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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 11  |  Page : 1649-1655

Comprehensive evaluation of factors that induce gingival enlargement during orthodontic treatment: A cross-sectional comparative study


1 Department of Stomatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China
2 Department of Preventive Dental Sciences, Division of Orthodontics and Dentofacial Orthopedics, College of Dentistry, Jazan University, Jazan, Saudi Arabia
3 Department of Prosthodontics, Faculty of Dentistry, Thamar University, Dhamar, Yemen
4 Department of Pathophysiology, Key Lab of Neurological Disorder of Education Ministry, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China; Department of Pathology, Faculty of Medicine, University of Saba Region, Marib, Yemen

Date of Submission08-Feb-2021
Date of Acceptance30-May-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Prof. J Mao
Department of Stomatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 13, Hangkong Road, Wuhan - 430030
PR China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_69_21

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   Abstract 


Background: Gingival enlargement (GE) is one of the most common soft tissue problems encountered during fixed orthodontic treatment. Aims: This study aimed to evaluate the factors affecting GE in adolescents and young adults, compared with their normal peers. Subjects and Methods: This is a cross-sectional comparative study. The sample consisted of 329 subjects (ages 10–30 years) of both genders, which was divided into four main groups: The control group (G0) with no orthodontic treatment; subjects who underwent orthodontic treatment were divided according to treatment duration into G1 (4–12 months), G2 (13–24 months), and G3 (>24 months). The clinical examinations included the level of debris, calculus (simplified oral hygiene), and GE indices. Regression analyses were used to assess the GE association in all the studied groups. Results: The mean GE score increased significantly with increased treatment duration (0.42 ± 0.29 for G0 and 1.03 ± 0.52 for G3). GE scores of the lower arch were significantly higher in the anterior segment than in the posterior segment among all treatment groups. Regression analysis revealed that gender, age, oral hygiene, and treatment duration had a significant effect on GE (P < 0.05), while angle classification, overjet, overbite, treatment stage, bracket type, and therapeutic extraction did not show significant associations (P > 0.05). Conclusion: Gender, age, oral hygiene, and treatment duration were the most important risk factors for GE during fixed orthodontic treatment.

Keywords: Fixed orthodontic appliances, gingival enlargement, malocclusion, orthodontic treatment


How to cite this article:
Almansob Y A, Alhammadi M S, Luo X J, Alhajj M N, Zhou L, Almansoub H A, Mao J. Comprehensive evaluation of factors that induce gingival enlargement during orthodontic treatment: A cross-sectional comparative study. Niger J Clin Pract 2021;24:1649-55

How to cite this URL:
Almansob Y A, Alhammadi M S, Luo X J, Alhajj M N, Zhou L, Almansoub H A, Mao J. Comprehensive evaluation of factors that induce gingival enlargement during orthodontic treatment: A cross-sectional comparative study. Niger J Clin Pract [serial online] 2021 [cited 2021 Dec 2];24:1649-55. Available from: https://www.njcponline.com/text.asp?2021/24/11/1649/330478




   Introduction Top


Patients commonly have misaligned teeth, promoting the accumulation of bacterial plaque and indirectly contributing to gingival inflammation.[1] This misalignment can be corrected by fixed orthodontic appliances, which can also facilitate plaque accumulation and consequent development of generalized hyperplastic gingivitis, gingival enlargement (GE), and gingival invaginations.[2],[3],[4] GE is an increase in the size of the gingival tissue in which the inflammatory process may be localized or generalized.[5],[6],[7] This unwanted enlargement typically begins at the interdental papillae 1–2 months after fixed appliance treatment is bonded, even if proper oral hygiene is maintained,[8],[9] and extends to the end of the treatment.[10] GE during orthodontic treatment has different effects: impeding oral hygiene, interfering with occlusion, mastication, phonetics, which can also cause aesthetic and psychological problems, in turn, compromising the orthodontic tooth movement.[8],[11],[12],[13]

Adolescence (puberty) is the time in which young boys and girls experience transition into adulthood. It begins between the ages of 11 and 14 years in most females and 13 years in males and terminates at 19 years.[14] Orthodontic treatment initiation is considered favorable in adolescence, as a patient's craniofacial growth is still progressing during this period, although permanent tooth eruption is complete. This offers advantages in terms of tooth movement and malocclusion correction while maintaining beneficial facial growth.[14]

The relationship between malocclusion, overjet, overbite, and periodontal status,[15],[16],[17],[18] and the effect of orthodontic treatment duration on GE[5],[19],[20] has been previously assessed. However, to our knowledge, the previous studies were limited to the evaluation of the effect of orthodontic treatment based on the malocclusion type, overjet, and overbite in the occurrence of GE among orthodontic patients. This study was designed to evaluate comprehensively the GE determinants; gender, age, malocclusion type, overjet, overbite, oral hygiene, bracket type, treatment stage, and treatment duration in orthodontic patients treated with fixed appliance therapy.


   Subjects and Methods Top


This cross-sectional comparative study was conducted at the outpatient clinic of the departments of Orthodontics and Restorations of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, from July 2017 to April 2018. It was approved by the institutional review board of Tongji Medical College, Huazhong University of Science and Technology. All procedures performed were in accordance with the guidelines provided by Helsinki and the ethical standards of the hospital research committee. All subjects, or subjects' parents, were informed about the study procedures, and voluntary informed consent was then obtained.

The sample size was calculated using the G power software (Universität Düsseldorf, Düsseldorf, Germany); an alpha value of 0.05 and a power of 90% were considered. The calculation was based on a previous study[5] in which the Seymour Index,[21] calculating the duration of orthodontic treatment as 18.71 ± 12.83 and 28.73 ± 11.17 for orthodontic subjects treated for 1 and 3 years, respectively. Power analysis indicated that at least 26 subjects were needed in each group. The sample increased to a minimum of 60 subjects in each treatment duration category and 40 subjects in each of the main subcategories (age, gender, bracket type, etc.).

Inclusion criteria of the study groups were (1) subjects aged 10–30 years; (2) those who received fixed orthodontic appliances with Damon Q (Ormco Corp., Glendora, CA, USA) and 3M MBT (3M Unitek, Monrovia, CA, USA) brackets, with 0.022 slots for both dental arches; (3) at least 3 months of orthodontic treatment; and (4) good general health. Exclusion criteria of the study groups were (1) subjects with surgical exposure of the impacted teeth; (2) pregnant or breastfeeding females; (3) smokers of any type; and (4) receiving any drugs which might cause GE. The control group inclusion criteria were: (1) subjects aged 10–30 years not undergoing orthodontic treatment (2) good general health. Exclusion criteria were the same as the study group's criteria.

The selected sample was divided into four main groups: The control group (G0) with no orthodontic treatment, and the study group divided into three groups according to treatment duration: G1 (4–12 months), G2 (13–24 months), and G3 (>24 months). Furthermore, subjects were classified into three categories based on age: Less than 15 years, 15–20 years, and older than 20 years, as well as into three categories based on stages of orthodontic treatment: alignment and leveling, space closure, and the finishing stage.

Clinical examination was systemically performed by the same examiner from the right maxillary sextant. All permanent and fully erupted teeth, excluding the third molars, were dried with a blast of air. Afterward, for facial and lingual/palatal surfaces, the simplified oral hygiene index (OHI-S),[22],[23] and the GE index proposed by Bökenkamp and Bohnhorst in 1994[24],[25] were recorded on appropriate sheets. These indices are described in [Table 1]. The GE scores were added and divided by the number of surfaces scored for each individual in order to yield the subjects' overall GE score. The same method was used to obtain the GE scores of a certain region in the mouth (anterior/posterior segment–upper/lower arch). The OHI-S values ranged from 0 to 6: 0.1–1.2 scored as good, 1.3–3 scored as fair, and 3.1–6.0 scored as poor. Data were analyzed using SPSS V25.0 (SPSS Inc., Chicago, IL, USA), and comparisons were performed using the Mann–Whitney U and Kruskal Wallis tests. Linear regression analysis determined the associated independent factors on the dependent factor (GE). The significance level was set at P < 0.05.
Table 1: Description of the assessed indices

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   Results Top


A total of 329 consecutive new subjects, who consented to participate, were included in the study. The mean age was 19.46 ± 5.44 years. Among the 329 subjects, 182 (55.3%) were females, and 147 (44.7%) were males. The control group (G0) comprised of 137 (41.6%) subjects, while there were 63 (19.2%) in G1, 68 (20.7%) in G2, and 61 (18.5%) in G3. According to age, 91 (27.7%) subjects were <15 years old, 82 (24.9%) were 15–20 years old, and 156 (47.4%) were >20 years old. As indicated, the GE significantly increased with the increasing duration of treatment in the whole mouth, different dental arches, and different segments of the mouth, except in the lower anterior segment (P = 0.145) [Table 2]. The variations between the upper and lower arch within the same treatment group revealed significant differences, except for the G1 group (P = 0.080). The lower arch scored a higher value than the upper arch in the control group, while the upper arch scored a higher value than the lower arch in the orthodontic groups [Table 2]. The pairwise comparison between the different treatment groups revealed significant differences between the groups: G0 and G2, G0 and G3, G1 and G3, and G2 and G3. The least mean difference was between G1 and G2 (95% CI = −0.31, −0.03) while the highest mean difference was between G0 and G3 (95% CI = −0.74, −0.49) [Table 3].
Table 2: Gingival enlargement scores of whole mouth, anterior segment, posterior segments, upper arch, and lower arch for the different treatment groups

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Table 3: Pairwise comparison of overall GE score between the different treatment groups

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Regarding the effect of age, only significant differences recorded in G1 and G3 (P = 0.003 and P = 0.015, for G1 and G3, respectively; [Table 4]), with higher values in the age group <15 years and lowest values in the age group >20 years [Table 4]. The pairwise comparison between age groups within the G1 group only revealed a significant difference between >20 years and <15 years groups (P = 0.002). Among the G3 group, the significance was between >20 years and 15–20-year groups (P = 0.028), and between >20 years and <15 years groups (P = 0.032) [Table 5]. The GE was significantly higher in males than females in the G1 and G2 groups (P = 0.003 and P = 0.014 for G1 and G2, respectively; [Table 4]). In terms of bracket type, only significant differences in G3 were reported (P = 0.012), with higher values in the subjects treated with conventional brackets [Table 4].
Table 4: Differences in overall gingival enlargement score between the studied categories across the different treatment groups

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Table 5: Pairwise comparison of overall GE score between the different age groups among G1 and G3

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For the regression analysis, the results revealed the following parameters: duration of treatment, gender, age, and OHI-S as having a significant effect on GE. The fit of the model was highly significant (ANOVA P < 0.001), and the R2 revealed that 42% of the variability in the sample was explained by the significant determinants [Table 6].
Table 6: Regression analysis for the whole sample and for the different treatment groups

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   Discussion Top


The World Health Organization (WHO) estimates malocclusions as the third most prevalent oral health problem, following dental caries, and periodontal disease.[26] The relationship between the second and third most prevalent oral health problems has been the focus of this study.

The regression analysis of this study revealed that just a few determinant factors had a significant effect on GE. The analysis was run for the whole sample in order to consider the effect of the fixed orthodontic treatment duration, which was noted to have a highly significant effect (β = 0.17; P < 0.001). This result agrees with the findings of Pinto et al.[5] and Ustaoglu et al.[19] and disagrees with the results of Zanatta et al.[20] They found no correlation between the orthodontic treatment duration and GE in the risk assessment analysis, although they did find a significantly higher frequency of GE scores of 2 and 3 in the orthodontic patients treated for more than 12 months, compared to those treated for 6–12 months. This disagreement is mostly due to the difference in the GE index used for both studies. The significant association between treatment duration and GE is actually more logical because, with each treatment duration, there is an aggravating factor: in the first year, most subjects were at the first stage of treatment (alignment and leveling), in which proper alignment of the teeth was accomplished with flexible archwires with a low force and the use of orthodontic accessories (e.g., open bite plate, elastomeric chain, and springs) by which the hindering of conventional brushing and flossing was less severe than at the advanced stages of orthodontic treatment.

When the treatment duration extends to more than 24 months, the subject's motivation toward brushing teeth is reduced as a function of lengthy treatment. Gender had a significant effect (β = −0.14; P = 0.001), with more males affected by GE. Our results are in line with the findings of Kudirkaite et al.[27] and Krupinska et al.[28] who found the periodontal health and condition of teeth in females to be better than those in males, as the former may pay more attention to their oral health—about which we would disagree with the results of Zanatta et al.[20] who found no association between gender and a GE score of 2.

Age also had a significant negative effect (β = −0.12; P < 0.001), which indicates that the GE score was higher in younger subjects. Although Eid et al.,[14] Akkaya et al.,[2] and Sadiq and Badea[29] ended up with the same findings as in our study, Zanatta et al.[20] disagreed with them, largely due to the differences in the distribution of age between both studies. Another factor was oral hygiene, which also had a highly significant effect (β = 0.42; P < 0.001) with higher GE scores among subjects with fair OHI-S (scoring system: 0 = good; 1 = fair). Our results are consistent with those of Beaumont et al.,[30] Montebugnoli et al.,[31] and Reali et al.[32] who proposed that plaque build-up and poor oral hygiene were important causal factors of GE: They were also significant in some groups when the analysis was run for each group independently, although the G3 group showed no significant effect with all factors. These differences might be due to multifactorial confounders, with overlaps between groups. However, most groups shared factors such as gender, age, and OHI-S as significant determinants of GE.

Our results revealed that the difference in GE between the anterior and posterior segments in the lower arch was significant across all the treatment groups (G0 through G3), with higher scores in the anterior segment [Table 2]. This difference may be due to the lower anterior segment usually being crowded, irregular, and susceptible to calculus formation on the lingual surface, which has the highest risk of developing GE.[18],[33] Although Hosadurga et al.[34] and Ainamo[35] had similar findings, Sreenivasan et al.[36],[37] disagreed with ours. The disagreement was mostly due to their sample having a higher age range (over 18 years old), in which multifactorial confounders can be causative factors of such differences, in addition to the level of oral hygiene between different cultures. The mean GE scores of the lower arch were higher than those of the upper arch in the control group (G0), possibly due to a calculus preferentially forming on the lingual surface of the lower teeth. This agreed with Sreenivasan et al.[36] who noted that a gingival score occurred more frequently on the posterior surfaces of the lower arch than on the upper arch: the mean GE scores of the upper arch were higher than those of the lower arch in the orthodontic groups, possibly because most orthodontic subjects in this study were treated with an open bite plate, which may cause direct injury to the gingival area across the upper arch resulting in GE.[38]

From the endpoint of this study, we may recommend more longitudinal research work with a larger sample and follow-up of the same subjects before and during orthodontic treatment to investigate factors that may influence GE during the orthodontic treatment.


   Conclusion Top


There is an association between the duration of fixed orthodontic treatment, gender, age, oral hygiene, and GE. As such, it is proposed that orthodontists attempt to optimize orthodontic treatment with minimal duration, as well as motivating and educating patients (especially males and adolescents) to perform oral hygiene measures regularly and efficiently, thereby reducing the incidence of GE during orthodontic treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/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.

Acknowledgments

I would like to thank all my friends, especially Dr. Wei, Dr. Wu, and Dr. Wang for their assistance and patience during data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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