of microorganisms in dental plaque after treatment
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Dental plaques were sampled from the oral cavity with a Gracey curette (Hu Friedy, Chicago, IL, USA). Tooth brushing using the model, interface cleaning with the interface brush, cleaning ligatures and brackets after bracket installation, and how to keep the hygiene have been explained to the patients. It was recommended that the brushing to be done in the mornings and evenings for 3–5 min by applying 8–10 sweeping motion on each tooth, motion starting from adherent gum to the tooth (roll technique), twice a day and by using a small, nylon, and medium-hard brush. It was explained that orthodontic brushes can also be used if needed. The same type of toothpaste and regular manual toothbrush were recommended.
The modified Ramfjord teeth of the individuals in both two groups were evaluated separately for evaluation of clinical and microbiological examination.[12] Plaque index, gingival index, and bacterial count were evaluated on the buccal, bucco-mesial, bucco-distal, lingual, mesiolingual, and distolingual of the teeth sides.
Measurements were taken in 4 different time periods. The first measurement was performed when the patient was enrolled for the study (baseline). One month after the training, second measurements were obtained and the brackets were applied. The third and fourth measurements were performed 1 and 2 months after bracket installation, respectively. The bracket types used in patients in each group were the same, and the metal bracket mbt system was used as a 0.22 inch slot ligature with an elastic ligature (AO American Orthodontics®). Breed method was used for microorganism counting.[13] Accordingly, 0.01 ml of plaque fluid was spread over an area of 1 cm2; then, the number of microorganisms in a microscope field of view was counted.
The data thus collected were assessed using SPSS 16.0 statistical software (SPSS Inc., Chicago, IL, USA). Data were presented as arithmetic mean ± standard deviation (SD) and categorical data as proportions. The normality of the variables was tested by using the Shapiro–Wilk test. The mean values were compared using two independent sample t-tests for continuous variables. The Mann–Whitney U-test was used for comparison of data distributed nonnormally. Gender ratios were compared by Chi-square test. Statistical significance was accepted as P < 0.05.
| Results | | |
The randomized patients' mean age was 15.9 ± 2.6 years and they were predominantly female [Table 1].
There was no difference between the two groups in gender or age. The demonstration of mobility of microorganisms taken from dental plaque by phase-contrast video microscope was quite impressive for the patients in test group. Nine (33.3%) out of 27 patients who trained with phase-contrast video microscopy technique stated that they were amazed, while 8 of them (29.6%) said that they could not find words to express their astonishment. Six patients (22.3%) indicate that they did not know there were bacteria in their mouth, and 4 patients (14.8%) commented as interesting.
After training with conventional and phase-contrast video microscopy and at second measurement before bracket bonding (after 1 month), gingival and plaque indexes were decreased. Compared to the second follow-up after first-month post bonding, an increase in plaque and gingival indexes was detected in both groups. As presented in [Table 2], the mean plaque index score, gingival index score, and mean number of bacteria of test group were statistically lower than those in control group at end of the study (t = 8.49, P < 0.001; t = 4.89, P < 0.001; t = 2.46; P = 0.018, respectively). | Table 2: Mean and standard deviation of measures at end points for the two groups
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The plaque index scores decreased in both group; however, there was a 45% reduction in test group as against a 24% reduction in control group at the end of third month [Figure 2].
As presented in [Figure 3], in both two groups, gingival index scores reduced as compared with in those before oral hygiene education. However, the decrease in the test group was two times higher than the control group (39% vs. 14%, respectively).
Bacterial growth was much less in the group trained with phase-contrast video microscope than in control group at end of the study [Figure 4].
It has been observed that phase-contrast microscopy video technique in addition to the conventional method of plaque disclosure has a long-lasting effect on plaque control programs.
| Discussion | | |
According our findings, outcome measure showed significantly better oral hygiene status scores in the phase-contrast training group as compared to the conventional training group. Acharya et al.[6] examined the effects of three different motivational techniques on oral hygiene and gingival health in individuals who underwent orthodontic treatment. In the study they performed on 62 individuals aged between 12 and 18 years, they observed the effects of conventional plaque control methods in the first group, the conventional method applied with the patient in the second group, and motivation training with phase-contrast microscopy in the third group during 6-month period. As a result of the study, they found the long-lasting effect of the cleaning method with phase-contrast microscopy and plaque painting, especially the horizontal sweeping method. For this reason, plaque control programs emphasize the importance of providing different motivation tests and more training beyond the current plaque control practices. Our study is very similar to the study of Acharya et al.[6] and Andrucioli et al.[14] conducted a molecular study of microbiota accumulated on orthodontic brackets. They focused on the importance of colonizing microorganisms on brackets in orthodontic applications, both as a treatment planning strategy and as a protective measure. The researchers emphasized that many bacterial species can grow on the brackets over a period of 1 month; therefore, it is very important to increase good oral hygiene habits on patients having orthodontic treatment. In the light of the findings and recommendations of previous researchers mentioned, we think that our results make a significant contribution to oral hygiene education.
Choo et al.[15] emphasized that support for oral hygiene was influenced by educational, organizational, economic, and environmental factors, but most importantly by educational factors. They mentioned that transferring knowledge is crucial for a healthy lifestyle and that health care costs need to be increased both by social programs and by personal technological systems. In very simple procedures they have described, the measurement indicated that showing the bleeding on the patient mirror would be a productive behavior.[16] When considering an inexpensive and easy training method, which shows small improvements in plaque control in the patients, the value of this method is somewhat large even though the effect size is small considering social and economic burden of periodontal diseases. We think that our study is also appropriate for reaching utilizing technology in personal education goal as mentioned in previous studies.
Numbers of techniques have been explored in the training of patients about the presence of bacterial plaque on the tooth surface, the diseases it may cause, and how it should be removed. It has been shown in several studies that providing verbal recommendations about oral hygiene practices alone has an extremely limited effect on individual oral health.[9] Although there is abundant evidence of what should be offered to the patients, there are few studies on how many of these suggestions can actually be passed on or how they can be presented in a most effective way.[17],[18]
Dental caries is a serious problem for many children living in developing and undeveloped countries. However, there is inadequate knowledge and lack of awareness of the causes and prevention of oral disease among the children, their parents, and teachers. Health education is a widely accepted approach in the prevention of oral diseases; a process of transmission of knowledge and skills are necessary for improvement in oral health and quality of life. The goal of planned health education program is not only to bring about new behaviors but also to reinforce and maintain healthy behaviors that will promote and improve individual, group, or community health.[5] Dentists aim to change patient behavior by recommending good oral and dental health practices.[17] The main objective of dental health education programs is to provide information to individuals so that they can gain desirable behaviors.[17] In recent years, advanced clinics in developed countries have used phase-contrast microscopy for patient motivation, in treatment and idle phases and also to keep brushing status under control at the beginning and in each stage, and to compare before and after the procedure. And also, phase-contrast microscopy may be beneficial for patients with different learning capacities.[19] The aim here is to increase the patient-physician communication, to obtain concrete data for the effectiveness of the treatment, and most importantly to make the brushing habit permanent. The visual presentation of clinical findings has always been one of the most powerful educational tools. The awareness of patients can be increased by this method which is easy to use in clinics and which is cheaper in long-term use compared to printed materials. A video film can be an effective mode of oral health education in an oral health-care setting such as dental hospitals, schools, nursing homes, or private clinics. Eaton et al.[20] concluded that even a slight gain in skill or improvement in knowledge is an indicator of success.[5] With a growing interest on visual knowledge in health, it is a perfect time to introduce the “intraoral images” of periodontal diseases, even for individuals who are afraid to go to the dentist.
In conclusion, training with phase-contrast microscopy in motivating oral hygiene education is more effective than verbal training. We observed the positive effect of training with phase-contrast microscopy in all clinical parameters. For this reason, we believe that the use of phase-contrast microscopy in patient motivation is important and useful as well as cheap and easy. In addition, the effect of phase-contrast microscopy on the patient is longer than the training given by the conventional method, because the use of this method has clinically reduced plaque formation significantly.
Limitations
The sample was collected from the patients presented to a tertiary dental clinic; thus, it does not represent the entire population.
Ethics approval and consent to participate
The study protocol was approved by the Ethics Committee of Clinical Research of Ondokuz Mayıs University (OMU KAEK 2014/624). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All participants provided written informed consent.
Declaration of patient consent
The authors declare that they have obtained all participants consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was financed by the Scientific Research Fund of Ondokuz Mayis University (PYO.DIS.1904.14.010).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]
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