Use of Removable Orthodontic Appliance: Does it influence The Salivary Components?

EGYPTIAN Vol. 65, 857:864, April, 2019 DENTAL JOURNAL I.S.S.N 0070-9484 Orthodontics, Pediatric and Preventive Dentistry www.eda-egypt.org • Codex : 45/1904 USE OF REMOVABLE ORTHODONTIC APPLIANCE: DOES IT INFLUENCE THE SALIVARY COMPONENTS? Marwa Sameh Shamaa* and Mostafa Mohamed Mansour** ABSTRACT Introduction: Saliva plays a key role in the oral cavity health. It contains many defense elements and is considered a cornerstone in the oral metabolism. Objective: The aim of this study was to investigate the changes in the salivary concentrations of calcium, glucose, total protein, lactate dehydrogenase and alkaline phosphatase in patients undergoing removable orthodontic appliances treatment. Methods: Ninety saliva samples were collected from thirty subjects ranging in age from 8 to 11 years. An initial sample was attained before starting treatment with removable orthodontic appliances; a second sample 1 month after treatment and a third sample was obtained three months following treatment. The saliva was collected from each patient in pre-labeled sterile containers using the passive drool method. Results: Salivary lactate dehydrogenase and alkaline phosphatase concentrations were significantly increased in patients undergoing removable orthodontic treatment after as compared to before treatment. There was also an increase in the calcium, glucose and total protein concentrations but the differences were insignificant. Conclusion: Removable orthodontic treatment changes the oral fluid contents, promotes an increase in the levels of salivary lactate dehydrogenase and alkaline phosphatase enzymes after one month of treatment with increased values after three months. These oral changes emphasize the importance of maintaining proper oral hygiene measures during treatment. KEY WORDS: Saliva, Interceptive orthodontics, Salivary proteins and peptides. INTRODUCTION a diagnostic medium has increased dramatically in the modern era2. It has been utilized as a tool for Saliva plays a fundamental role in the oral periodontal diagnosis and to assess the caries risk in environment and it assumes a critical part in oral orthodontic patients. These diseases may necessitate health protection 1. The interest in using saliva as premature removal of the appliances. Salivary tests * Lecturer of Orthodontics, Faculty of Dentistry, Mansoura University. ** Lecturer of Clinical Pathology, Faculty of Medicine, Mansoura University. (858) E.D.J. Vol. 65, No. 2 Marwa Sameh Shamaa and Mostafa Mohamed Mansour are valuable both in assessment of the treatment the salivary parameters at baseline, after one and result and in planning the preventive measures 3. three months of treatment. The salivary calcium has high affinity to be easily MATERIALS AND METHODS taken up by plaque. Thus, it is an imperative factor not just concerning the beginning of periodontitis Study design and patient selection but significantly with respect to the dental health 4. This is a prospective clinical study comparing The salivary glucose level increases with the levels of salivary calcium, glucose, total protein, increasing DMFT index [Decayed Missing Filled LDH and ALP in children treated with removable teeth Index] and it assumes a fundamental role in orthodontic appliances before treatment and one high caries incidence5. and three months after treatment. A total of thirty patients (19 females and 11 males) aging from 8 The salivary total protein was reported to increase to 11 years were selected from the patients who in patients undergoing orthodontic treatment 6 required orthodontic treatment with removable and in patients with active caries than caries free appliances at the Department of Orthodontics, individuals 7. Faculty of Dentistry, Mansoura University. The Lactate dehydrogenase (LDH) is an enzyme selection was based on the following criteria:(1) that is released extracellularly only after cell death free from any systemic or chronic diseases, (2) no as it is normally limited to the cytoplasm. Thus previous orthodontic or orthopedic treatment, (3) its extracellular detection is attributed to tissue good oral health, (4) didn’t receive any medications breakdown and cell necrosis8. The enzyme Alkaline one month before and throughout the study period, Phosphatase (ALP) is considered as a potential (5) patient cooperation. The study was initiated after marker for periodontal disease. The increased receiving signed informed consent forms from the activity of ALP was observed in the acute phase of participants keeping all their rights. . The research periodontal disease in many studies9. protocol was reviewed and approved by the Ethical Committee, Faculty of Dentistry, Mansoura Removable appliances have played an important University (No. 05130818). role in contemporary orthodontic treatment. It is the type of orthodontic appliances that is not permanently All the patients received oral hygiene instructions attached to the teeth and can be removed by the and they were guided to the proper tooth brushing patient without orthodontist supervision. It can be technique before the beginning of treatment to ensure good oral hygiene at the onset of the study. effectively used for treatment of a great number of Patients were instructed to wear the appliances minor malocclusions10. all times except during eating and tooth brushing Previous studies have focused on evaluating which should be done three times daily. They were the changes in the saliva of patients undergoing also instructed to clean the appliances by brushing orthodontic treatment with fixed appliances and them and rinsing with running tap water. The no investigations have been made on the effect appliances were in passive contact with the mucosa, of removable orthodontic appliances treatment. even though slight pressure could be produced from Thus, the objective of this prospective study was chewing. to examine the changes in the salivary: calcium, Salivary Analysis glucose, total protein, LDH and ALP in patients undergoing removable appliances treatment with the Salivary samples were taken from each patient null hypothesis that there is no difference between in three stages, the first before insertion of the USE OF REMOVABLE ORTHODONTIC APPLIANCE (859) removable appliance, the second stage one month were detected with spectrophotometer (Erba Chem after the appliance placement and the third stage 7 Mannheim) at 405 nm. three months following treatment. Data entry and analysis were done using SPSS The participants were instructed not to eat or drink (version 20) under windows. Test for data distribution and avoid tooth brushing at least two hours before was done by one sample Kolmogorov- Smirnov test. sample collection in the three stages. The saliva was Normally distributed data were described as mean collected from each patient in the morning between ± SD. Non normal data were described by median, 9 and 11 a.m in pre-labeled sterile containers. It minimum and maximum. Comparison of matched was collected using the passive drool method. The pairs was done by paired t test and Wilcoxon signed patients were asked to accumulate the saliva in the rank test. P value was considered significant when mouth floor and spit it into the containers. 1.5ml of less than 0.05. saliva was then taken by a micropipette and stored in eppendorf tubes. The salivary samples were placed RESULTS on dry ice and sent immediately to the laboratory where they were preserved frozen at -20˚c. In the current study, thirty participants (19 females and 11 males) were involved. The mean age The Calcium concentrations were measured of patients was 9.066 years with a range from 8 to with calium_MTB (BioSytem S. A Costa Brava, 11 years. 30.08030 Barcelona, Spain) and the absorbance values were detected with spectrophotometer (Erba Table 1 shows the changes in the salivary Chem 7 Mannheim) at 600 nm. concentrations of calcium, glucose and total protein Glugose was estimated using Glugose - TR in patients undergoing removable orthodontic (SPINREACT. Ctra. Santa Coloma, 7 E-17176 appliances treatment. There was no statistically SANT ESTEVE DE BAS (GI) SPAIN) and its significant difference in calcium, glucose and total readings were detected using spectrophotometer protein levels after one month compared to base line (Erba Chem 7 Mannheim) at 505 nm. values (p 0.1, 0.4 and 0.7 respectively). The same was also detected after three months compared to Total protein was assessed using Chromarest baseline readings (p 0.08, 0.4 and 0.2 respectively). (LINEAR CHEMICALS S.L Joaquim Costa 18 2 planta. 08390 Montgat, Barcelona, Spain) Furthermore, no significant difference was found and the absorbance values were detected with in these salivary parameters after three months of spectrophotometer (Erba Chem 7 Mannheim) at treatment compared to one month (p 0.7, 0.08 and 600 nm. 0.1 respectively) as shown in figures (1 & 2). The LDH activity was measured with LDH SCE Treatment using removable orthodontic mod. liqui UV (Human Geselischaft fur Biochemica appliances exhibited significant (p<0.05) increase und Diagnostica mbH-Max-Planck-ring 21.65205 in both lactate dehydrogenase (figure 3) and alkaline Wiesbaden Germany). The absorbance readings phosphatase enzymes after 1 month (p<0.001) were detected with spectrophotometer (Erba Chem and 3 months of treatment (p<0.001) compared 7 Mannheim) at 340 nm. to baseline readings. The values of salivary LDH The ALP activity was measured with ALP (DEA) and ALP enzymes at 3 months were significantly SL (EliTech Clinical Systems SAS-Zone Industrielle higher compared to those after 1 month of treatment - 61500 SEES FRANCE) and the absorbance values (p<0.001 and 0.001 respectively) (Table 2). (860) E.D.J. Vol. 65, No. 2 Marwa Sameh Shamaa and Mostafa Mohamed Mansour TABLE (1): Comparison between the salivary concentrations of calcium, glucose and total protein in patients treated with removable orthodontic appliances. Baseline 1Month 3 Months P1 P2 P3 Mean ± SD Mean ± SD Mean ±SD Calcium (mg/dL) 4.55± 1.01 4.45± 1.01 4.42 ± 0.9 0.1 0.08 0.7 Glucose (mg/dL) 3.18± 1.58 3.17± 1.57 3.24± 1.5 0.4 0.4 0.08 Total protein (g/dL) 5.9± 2.23 5.9± 2.28 5.9± 2.24 0.7 0.2 0.1 P 1: p values of the salivary parameters after 1 month of treatment compared to baseline. P2: p values of the salivary parameters after 3 months of treatment compared to baseline. P3: p values of the salivary parameters after 3 months of treatment compared to 1 month. Fig. (1): Error bar chart for mean values of calcium at baseline, Fig. (2): Error bar chart for mean values of glucose at baseline, 1 month and three months of treatment. 1 month and three months of treatment. TABLE (2): Comparison between the salivary concentrations of lactate dehydrogenase and alkaline phosphatase in patients treated with removable orthodontic appliances. 1 3 P1 P2 P3 Baseline month Months LDH Median 408.5 426.5 509.5 <0.001* <0.001* <0.001* (min-max) (U/L) 114-1459 202-1501 211-1650 Alkaline phosphatase 44.6 ± 15.1 49.4 ± 15.6 64.6 ± 23.6 <0.001* <0.001* 0.001* Mean ± SD (U/L) P 1: p values of the salivary parameters after 1 month of treatment compared to baseline P2: p values of the salivary parameters after 3 months of treatment compared to baseline P3: p values of the salivary parameters after 3 months of treatment compared to 1 month. USE OF REMOVABLE ORTHODONTIC APPLIANCE (861) glycoproteins, antimicrobial agents and enzymes (such as amylase and lipase)13 . The salivary enzymes play a fundamental role in the process of digestion of dietary fat and starch. They also help in breaking down the entrapped food particles within dental crevices, thus they protect the teeth from bacterial decay. Moreover, saliva has a lubricative function and prevents dryness of the mucosal surfaces of the oral cavity 14. Saliva has been utilized as a diagnostic tool in Fig. (3): Box plot for median LDH at baseline, 1month and 3 dentistry and medicine 15. The key to successful months. prognostic outcome is the detection of disease in its early stage. Early detection tools should be DISCUSSION non-invasive and easy to attain, this makes saliva a suitable diagnostic alternative to blood. There Removable appliances could be considered as are many advantages of using the salivary fluid a mean of interceptive orthodontic treatment and as a diagnostic tool compared to tissues or serum. it is mostly used in the mixed dentition period. It The good patient compliance as a result of its non- essentially either corrects the forthcoming dental invasive collection method, the correlation with malocclusion or decreases its severity 11. levels in blood, greater sensitivity and easy storage Various tooth movements can be accomplished and transportation are the advantages of using saliva with removable orthodontic appliances, either for diagnostic purpose 16. individually or on group of teeth such as tipping, Calcium is one of the most extensively studied cross bite correction, overbite reduction, intrusion salivary components as it is the fifth most copious and extrusion. A removable appliance is considered mineral in the human body which plays an a successful way for reduction of deep overbite in important role in both dental and gingival health a growing child as it could increase the vertical 17 . In our study, there was non-significant increase dimension by allowing differential eruption of the in the salivary calcium in the experimental group posterior teeth through comprising anterior bite undergoing removable appliances treatment. Corega plane. If there is an available space, a removable et al 4 found a significant correlation between appliance with an activated screw or palatal spring higher salivary calcium and orthodontic treatment. can be used for treatment of cross bite in the anterior Bhavsar et al 6 detected that the salivary calcium teeth. Removable appliances are also effective in was significantly increased in patients undergoing treatment of posterior dental cross bites through fixed orthodontic treatment. This increase in the incorporating a midline expansion screw or spring concentration of salivary calcium may result from resulting in widening of the maxillary arch in the demineralisation of the teeth subjected to fixed mixed dentition 12. orthodontic appliances treatment. The salivary Saliva is a complex mixture of fluids formed calcium affects the dissolution or precipitation of in the mouth and secreted by the salivary glands. the enamel hydroxyapatite. In the present study, the The human saliva consists mainly of water in non-significant change in the salivary calcium which addition to leukocytes, electrolytes, epithelial cells, is considered a marker of dimeneralisation suggests (862) E.D.J. Vol. 65, No. 2 Marwa Sameh Shamaa and Mostafa Mohamed Mansour that using removable appliances for a period of in saliva was significantly increased in patients three months did not affect tooth dimineralisation. undergoing removable appliances treatment both at 1 and 3 months. Values were significantly higher The saliva of the experimental group revealed after 3 months compared to after 1month, meaning a greater glucose concentration after three months of treatment, even though this difference was not that there was a progressive rise with increased significant. This is in consistency with Forsberg treatment duration. The present study was in et al 18 who found an increase in the salivary line with that of Husin et al 22 who reported that glucose concentration after insertion of orthodontic orthodontic interrupted force application caused appliances. This finding may be correlated with the an increase in the salivary LDH. The increase in increased salivary flow rate. LDH activity in the saliva of our patients during removable appliances treatment may be explained Salivary proteins are contributed in multiple by having increased retention sites for microbial biological processes including the immune response, samples compared to before treatment which may cellular support, tissue flexibility and strain. They be responsible for gingivitis. The result of the have different functions like soft tissue repair, current work is in accordance with another study regulation of both antimicrobial activity and pH and that related the increased lactate dehydrogenase maintenance of the dental and mucosal integrity. activity to tissue inflammation and damage The concentration of the salivary proteins may be mostly caused by gingivitis and periodontitis affected by many factors such as tooth brushing respectively 23. and/or exercise, psychological disorders and the presence of hormones 19. Alkaline phosphatase is an enzyme secreted by neutrophils and its level is markedly increased In our study, there was non-significant increase with inflammation and plaque accumulation. Some in the salivary total protein concentration in the investigators recorded high salivary ALP level treated cases. However, Bhavsar et al 6 reported that in the acute phases of periodontal disease and in patients undergoing fixed orthodontic treatment, they found that its level was returned to normal the total protein concentration was increased in after periodontal therapy 9. Therefore, change saliva. Also, Arash et al 20found an increase in the in the ALP level in saliva has been utilized as an salivary total protein in patients after orthodontic inflammatory marker of the periodontium as well tooth movement. They stated that the increase in as bone metabolism 24. In the current study, ALP the salivary total protein may be due to mechanical activity was significantly increased in the saliva stresses that modify the concentration of the of patients undergoing removable appliances secretory proteins at the local level in the oral cavity. treatment both at 1 and 3 months, also the values So, removable appliances treatment for that period at 3 months were significantly higher than at 1 of time may have little effect on the salivary total month. This may be attributed to that removable protein in comparison to fixed appliances. appliances produce forces that are of intermittent Among the important constituents of saliva, type. An intermittent pressure may act as an irritant there are various enzymes. Lactate dehydrogenase and usually produces formative changes, especially is a prevalent enzyme that plays an important role in young individuals. Also, tipping movements are in the clinical diagnosis of pathologic processes. produced when a single force is applied against LDH was believed to have the capability to be the crown of a tooth leading to concentration utilized as a marker for inflammation process during of pressure in limited areas of the periodontal orthodontic treatment21 . In our study, LDH activity ligament. Furthermore, experimental studies in USE OF REMOVABLE ORTHODONTIC APPLIANCE (863) beagles have demonstrated that orthodontic tipping 5. Vibhakar P, Patankar SR, Yadav M and Vibhakar P. Cor- forces could shift a supragingivally located plaque relation of Salivary Glucose Levels with Dental Caries: A Biochemical Study. Int J Oral Maxillofal Pathol. 2014; subgingivally resuling in the infrabony pockets 5(1):17-20. formation 25. Our results agree with that of Ameer et al 26 who reported a significant increase in the level 6. Bhavsar A., Goje SK and Patel J. Comparative Evaluation of Salivary Parameters Before and During Orthodontic of alkaline phosphatase enzyme during orthodontic Treatment. Int J Recent Sci Res. 2017; 8(7): 18630-18634. treatment. They concluded that the level of ALP can reflect the biological activity occurring in the 7. Tulunoglu O, Demirtas S and Tulunoglu I. Total antioxi- dant Levels of saliva in children related to caries, age, and periodontium during orthodontic tooth movement. Gender. Int j Paediatr Dent. 2006; 16:186 Thus, clinical and experimental researches stress the importance of adequate oral hygiene during 8. Serra E, Perinetti G,and D’attilio M. Lactate dehydro- genase activity in gingival crevicular fluid during orth- orthodontic treatment. odontic treatment. Am J Orthod Dentofac Orthop. 2003; 124:206-­11. CONCLUSION 9. Yan F. Alkaline phosphatase level in gingival crevicular According to our results, we can conclude that fluid of periodontitis before and after periodontal treat- orthodontic treatment with removable appliances ment. Chung Hua Kou Chiang Hseueh Tsa Chin 1995; 30: didn’t induce significant changes in the salivary 255-66. concentrations of calcium, glucose and total protein, 10. Singh G. Removable orthodontic appliances. In: Textbook while the inflammatory markers like LDH and ALP of orthodontics 2nd Ed. Jaypee Brothers Medical Publishers increased significantly which may reflect the effect 2007, pp 421-448. of treatment on gingiva and periodontium. This 11. Zafarmand AH. Removable Orthodontic Appliances: The emphasizes the importance of maintaining proper Mechanical Efficiency. Pediatr Dent Care. 2016; 1:124. oral hygiene measures throughout the treatment 12. Cobourne MT and DiBiase AT. Contemporary removable period. appliances. In: Handbook of Orthodontics. Mosby Else- vier 2011; 209 - 234. REFERENCES 13. Fejerskov, O.; Kidd, E. (2007). Dental Caries: The Disease 1. Chiappin S, Antonellia G, Gatti R, Palo E. Invited critical and Its Clinical Management 2nd Ed. Wiley-Blackwell. review: Saliva specimen: A new laboratory tool for diag- ISBN 978-1-4051-3889-5. nostic and basic investigation. Clinica Chimica Acta 2007; 14. Edgar, M.; Dawes, C.; O’Mullane, D. (2004). Saliva and (383): 30-40. Oral Health 3rd Ed. British Dental Association Manage- 2. Kinney JS, Ramseier CA and Giannobile WV. Oral fluid ment 2nd Ed. Wiley-Blackwell. ISBN 978-1-4051-3889-5. based biomarkers of alveolar bone loss in periodontitis. 15. Kinney JS, Ramseier CA, Giannobile WV. Oral fluid based Ann N Y Acad Sci. 2007; 1098: 230-51. biomarkers of alveolar bone loss in periodontitis. Ann N Y 3. TeixeiraI HS; Kaulfuss SMO; Ribeiro JS; Pereira BR; Acad Sci. 2007; 1098: 230-51. Brancher JA and Camargo ES. Calcium, amylase, glucose, 16. Malathi N, Mythili S, Vasanthi HR. Salivary diagnostics: a total protein concentrations, flow rate, pH and buffering brief review. ISRN Dent 2014 Jan; 29:158786. capacity of saliva in patients undergoing orthodontic treat- ment with fixed appliances. Dental Press J. Orthod. 2012; 17. Peacock M. Calcium metabolism in health and disease. 17(2). Clin J Am Soc Nephrol, 5 (2010), pp. s23-s30. 4. Corega C1, Vaida L, Festila DG, Rigoni G, Albanese M, 18. Forsberg C, Oliveby A, Lagerlöf F. Salivary clearance D’Agostino A, Chiarini G, Barone A, Covani U, Nocini PF of sugar before and after insertion of fixed orthodon- and Bertossi D. Salivary calcium levels during orthodontic tic appliances. Am J Orthod Dentofac Orthop. 1992; treatment. Minerva Stomatol. 2014; 62. 102(6):527-30. (864) E.D.J. Vol. 65, No. 2 Marwa Sameh Shamaa and Mostafa Mohamed Mansour 19. Zárate Daza AN, Leyva Huerta ER, Franco Martínez F. 23. Rohaya MAW, Sahidan S, Zaidah ZA, Fahrul ZH, Nural- Determination of pH and total proteins in saliva in pa- iza AW, Shahrul HZA. Stability of human salivary lactate tients with and without fixed orthodontic appliances (pilot dehydrogenase in present of ethyl-enediaminetetraacetic study). Rev Odontol Mex. 2004; 8: 59-63. acid, glycerol, and polyethylene glycol at various tempera- 20. Arash V, Mahjoub S, Haji Ahmadi M, Padganeh T. tures: preliminary study. J Biol Sci10:520-5; 2010 .. Amounts of Salivary Total Protein before and After Orth- 24. Marjanovic M, Knezevic M. Salivary enzymes and peri- odontic Tooth Movement. 2014; 10(2): 7-11. odontal disease. Med Oral Patol Oral Cir Bucal. 2006; 11: 21. Shahrul HZA, Mohdfaiz E, Rohaya MAW, Yosni B, Sahin- E115-9. dan S. Profiles of lactate dehydrogenase tartrate resistant 25. Ericsson I et al: The effect of orthodontic tilting move- acid phosphatase and alkaline photophatase in saliva dur- ing orthodontic treatment. Sains Malays12 39:405- ;2010.. ments on the periodontal tissues of infected and non-in- fected dentitions in dogs, J Clin Periodontal 4: 278, 1977. 22. Husin E, Tjandrawinata R, Juliani M, Roeslan BO. Orth- odontic Force Application in Correlation with Salivary 26. Ameer SA, Alhuwaizi AF. The effect of orthodontic force Lactate Dehydrogenase Activity. J of Dent Indonesia. 2013 on salivary levels of alkaline phosphatase enzyme. J Bagh Aug 20; 19(1):10-13. Coll Dentistry 2015; 27(4):175-179.