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Hussain U, Campobasso A, Noman M, Alam S, Mujeeb R, Shehzad S, Papageorgiou SN. Influence of elastomeric and steel ligatures on periodontal health during fixed appliance orthodontic treatment: a systematic review and meta-analysis. Prog Orthod 2024; 25:24. [PMID: 38880839 PMCID: PMC11180646 DOI: 10.1186/s40510-024-00520-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/20/2024] [Indexed: 06/18/2024] Open
Abstract
INTRODUCTION Metallic and elastomeric ligatures are widely used in orthodontics to secure the archwire within the bracket slots, but elastomeric ligatures have traditionally been associated with increased microbial colonization, which could adversely affect periodontal health. AIM This systematic review compares the periodontal effects of elastomeric and steel ligatures used for orthodontic fixed appliances. METHODS Unrestricted literature search of 7 databases (MEDLINE, Scopus, Web of Science, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Virtual Health Library) up to July 2023 were performed for randomized / non-randomized clinical studies on humans comparing the two ligation methods during fixed-appliance therapy. After duplicate study selection, data extraction, and risk-of-bias assessment with the Risk of Bias (RoB) 2 or the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool, random-effects meta-analyses of Mean Differences (MD) or Standardized Mean Differences (SMD) and their 95% confidence intervals (CIs) were carried out, followed by assessment of certainty of existing evidence with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. RESULTS A total of 11 studies (3 randomized / 8 non-randomized) with 354 patients (mean age 14.7 years and 42% male) were included. No statistically significant differences were seen for plaque index (5 studies; SMD = 0.48; 95% CI = -0.03 to 1.00; P = 0.07), gingival index (2 studies; MD = 0.01; 95% CI = -0.14 to 0.16; P = 0.89), probing pocket depth (2 studies; MD = 0; 95% CI = -0.17 to 0.16; P = 0.97), or Streptococcus mutans counts (4 studies; SMD = 0.40; 95% CI=-0.41 to 1.20; P = 0.21). Elastomeric ligatures were associated with moderately increased total bacterial load (3 studies; SMD = 0.43; 95% CI = 0.10 to 0.76; P = 0.03). Confidence in these estimates was low in all instances due to the inclusion of non-randomized studies with high risk of bias. CONCLUSIONS Existing low quality evidence indicates that ligature method does not seem to influence the periodontal health during fixed treatment, even if elastomeric ligatures are associated with a moderate increase of bacterial load. REGISTRATION PROSPERO (CRD42023444383).
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Affiliation(s)
| | - Alessandra Campobasso
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | | - Shamsul Alam
- Health Department Khyber Pakhtunkhwa, Peshawar, Pakistan
| | | | - Sofia Shehzad
- Community Dentistry, Sardar Begum Dental College, Gandhara University, Peshawar, Pakistan
| | - Spyridon N Papageorgiou
- Clinic of Orthodontics and Pediatric Dentistry, Center for Dental Medicine, University of Zurich, Plattenstrasse 11, Zurich, 8032, Switzerland.
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Oruba Z, Gibas-Stanek M, Pihut M, Cześnikiewicz-Guzik M, Stós W. Orthodontic treatment in patients with periodontitis - a narrative literature review. Aust Dent J 2023; 68:238-246. [PMID: 37688346 DOI: 10.1111/adj.12974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/10/2023]
Abstract
Patients with periodontitis often require an inter-disciplinary approach, including orthodontic treatment, for effective rehabilitation of masticatory function, aesthetics and quality of life. The aim of this narrative review was to comprehensively discuss literature focusing on the biology, indications and inter-disciplinary connections related to the orthodontic approach in patients with periodontitis and to present clinical concepts in accordance with valid guidelines. The outcomes of the experimental studies indicate that orthodontic tooth movement (OTM) can be performed safely for teeth with reduced periodontium, provided infection and inflammation are controlled. Orthodontic treatment can correct pathological tooth migration, is not associated with deterioration of clinical periodontal parameters and improves aesthetics. Intrusion is safe when performed with light forces and under a strict oral hygiene regimen. Teeth can be moved either towards or away from the intrabony defect previously subjected to regenerative procedures, and research suggests that OTM has the potential to enhance bone formation after regenerative therapy. The data on orthodontic movement of teeth with furcation involvement are very scarce. The improvement in furcation involvement following either combined periodontal and orthodontic treatment was only documented in animal model studies. Due to bone and tooth loss, special consideration should be given to orthodontic treatment mechanics. © 2023 Australian Dental Association.
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Affiliation(s)
- Z Oruba
- Faculty of Medicine, Department of Periodontology, Preventive Dentistry and Oral Pathology, Institute of Dentistry, Jagiellonian University Medical College, Kraków, Poland
| | - M Gibas-Stanek
- Faculty of Medicine, Institute of Dentistry, Jagiellonian University Medical College, Chair of Prosthodontics and Orthodontics, Kraków, Poland
| | - M Pihut
- Faculty of Medicine, Institute of Dentistry, Jagiellonian University Medical College, Chair of Prosthodontics and Orthodontics, Kraków, Poland
| | - M Cześnikiewicz-Guzik
- Faculty of Medicine, Department of Periodontology, Preventive Dentistry and Oral Pathology, Institute of Dentistry, Jagiellonian University Medical College, Kraków, Poland
| | - W Stós
- Faculty of Medicine, Institute of Dentistry, Jagiellonian University Medical College, Chair of Prosthodontics and Orthodontics, Kraków, Poland
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Jepsen K, Sculean A, Jepsen S. Complications and treatment errors involving periodontal tissues related to orthodontic therapy. Periodontol 2000 2023; 92:135-158. [PMID: 36920050 DOI: 10.1111/prd.12484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/25/2022] [Accepted: 01/04/2023] [Indexed: 03/16/2023]
Abstract
In this review, typical clinical complications involving periodontal tissues are illustrated that can be encountered in conjunction with orthodontic therapy (OT). Special considerations are given for various clinical scenarios, such as the patient presenting in periodontal health, with periodontitis, or with mucogingival conditions. While some of the complications are seen as common side effects of OT, other, more severe, problems that could have been avoided may be viewed as treatment errors. Recommendations are made on how to prevent these complications, based on the currently available evidence, on clinical practice guidelines, and on expert opinion. In conclusion, while there are several areas in which OT can have unwanted adverse effects on periodontal/mucogingival conditions, there is also great potential for synergies, offering opportunities for close cooperation between the two specialties (periodontics and orthodontics) for the benefit of patients affected by tooth malpositioning and/or periodontal or mucogingival problems.
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Affiliation(s)
- Karin Jepsen
- Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Bonn, Germany
| | - Anton Sculean
- Department of Periodontology, University of Bern, Bern, Switzerland
| | - Søren Jepsen
- Department of Periodontology, Operative and Preventive Dentistry, University of Bonn, Bonn, Germany
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Hussain U, Alam S, Rehman K, Antonoglou GN, Papageorgiou SN. Effects of chlorhexidine use on periodontal health during fixed appliance orthodontic treatment: a systematic review and meta-analysis. Eur J Orthod 2023; 45:103-114. [PMID: 36001494 DOI: 10.1093/ejo/cjac044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Proper oral hygiene and absence of periodontal inflammation is pre-requisite for orthodontic treatment. Chlorhexidine (CHX) is an established oral antiseptic used in the treatment of periodontal disease, but its role in orthodontic therapy is unclear. OBJECTIVES To assess the efficacy of adjunct use of CHX-containing products in maintaining gingival health among orthodontic patients with fixed appliances. SEARCH METHODS Five databases were searched without limitations up to August 2021. SELECTION CRITERIA Randomized clinical trials (RCTs) assessing Gingival Index (GI) (primary outcome), Plaque Index (PI), Bleeding Index (BI), or Pocket Probing Depth (PPD). DATA COLLECTION AND ANALYSIS Study selection, data extraction, and risk of bias assessment were done independently in duplicate. Random-effects meta-analyses of mean differences (MDs) or standardized mean differences (SMDs) with their 95% confidence intervals (CIs) were conducted, followed by sensitivity and Grades of Recommendations, Assessment, Development and Evaluation analysis. RESULTS Twenty RCTs (1001 patients) were included assessing CHX-containing mouthwashes (n = 11), toothpastes (n = 2), gels (n = 3), or varnishes (n = 4) compared to placebo/control (n = 19) or sodium fluoride-products (n = 4). In the short-term, CHX-containing mouthwash was associated with lower GI (n = 9; MD = -0.68; 95% CI = -0.97 to -0.38; P < 0.001; high quality), lower PI (n = 9; MD = -0.65; 95% CI = -0.86 to -0.43; P < 0.001; high quality), lower BI (n = 2; SMD = -1.61; 95% CI = -2.99 to -0.22; P = 0.02; low quality), and lower PPD (n = 2; MD = -0.60 mm; 95% CI = -1.06 to -0.14 mm; P = 0.01; low quality). No considerable benefits were found from the use of CHX-gel or CHX-varnish in terms of GI, PI, or PPD (P > 0.05/low quality in all instances). Use of a CHX-containing toothpaste was more effective in lowering PI (Heintze-index) than adjunct use of fluoride-containing mouthwash (n = 2; MD = -5.24; 95% CI = -10.46 to -0.02; P = 0.04), but not GI (P = 0.68) or BI (P = 0.27), while sensitivity analyses indicated robustness. CONCLUSIONS Adjunct use of CHX mouthwash during fixed-appliance treatment is associated with improved gingival inflammation, plaque control, and pocket depths, but caution is warranted and recommendations about CHX use during orthodontic treatment of children/adults should consider the heterogeneous patient response, cost-effectiveness, and potential adverse effects. REGISTRATION PROSPERO registration (CRD42021228759).
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Affiliation(s)
- Umar Hussain
- Department of Orthodontics, Saidu College of Dentistry, Swat, Pakistan
| | - Shamsul Alam
- Health Department Khyber Pakhtunkhwa, Peshawar, Pakistan
| | - Khalid Rehman
- Department of Public Health, Khyber Medical University, Peshawar, Pakistan
| | - Georgios N Antonoglou
- Periodontology Unit, Centre for Host Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
| | - Spyridon N Papageorgiou
- Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
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Zhao NR, Guo YN, Cui SJ, Tian YJ, Zhou YH, Wang XD. Microbiological Advances in Orthodontics: An Overview and Detailed Analysis of Temporary Anchorage Devices. Curr Med Sci 2022; 42:1157-1163. [PMID: 36544036 DOI: 10.1007/s11596-022-2653-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 08/08/2022] [Indexed: 12/24/2022]
Abstract
Dental biofilm is the initiating factor of oral diseases, such as periodontitis and caries. Orthodontic treatment could alter the microbiome structure balance, and increase the risk of such diseases. Furthermore, fixed appliances can induce temporary changes in the microbiome community, and the changes that clear aligners bring are smaller by comparison. Temporary anchorage devices (TADs) are skeletal anchorages that are widely used in orthodontic treatment. Microorganisms affect the occurrence and development of inflammation surrounding TADs. At present, existing researches have verified the existence of plaque biofilm on the surface of TADs, but the formation of plaque biofilm and plaque composition under different stable conditions have not been fully understood. The development of high-throughput sequencing, molecular biology experiments, and metabonomics have provided new research ideas to solve this problem. They can become an effective means to explore the microbiome surrounding TADs.
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Affiliation(s)
- Ning-Rui Zhao
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, 100081, China
| | - Yan-Ning Guo
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, 100081, China
| | - Sheng-Jie Cui
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, 100081, China
| | - Ya-Jing Tian
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, 100081, China
| | - Yan-Heng Zhou
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, 100081, China
| | - Xue-Dong Wang
- Department of Orthodontics, Peking University School and Hospital of Stomatology, Beijing, 100081, China.
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Kunimatsu R, Tsuka Y, Nakajima K, Sumi K, Yoshimi Y, Kado I, Inada A, Kiritoshi Y, Tanimoto K. The Influence of 2-Methacryloyloxyethyl Phosphorylcholine Polymer Materials on Orthodontic Friction and Attachment of Oral Bacteria. MATERIALS (BASEL, SWITZERLAND) 2022; 15:ma15165770. [PMID: 36013906 PMCID: PMC9415717 DOI: 10.3390/ma15165770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 05/13/2023]
Abstract
There is no clinical evidence of the usage of 2-methacryloyloxyethyl phosphorylcholine (MPC) polymers in dental practice. We performed in vitro studies to determine whether the application of an MPC coating to stainless steel orthodontic wires confers low-friction and antimicrobial properties to these wires. The friction test on MPC-coated wires was performed using a precision universal/tensile tester. MPC polymer was coated on a 50 × 50 mm stainless steel plate, and samples were assessed using an antimicrobial activity test. To verify the effect of MPC polymer-treated wires on experimental tooth movement models in vitro, examinations were performed on typodonts to determine the improvement in tooth movement efficiency. The polymer treatment wire groups demonstrated significantly enhanced tooth movement compared with the untreated wire groups, at both 50 g and 100 g traction forces. The results indicated that MPC coating inhibited the attachment of oral bacteria, such as Streptococcus mutans, on a stainless steel plate. Additionally, the coating seemed to improve the efficiency of tooth movement by reducing the occurrence of friction. The application of an MPC coating onto stainless steel wires, which are used as orthodontic materials, may reduce static friction and bacterial adherence to the oral cavity and improve tooth movement.
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Affiliation(s)
- Ryo Kunimatsu
- Department of Orthodontics and Craniofacial Development Biology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
- Correspondence: ; Tel.: +81-82-257-5686
| | - Yuji Tsuka
- Department of Orthodontics and Craniofacial Development Biology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
| | - Kengo Nakajima
- Department of Orthodontics and Craniofacial Development Biology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
| | - Keisuke Sumi
- Department of Orthodontics and Craniofacial Development Biology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
| | - Yuki Yoshimi
- Department of Orthodontics and Craniofacial Development Biology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
| | - Isamu Kado
- Department of Orthodontics and Craniofacial Development Biology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
| | - Ayako Inada
- Intelligent Surfaces, Inc., Kashiwa 277-0882, Japan
| | | | - Kotaro Tanimoto
- Department of Orthodontics and Craniofacial Development Biology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan
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Rashid ZJ, Gul SS, Shaikh MS, Abdulkareem AA, Zafar MS. Incidence of Gingival Black Triangles following Treatment with Fixed Orthodontic Appliance: A Systematic Review. Healthcare (Basel) 2022; 10:healthcare10081373. [PMID: 35893195 PMCID: PMC9331869 DOI: 10.3390/healthcare10081373] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
This systematic review aimed to investigate the relation between orthodontic treatment (OT) and the incidence of the gingival black triangle (GBT) after completing treatment with a fixed orthodontic appliance, as well as the associated risk factors and the level of alveolar bone. Electronic and hand searches were conducted in three electronic databases for relevant articles published up to March 2022. Retrieved articles went through a two-step screening procedure, and the risk of bias (RoB) was assessed by the Joanna Briggs Institute checklists. The incidence of GBT after OT was set as the primary outcome, while the secondary outcomes were the risk factors associated with GBT and alveolar bone loss following OT. Out of 421 papers, 5 were selected for the final analysis. The RoBs of three studies were moderate and the remaining two were low. The incidence of GBT following OT ranged from 38% to 58%. In addition, three studies reported that alveolar bone loss was reduced significantly following OT and associated with GBT, while one study found the opposite. Regarding the risk factors associated with GBT, the reported results attributed GBT to several factors including age, tooth-related factors, treatment duration, and soft tissue factors. The analysis indicates an increased incidence of GBT following OT; however, a firm conclusion cannot be drawn. Additionally, it was not possible to reach a consensus on risk factors associated with GBT due to the heterogeneity of the data. Therefore, further randomized clinical trials are highly recommended to draw a firm conclusion.
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Affiliation(s)
- Zhwan Jamal Rashid
- College of Dentistry, University of Sulaimani, Sulaymaniyah 46001, Iraq;
| | - Sarhang Sarwat Gul
- College of Dentistry, University of Sulaimani, Sulaymaniyah 46001, Iraq;
- Correspondence:
| | - Muhammad Saad Shaikh
- Department of Oral Biology, Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University, Karachi 75510, Pakistan;
| | | | - Muhammad Sohail Zafar
- Department of Restorative Dentistry, College of Dentistry, Taibah University, Al Madina, Al Munawwarra 41311, Saudi Arabia;
- Department of Dental Materials, Islamic International Dental College, Riphah International University, Islamabad 44000, Pakistan
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Seidel CL, Gerlach RG, Weider M, Wölfel T, Schwarz V, Ströbel A, Schmetzer H, Bogdan C, Gölz L. Influence of probiotics on the periodontium, the oral microbiota and the immune response during orthodontic treatment in adolescent and adult patients (ProMB Trial): study protocol for a prospective, double-blind, controlled, randomized clinical trial. BMC Oral Health 2022; 22:148. [PMID: 35477563 PMCID: PMC9044659 DOI: 10.1186/s12903-022-02180-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/18/2022] [Indexed: 12/13/2022] Open
Abstract
Background Orthodontic treatment with fixed appliances is often necessary to correct malocclusions in adolescence or adulthood. However, oral hygiene is complicated by appliances, and prior studies indicate that they may trigger oral inflammation and dysbiosis of the oral microbiota, especially during the first 3 months after insertion, and, thus, may present a risk for inflammatory oral diseases. In recent periodontal therapeutic studies, probiotics have been applied to improve clinical parameters and reduce local inflammation. However, limited knowledge exists concerning the effects of probiotics in orthodontics. Therefore, the aim of our study is to evaluate the impact of probiotics during orthodontic treatment. Methods This study is a monocentric, randomized, double blind, controlled clinical study to investigate the effectiveness of daily adjuvant use of Limosilactobacillus reuteri (Prodentis®-lozenges, DSM 17938, ATCC PTA 5289) versus control lozenges during the first three months of orthodontic treatment with fixed appliances. Following power analysis, a total of 34 adolescent patients (age 12–17) and 34 adult patients (18 years and older) undergoing orthodontic treatment at the University Hospital Erlangen will be assigned into 2 parallel groups using a randomization plan for each age group. The primary outcome measure is the change of the gingival index after 4 weeks. Secondary outcomes include the probing pocket depth, the modified plaque index, the composition of the oral microbiota, the local cytokine expression and—only for adults—serum cytokine levels and the frequencies of cells of the innate and adaptive immune system in peripheral blood. Discussion Preventive strategies in everyday orthodontic practice include oral hygiene instructions and regular dental cleaning. Innovative methods, like adjuvant use of oral probiotics, are missing. The aim of this study is to analyse, whether probiotics can improve clinical parameters, reduce inflammation and prevent dysbiosis of the oral microbiota during orthodontic treatment. If successful, this study will provide the basis for a new strategy of prophylaxis of oral dysbiosis-related diseases during treatment with fixed appliances. Trial registration This trial is registered at ClinicalTrials.gov in two parts under the number NCT04598633 (Adolescents, registration date 10/22/2020), and NCT04606186 (Adults, registration date 10/28/2020).
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Affiliation(s)
- Corinna L Seidel
- Department of Orthodontics and Orofacial Orthopedics, Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Glückstr. 11, 91054, Erlangen, Germany.
| | - Roman G Gerlach
- Mikrobiologisches Institut-Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Wasserturmstraße 3/5, 91054, Erlangen, Germany
| | - Matthias Weider
- Department of Orthodontics and Orofacial Orthopedics, Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Glückstr. 11, 91054, Erlangen, Germany
| | - Theresa Wölfel
- Department of Orthodontics and Orofacial Orthopedics, Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Glückstr. 11, 91054, Erlangen, Germany
| | - Vincent Schwarz
- Department of Orthodontics and Orofacial Orthopedics, Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Glückstr. 11, 91054, Erlangen, Germany
| | - Armin Ströbel
- Center for Clinical Studies (CCS), Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Helga Schmetzer
- Med III, University Hospital of Munich, Workgroup: Immune Modulation, Marchioninistraße 15, 81377, Munich, Germany
| | - Christian Bogdan
- Mikrobiologisches Institut-Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Wasserturmstraße 3/5, 91054, Erlangen, Germany.,Medical Immunology Campus Erlangen, Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - Lina Gölz
- Department of Orthodontics and Orofacial Orthopedics, Universitätsklinikum Erlangen and Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Glückstr. 11, 91054, Erlangen, Germany
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Bergamo AZN, Casarin RCV, do Nascimento C, Matsumoto MAN, de Carvalho FK, da Silva RAB, da Silva LAB, Nelson-Filho P. Self-ligating brackets exhibit accumulation of high levels of periodontopathogens in gingival crevicular fluid. Odontology 2022; 110:460-466. [PMID: 35037112 DOI: 10.1007/s10266-021-00677-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
Different types of brackets seem to influence the disruption of the oral microbial environment. Therefore, the aim of this study was to evaluate the influence of self-ligating brackets on the gingival crevicular fluid levels of the putative periodontal pathogens Aggregatibacter actinomycetemcomitans sorotype a (Aaa), Tannerella forsythia, Fusobacterium nucleatum, and Porphyromonas gingivalis. Sixty samples of crevicular fluid of twenty patients (11 boys and 9 girls) were analysed at baseline (T0) and after 30 (T1) and 60 (T2) days of bonding of the self-ligating (In-Ovation®R, Dentsply, GAC or SmartClip™, 3 M Unitek, Monrovia, CA, USA) and of one conventional bracket (Gemini™, 3 M Unitek, Monrovia, CA, USA) used with elastomeric ligatures. Total DNA from samples was extracted using CTAB-DNA precipitation method and Real-time PCR was performed to analyse bacterial level. Non-parametric Friedman and Wilcoxon tests were used for data analysis (p value of < 0.05). F. nucleatum presented a different level among the different brackets at T1 (p = 0.025), the highest level in the Gemini™ bracket when compared to the SmartClip™ bracket (p = 0.043). P. ginigvalis levels increased in the In-Ovation®R (p = 0.028) at T1. The subgingival levels of bacterial species associated with periodontal disease P. ginigvalis increased in the self-ligating brackets In-Ovation®R.Clinical Relevance: Some kinds of brackets could provide more retentive sites than others, and it seems to modulate the subgingival microbiota, since, in this study, we could observe the increase of the species associated with periodontal disease. Preventive protocols should be adopted in the use of self-ligating brackets.
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Affiliation(s)
- Ana Zilda Nazar Bergamo
- Department of Pediatric Clinics, School of Dentistry of Ribeirão Preto, University of São Paulo, Avenida Do Café, S/N, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-904, Brazil.
| | - Renato Corrêa Viana Casarin
- Department of Prosthodontics and Periodontology, School of Dentistry of Piracicaba, University of Campinas, Campinas, SP, Brazil
| | - Cássio do Nascimento
- Department of Dental Materials and Prosthodontics, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Mírian Aiko Nakane Matsumoto
- Department of Pediatric Clinics, School of Dentistry of Ribeirão Preto, University of São Paulo, Avenida Do Café, S/N, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-904, Brazil
| | - Fabrício Kitazono de Carvalho
- Department of Pediatric Clinics, School of Dentistry of Ribeirão Preto, University of São Paulo, Avenida Do Café, S/N, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-904, Brazil
| | - Raquel Assed Bezerra da Silva
- Department of Pediatric Clinics, School of Dentistry of Ribeirão Preto, University of São Paulo, Avenida Do Café, S/N, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-904, Brazil
| | - Léa Assed Bezerra da Silva
- Department of Pediatric Clinics, School of Dentistry of Ribeirão Preto, University of São Paulo, Avenida Do Café, S/N, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-904, Brazil
| | - Paulo Nelson-Filho
- Department of Pediatric Clinics, School of Dentistry of Ribeirão Preto, University of São Paulo, Avenida Do Café, S/N, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-904, Brazil
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Taxonomic Analysis of Oral Microbiome during Orthodontic Treatment. Int J Dent 2021; 2021:8275181. [PMID: 34745264 PMCID: PMC8568516 DOI: 10.1155/2021/8275181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/18/2021] [Indexed: 12/31/2022] Open
Abstract
Background Orthodontic appliances induce significant changes in the oral microbiome, but this shift in microbial composition has not been well established by the available evidence yet. Objectives To perform a systematic review of existing literature in order to assess the taxonomic microbial changes in orthodontic patients during Fixed Appliance Treatment (FAT) and Clear Aligner Treatment (CAT), using next-generation sequencing (NGS) technique of the bacterial 16S rRNA gene. Search Methods and Selection Criteria. The search for articles was carried out in PubMed, including articles published in English until May 2021. They included every human study report potentially relevant to the review. Data Collection and Analysis. After duplicate study selection and data extraction procedures according to the PICOS scheme, the methodological quality of the included papers was assessed by the Swedish Council on Technology Assessment in Health Care Criteria for Grading Assessed Studies (SBU) method. Results The initial search identified 393 articles, 74 of which were selected by title and abstract. After full-text reading, six articles were selected according to inclusion criteria. The evidence quality for all the studies was moderate. Conclusions Orthodontic treatment seems to transiently affect the composition of subgingival microbiome, although not salivary, maintaining a stable microbial diversity. Different results were found in the shift of microbiome between plaque and saliva, depending on the type of orthodontic treatment. This review should be interpreted with some caution because of the number, quality, and heterogeneity of the included studies.
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Papageorgiou SN, Antonoglou GN, Michelogiannakis D, Kakali L, Eliades T, Madianos P. Effect of periodontal-orthodontic treatment of teeth with pathological tooth flaring, drifting, and elongation in patients with severe periodontitis: A systematic review with meta-analysis. J Clin Periodontol 2021; 49 Suppl 24:102-120. [PMID: 34327710 PMCID: PMC9290963 DOI: 10.1111/jcpe.13529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/25/2021] [Indexed: 12/28/2022]
Abstract
Aim To assess the beneficial and adverse effects on the dental and periodontal issues of periodontal–orthodontic treatment of teeth with pathological tooth flaring, drifting, and elongation in patients with severe periodontitis. Materials and methods Nine databases were searched in April 2020 for randomized/non‐randomized clinical studies. After duplicate study selection, data extraction, and risk‐of‐bias assessment, random‐effect meta‐analyses of mean differences (MDs) and their 95% confidence intervals (CIs) were performed, followed by subgroup/meta‐regression analyses. Results A total of 30 randomized and non‐randomized clinical studies including 914 patients (29.7% male; mean age 43.4 years) were identified. Orthodontic treatment of pathologically migrated teeth was associated with clinical attachment gain (−0.24 mm; seven studies), pocket probing depth reduction (−0.23 mm; seven studies), marginal bone gain (−0.36 mm; seven studies), and papilla height gain (−1.42 mm; two studies) without considerable adverse effects, while patient sex, gingival phenotype, baseline disease severity, interval between periodontal and orthodontic treatment, and orthodontic treatment duration affected the results. Greater marginal bone level gains were seen by additional circumferential fiberotomy (two studies; MD = –0.98 mm; 95% CI = –1.87 to −0.10 mm; p = .03), but the quality of evidence was low. Conclusions Limited evidence of poor quality indicates that orthodontic treatment might be associated with small improvements of periodontal parameters, which do not seem to affect prognosis, but more research is needed.
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Affiliation(s)
- Spyridon N Papageorgiou
- Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Georgios N Antonoglou
- ETEP (Etiology and Therapy of Periodontal Diseases) Research Group, Department of Periodontology, Faculty of Dentistry, University Complutense, Madrid, Spain
| | - Dimitrios Michelogiannakis
- Division of Orthodontics and Dentofacial Orthopedics, Eastman Institute for Oral Health, University of Rochester, Rochester, New York, USA
| | - Lydia Kakali
- Department of Orthodontics, School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodore Eliades
- Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Phoebus Madianos
- Department of Periodontology, School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
Acquisition and establishment of the oral microbiota occur in a dynamic process over various stages and involve close and continuous interactions with the host and its environment. In the present review, we discuss the stages of this process in chronological order. We start with the prenatal period and address the following questions: ‘Is the fetus exposed to maternal microbiota during pregnancy?’ and ‘If so, what is the potential role of this exposure?’ We comment on recent reports of finding bacterial DNA in placenta during pregnancies, and provide current views on the potential functions of prenatal microbial encounters. Next, we discuss the physiological adaptations that take place in the newborn during the birth process and the effect of this phase of life on the acquisition of the oral microbiota. Is it really just exposure to maternal vaginal microbes that results in the difference between vaginally and Cesarian section‐born infants? Then, we review the postnatal phase, in which we focus on transmission of microbes, the intraoral niche specificity, the effects of the host behavior and environment, as well as the role of genetic background of the host on shaping the oral microbial ecosystem. We discuss the changes in oral microbiota during the transition from deciduous to permanent dentition and during puberty. We also address the finite knowledge on colonization of the oral cavity by microbes other than the bacterial component. Finally, we identify the main outstanding questions that limit our understanding of the acquisition and establishment of a healthy microbiome at an individual level.
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Affiliation(s)
- A M Marije Kaan
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), Vrije Universiteit Amsterdam and University of Amsterdam, Amsterdam, The Netherlands
| | - Dono Kahharova
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), Vrije Universiteit Amsterdam and University of Amsterdam, Amsterdam, The Netherlands
| | - Egija Zaura
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), Vrije Universiteit Amsterdam and University of Amsterdam, Amsterdam, The Netherlands
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The impact of fixed orthodontic appliances on oral microbiome dynamics in Japanese patients. Sci Rep 2020; 10:21989. [PMID: 33319834 PMCID: PMC7738506 DOI: 10.1038/s41598-020-78971-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 11/25/2020] [Indexed: 12/31/2022] Open
Abstract
Fixed orthodontic appliances are common and effective tools to treat malocclusion. Adverse effects of these appliances, such as dental caries and periodontitis, may be associated with alteration of the microbiome. This study investigated the impact of these appliances on the dynamics of the oral microbiome. Seventy-one patients were selected. Supragingival plaque samples were collected before placement (T0) and six months after placement (T1). Saliva samples were collected at T0 and T1, and then when appliance removal (T2). Microbial DNA was analyzed by 16S rRNA meta-sequencing. The diversity analysis indicated dynamic changes in the structure of the oral microbiome. Taxonomic analysis at phylum level showed a significant increase in Bacteroidetes and Saccharibacteria (formally TM7) and decrease in Proteobacteria and Actinobacteria over time, in both plaque and saliva. Genus level analysis of relative abundance indicated a significant increase in anaerobic and facultative anaerobes in both plaque and saliva. Fixed orthodontic appliances induced measurable changes in the oral microbiome. This was characterized by an increase in relative abundance of obligate anaerobes, including periodontal pathogens. It can be concluded that this dysbiosis induced by fixed orthodontic appliances is likely to represent a transitional stage in the shift in microbiome from healthy to periodontitis.
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Donkor ES, Kotey FCN. Methicillin-Resistant Staphylococcus aureus in the Oral Cavity: Implications for Antibiotic Prophylaxis and Surveillance. Infect Dis (Lond) 2020; 13:1178633720976581. [PMID: 33402829 PMCID: PMC7739134 DOI: 10.1177/1178633720976581] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/03/2020] [Indexed: 02/06/2023] Open
Abstract
The oral cavity harbors a multitude of commensal flora, which may constitute a repository of antibiotic resistance determinants. In the oral cavity, bacteria form biofilms, and this facilitates the acquisition of antibiotic resistance genes through horizontal gene transfer. Recent reports indicate high methicillin-resistant Staphylococcus aureus (MRSA) carriage rates in the oral cavity. Establishment of MRSA in the mouth could be enhanced by the wide usage of antibiotic prophylaxis among at-risk dental procedure candidates. These changes in MRSA epidemiology have important implications for MRSA preventive strategies, clinical practice, as well as the methodological approaches to carriage studies of the organism.
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Affiliation(s)
- Eric S Donkor
- Department of Medical Microbiology, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Fleischer CN Kotey
- Department of Medical Microbiology, College of Health Sciences, University of Ghana, Accra, Ghana
- FleRhoLife Research Consult, Teshie, Accra, Ghana
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Lombardo L, Palone M, Scapoli L, Siciliani G, Carinci F. Short-term variation in the subgingival microbiota in two groups of patients treated with clear aligners and vestibular fixed appliances: A longitudinal study. Orthod Craniofac Res 2020; 24:251-260. [PMID: 32965768 DOI: 10.1111/ocr.12427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the subgingival microbiological changes during the first six months of therapy with clear aligners (CAs) and fixed appliances (FAs). The null hypothesis was that there would be no microbiological differences between the two. SETTING/SAMPLE Two groups of patients to be treated, respectively, with CAs (14 patients; 9 females and 5 males; mean age 21 years ± 0.25) and FAs (13 patients; 8 females and 5 males; mean 14 years ± 0.75) were consecutively recruited. MATERIALS AND METHODS Subgingival microbiological samples were obtained at the right upper central incisor and right first molar at four different time points: before appliance fitting (T0), and at 1 month (T1), 3 months (T3) and 6 months (T6) thereafter. Total bacterial load (TBL) and counts of the bacteria Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Fusobacterium nucleatum, Campylobacter rectus, Treponema denticola and Tannerella forsythia were determined using real-time PCR. RESULTS Total bacterial load did not vary in the CA group, while a significant increase was detected after 3 and 6 months of treatment in the FA group. Unlike red complex species, C rectus and F nucleatum were often detected: levels remained stable in the CA group but increased progressively in the FA group. CONCLUSION The type of orthodontic appliance influences the subgingival microbiota. TBL increased in the FA group but not in the CA group, although the levels of the individual periodontal pathogenic bacteria species did not significantly increase during the observation period.
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Affiliation(s)
- Luca Lombardo
- Postgraduate School of Orthodontics, University of Ferrara, Ferrara, Italy
| | - Mario Palone
- Postgraduate School of Orthodontics, University of Ferrara, Ferrara, Italy
| | - Luca Scapoli
- Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giuseppe Siciliani
- Postgraduate School of Orthodontics, University of Ferrara, Ferrara, Italy
| | - Francesco Carinci
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Ebersole J, Samburova V, Son Y, Cappelli D, Demopoulos C, Capurro A, Pinto A, Chrzan B, Kingsley K, Howard K, Clark N, Khlystov A. Harmful chemicals emitted from electronic cigarettes and potential deleterious effects in the oral cavity. Tob Induc Dis 2020; 18:41. [PMID: 32435175 PMCID: PMC7233525 DOI: 10.18332/tid/116988] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/20/2019] [Accepted: 01/22/2020] [Indexed: 12/29/2022] Open
Abstract
Use of electronic nicotine delivery systems (ENDS), such as electronic cigarettes (e-cigs), is increasing across the US population and is particularly troubling due to their adoption by adolescents, teens, and young adults. The industry’s marketing approach for these instruments of addiction has been to promote them as a safer alternative to tobacco, a behavioral choice supporting smoking cessation, and as the ‘cool’ appearance of vaping with flavored products (e.g. tutti frutti, bubble gum, and buttered popcorn etc.). Thus, there is a clear need to better document the health outcomes of e-cig use in the oral cavity of the addicted chronic user. There appears to be an array of environmental toxins in the vapors, including reactive aldehydes and carbonyls resulting from the heating elements action on fluid components, as well as from the composition of chemical flavoring agents. The chemistry of these systems shows that the released vapors from the e-cigs frequently contain levels of environmental toxins that considerably exceed federal occupational exposure limits. Additionally, the toxicants in the vapors appear to be retained in the host fluids/tissues at levels often approximating 90% of the levels in the e-cig vapors. These water-soluble reactive toxins can challenge the oral cavity constituents, potentially contributing to alterations in the autochthonous microbiome and host cells critical for maintaining oral homeostasis. This review updates the existing chemistry/environmental aspects of e-cigs, as well as providing an overview of the somewhat limited data on potential oral health effects that could occur across the lifetime of daily e-cig users.
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Affiliation(s)
- Jeffrey Ebersole
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
| | - Vera Samburova
- Organic Analytical Laboratory, Division of Atmospheric Sciences, Desert Research Institute, Reno, United States
| | - Yeongkwon Son
- Organic Analytical Laboratory, Division of Atmospheric Sciences, Desert Research Institute, Reno, United States
| | - David Cappelli
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
| | - Christina Demopoulos
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
| | - Antonina Capurro
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
| | - Andres Pinto
- Oral and Maxillofacial Medicine and Diagnostic Sciences, School of Dental Medicine, Case Western University, Cleveland, United States
| | - Brian Chrzan
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
| | - Karl Kingsley
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
| | - Katherine Howard
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
| | - Nathaniel Clark
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
| | - Andrey Khlystov
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, United States
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Clinical efficacy of an Aloe Vera gel versus a 0.12% chlorhexidine gel in preventing traumatic ulcers in patients with fixed orthodontic appliances: a double-blind randomized clinical trial. Odontology 2019; 108:470-478. [PMID: 31664632 DOI: 10.1007/s10266-019-00468-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/07/2019] [Indexed: 10/25/2022]
Abstract
Traumatic oral ulceration (TOU) is one of the most common side effects of orthodontic treatments. The objective of this trial is to compare the clinical efficacy of an 80% Aloe Vera gel, prepared using a master formula, versus a commercial 0.12% Chlorhexidine (CHX) gel for TOU prevention in participants wearing fixed orthodontic appliances. This report represents a single-centre, university-based, double-blinded, randomized controlled trial with 2 parallel arms. Patients aged 12 years or older, in the permanent dentition, and about to start fixed orthodontic treatment in this university setting were randomly allocated to use either Aloe Vera or CHX gel, following the cementation procedure. Pre-treatment and 1 month after the cementation clinical assessment and digital photographic images were taken of the teeth and assessed by 2 clinical assessors for the presence or absence of TOUs. A total of 140 were randomized and completed the trial. The overall prevalence of TOUs was 43.6%. Overall 5.7% of patients treated with Aloe Vera gel showed did not suffer from TOUs, whereas in the CHX arm, a total of 57 (81.4%) were affected by this outcome reaching a significant result (p < 0.001). In terms of relative risk (RRs) and confidence intervals (CIs), Aloe Vera provided better results than CHX with an RR of 0.07 (95%CI 0.03-0.16; p < 0.001), and with a patients' number needed to treat of 1.3 (95%CI 1.16-1.54). There were no adverse effects. These results suggest that Aloe Vera gel administration in patients with fixed orthodontic appliances could be important for effective prevention of TOU.
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Elkordy SA, Palomo L, Palomo JM, Mostafa YA. Do fixed orthodontic appliances adversely affect the periodontium? A systematic review of systematic reviews. Semin Orthod 2019. [DOI: 10.1053/j.sodo.2019.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Tasios T, Papageorgiou SN, Papadopoulos MA, Tsapas A, Haidich A. Prevention of orthodontic enamel demineralization: A systematic review with meta‐analyses. Orthod Craniofac Res 2019; 22:225-235. [DOI: 10.1111/ocr.12322] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/15/2019] [Accepted: 05/08/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Thomas Tasios
- Department of Hygiene, Social‐Preventive Medicine & Medical Statistics, Medical School Aristotle University of Thessaloniki Thessaloniki Greece
- Private practice Hengelo The Netherlands
| | - Spyridon N. Papageorgiou
- Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine University of Zurich Zurich Switzerland
| | - Moschos A. Papadopoulos
- Department of Orthodontics, Faculty of Dentistry Aristotle University of Thessaloniki Thessaloniki Greece
| | - Apostolos Tsapas
- Second Medical Department, Clinical Research and Evidence‐Based Medicine Unit Aristotle University of Thessaloniki Thessaloniki Greece
| | - Anna‐Bettina Haidich
- Department of Hygiene, Social‐Preventive Medicine & Medical Statistics, Medical School Aristotle University of Thessaloniki Thessaloniki Greece
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