European Journal of Orthodontics 32 (2010) 94–99 © The Author 2009.

thor 2009. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjp033 All rights reserved. For permissions, please email: [email protected]
Advance Access Publication 27 May 2009

Salivary Streptococcus mutans levels in patients with

conventional and self-ligating brackets
Nikolaos Pandis*, William Papaioannou**, Efterpi Kontou***, Melachrini Nakou***,
Margarita Makou**** and Theodore Eliades*****

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*Private Practice, Corfu, Departments of **Preventive and Community Dentistry, ***Periodontology, and
****Orthodontics, School of Dentistry, University of Athens and *****Department of Orthodontics, Aristotle
University of Thessaloniki, Greece

SUMMARY The objective of this study was to investigate the effect of bracket type (conventional and self-
ligating) on the levels of Streptococcus mutans and total bacterial counts in whole saliva of orthodontic
patients. Thirty-two male and female patients were selected using the following inclusion criteria:
adolescents (mean age 13.6 years, range 11–17 years), fixed appliances in both arches, non-smoker, and
no reported oral habits. Demographic and oral hygiene characteristics were determined for each subject.
The patients were subdivided into two groups with random allocation of bracket type (conventional or self-
ligating). An initial saliva sample was obtained before the initiation of treatment (T1) and a second sample
2–3 months following appliance bonding (T2). Salivary S. mutans and total bacteria were enumerated
and analysed after growth in culture. The demographic and clinical characteristics of the samples were
analysed with a t- or chi-square test, where applicable, to assess the random allocation of bracket group
to participants. The results of S. mutans and total facultative bacterial counts were log transformed and
statistically analysed with analysis of covariance with bracket (conventional versus self-ligating) as the
categorical variable and initial total bacterial counts or initial S. mutans levels serving as the covariate.
No difference was found in the demographics and oral hygiene indices between the two groups,
verifying the random assignment of brackets to the population sample. The levels of S. mutans in whole
saliva of orthodontically treated patients do not seem to be significantly different between conventional
and self-ligating brackets. The pre-treatment levels of S. mutans are significant predictors of the levels
of S. mutans after placement of orthodontic appliances, while this was not the case for total bacterial
counts.

Introduction
balance, creating conditions conducive to the growth, and
Although self-ligation in orthodontics was described several appearance of cariogenic and/or periodontopathic bacteria
decades ago, the first commercially viable system, the Speed (Marsh, 2003).
bracket, was not introduced until the early 1980s. The late The different components of the fixed orthodontic system
1990s marked a significant increase in the popularity of may contribute to a shift in the balance of the oral ecology.
self-ligation with almost all major orthodontic companies A large amount of research has dealt with the intimate
listing them among their products (Harradine, 2003). contact of orthodontic materials with the tooth and
One of the proposed favourable aspects of self-ligating periodontal tissue. The presence of brackets and ligatures
brackets is the elimination of elastomeric or stainless steel has been shown to be related to an increase in gingival
ligatures. It has been proposed that this feature brings two inflammation and increased risk of decalcification. This
basic advantages: the eradication of cross-contamination, demineralization of the tooth surfaces results in the
which may accidentally be involved in the process of appearance of white spots or even carious lesions (Gorelick
ligature change, and the claimed improvement in the oral et al., 1982; Øgaard et al., 1988; Fournier et al., 1998;
hygiene of patients. The latter has been attributed to the fact Naranjo et al., 2006).
that the patient is given the opportunity to clean surfaces of Oral microbiota attachment in orthodontic patients has
reduced complexity and with less retentive sites for been mainly associated with increased risk of Streptococcus
microbial colonization (Øgaard et al., 1988). mutans and lactobacilli colonization, among other species,
The oral cavity is a rich ecosystem with a plethora of thus initiating a series of events, which may lead to the
microorganisms. While both periodontal disease and caries development of pathology of the hard tissues such as
are considered multifactorial diseases, plaque bacteria are decalcification and, in specific cases, caries development
the major factor in their onset and progression. However, (Gorelick et al., 1982; Øgaard et al., 1988; Fournier et al.,
there are situations which comprise what has been termed 1998). Moreover, the accumulation of plaque and the
‘ecological stress’, referring to the shift of the microbiological resultant alteration of the local microbial milieu may
S. MUTANS AND SELF-LIGATING BRACKETS 95

expose the tissues to the risk of developing periodontal brushing or other hygiene measures were carried out. For
inflammation, with notable changes in the biota (Naranjo each participant, the following clinical variables were
et al., 2006). assessed: the simplified plaque index (S-PlI), where the
Even though the aforementioned effects have been percentage of surfaces with plaque is recorded (taking into
studied extensively, there is a lack of substantiation of the consideration all surfaces per tooth for all erupted teeth),
hypothesis of decreased plaque retention related to the use and the decayed, missing, and filled teeth (DMFT) index for
of self-ligating brackets. The hypothesis investigated in the prevalence of caries. Both indices were recorded after
the present research was that bracket ligation mode has an each saliva sample collection at each visit without the use of

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effect on the microbiological profile of the patients’ oral a plaque disclosing agent.
environment. Therefore, the objectives of this study were Serial 10-fold dilutions of the saliva samples were
to investigate the effect of bracket type (conventional or inoculated on a non-selective medium and on a selective
self-ligating) on salivary S. mutans counts and total bacterial growth medium for S. mutans. Aliquots of 0.1 ml of the
count levels in patients undergoing treatment with dilutions were inoculated onto non-selective blood agar
conventional and self-ligating appliances. plates supplemented with 7 per cent sterile blood for
the evaluation of the composition of the predominant
cultivatable microbiota of the saliva. The blood agar
Subjects and methods
plates were incubated at 37°C for 3 days in a CO2
The individuals participating in the study group were atmosphere, following which the total number of CFU
selected from a larger pool of patients from the practice of was counted.
one author (NP), using the following inclusion criteria: The selective medium used was Mitis Salivarius agar
adolescents treated with fixed appliances, no reported oral supplemented with sucrose (20 per cent w/v), bacitracin,
habits detrimental to health, including smoking, absence of and tellurite solution. The plates were incubated for up to 7
restorations, and/or missing teeth due to dental caries. The days in a CO2 atmosphere at 37°C. The above process was
patients who fulfilled these criteria were randomly assigned repeated 2–3 months after the orthodontic appliances were
to one of the treatment groups. The orthodontist did not bonded. The presumptive characterization and identification
know the bracket group assignment at the time of the first of S. mutans was based upon colony morphology, Gram
saliva collection. Consent for saliva collection was obtained stain, and catalase activity. From these, representative
from all patients. colonies were subcultured and biochemical tests performed
The 32 male and female patients were divided into two for definitive species identification. All laboratory procedures
equal groups based on bracket type used, i.e. conventional were carried out without the personnel knowing the
(Microarch, GAC International, Central Islip, New York, allocation of saliva samples to bracket groups. Additionally,
USA), ligated with conventional (no fluoride-releasing) in an effort to minimize variation, the S. mutans counts were
elastomeric modules, or self-ligating (In-Ovation-R, GAC also recorded as a proportion of total bacterial counts
International). From previous studies (Forsberg et al., (S. mutans counts/total bacterial counts) at T1 and T2.
1991; Attin et al., 2005), it is inferred that a mean colony- Demographic and clinical characteristics of the sample
forming unit (CFU) difference of approximately one log were investigated with conventional descriptive statistics.
[standard deviation (SD) = approximately 1] will result in Differences of means (gender, age, S-PlI, DMFT, and days
a clinically significant increase in S. mutans counts. between T1 and T2 sample) were determined with a t-test,
Therefore, the sample size of 16 patients per group, at whereas differences in proportion (males–females
a = 0.05, yields a statistical power very close to 0.80 for proportion between the two groups) were studied with the
this study. chi-square test.
Whole stimulated saliva was collected from each patient at Comparisons of the total cultivatable counts (total
two time points before bonding and initiation of orthodontic number of CFU) and total CFU of S. mutans per millilitre
therapy (baseline at T1) and after at a period of 2–3 months of saliva between the two bracket groups were performed
(T2) after full bonding had taken place. At both time points, independently; they were log transformed and statistically
each subject was asked to collect saliva in the mouth and to analysed with analysis of covariance (ANCOVA) with
expectorate into a chilled empty Petri dish approximately 3 bracket (conventional versus self-ligating) as the categorical
ml of saliva. The subjects had refrained from eating or variable and initial total bacterial counts or initial S. mutans
drinking beverages for at least 1 hour before saliva collection. levels serving as the continuous covariate. Data were further
Collection of saliva samples was performed before any oral analysed with simple linear regression analysis to evaluate
examination or manipulation so as not to disrupt the oral the initial levels of facultative total bacteria counts and
microbiota. S. mutans as predictors of the levels of these at the second
Standard oral hygiene instructions were provided at the time interval. Data analysis was conducted with the statistical
beginning of treatment using a model, with specific attention package, Minitab 14.20 (State College, Pennsylvania, USA),
to the orthodontic appliances. Prior to all examinations, no at the 0.05 level of significance.
96 N. PANDIS ET AL.

Results detected between the bracket groups. Additionally, total

bacterial counts at T1 were not found to be significant
Table 1 shows the distribution of demographic, oral hygiene
predictors of the total bacterial counts at T2.
variables, and the average number of days between the T1
The corresponding ANCOVA for the S. mutans levels are
and T2 saliva samples for the two groups. The distribution
illustrated in Table 4; again the variable ‘bracket’ had no
of gender, age, and treatment duration prior to the T2 saliva
effect as depicted in Table 3, where no difference between
sample did not show any difference between the two bracket
the bracket groups was identified. However, the T1 levels of
groups verifying the random selection of these variables
S. mutans in saliva (the covariate) were shown to be
across the two populations. Additionally, the oral hygiene

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significant predictors of the levels of S. mutans at T2. This
status as determined by the S-PlI and DMFT indices for the
was also confirmed by simple linear regression (r = 0.474,
prevalence of caries are shown.
P = 0.022). The low values for the adjusted r2 signify the
The mean logs and SDs for total bacterial and S. mutans
low fit of the model with regard to the variables used,
counts at T1 and T2 sample collection for the two bracket
which means that the variable bracket type and initial
groups are shown in Table 2. Statistical analysis showed no
S. mutans counts (T1) in combination are not good predictors
difference with respect to total bacterial and S. mutans
of S. mutans counts at T2. However, initial S. mutans counts
counts between the two bracket groups at either T1 or T2.
on their own are significant predictors (P = 0.033) of the
ANCOVA results for total salivary microbial counts for
final S. mutans counts (Draper and Smith, 1988; Kim and
the conventional and self-ligating bracket groups are shown
Dailey, 2008). Some of the individuals had no detectable
in Table 3. No statistically significant difference was
S. mutans counts and the zero values were not included in
the model because they would have produced misleading
Table 1 Demographic and clinical characteristics of the subjects results by lowering the means and thus the S. mutans counts
included in the study. would have been under-represented.
Table 5 shows the mean logs and SDs for the ratio of
Variable—bracket group Mean SD P level S. mutans counts to total bacterial counts. Again, statistical
analysis showed no difference in total S. mutans/total
S-PlI—conventional (initial, %) 48.1 13.2 NS bacterial count ratios between the two bracket groups at T1
S-PlI—self-ligating (initial, %) 47.3 9.8
and T2, confirming the results of the previous analyses.
S-PlI—conventional (2–3 months) 46.1 8.4 NS
S-PlI—self-ligating (2–3 months) 46.5 6.6
DMFT—conventional 1.4 0.4 NS Discussion
DMFT—self-ligating 1.8 0.4
Gender ratio—conventional 0.5 NS The initial affinity of bacteria to solid surfaces is mostly due
Gender ratio—self-ligating 0.5 to electrostatic and hydrophobic interactions, while surfaces
Age (years)—conventional 13.38 1.5 NS with high surface-free energy more easily attract bacteria
Age (years)—self-ligating 13.81 1.5 such as S. mutans (Van Dijk et al., 1987). A recent in vitro
Days from first sample—conventional 84.5 5 NS study (Papaioannou et al., 2007) assessed the adhesion of a
Days from first sample—self-ligating 89.9 5
clinical strain of S. mutans on brackets of different
composition, with a saliva coating as well as uncoated. The
NS, non-significant; S-PlI, simplified plaque index for percentage of
surfaces with plaque considering all surfaces per tooth; DMFT, decayed, effect of Streptococcus sanguinis was also examined by
missing, and filled teeth, total indicating the sum of DMF. allowing these bacteria to adhere before the adhesion of
S. mutans. It was clear from the results that there were no
Table 2 Mean and standard deviation (SD) of log-total bacteria significant differences in the adherence of S. mutans to the
and Streptococcus mutans counts per millilitre saliva before the three different types of brackets. For uncoated brackets, it is
start of treatment (T1) and following appliance bonding (T2) for expected that only surface characteristics would determine
the bracket groups.
adhesion of bacteria, suggesting that bacteria with high
surface-free energy such as S. mutans (Weerkamp et al.,
Variable Bracket type Mean SD P level 1985) should prefer surfaces with high surface-free energy
materials such as stainless steel brackets. However, this has
Log-total count T1 Conventional 6.78 1.79 NS not been confirmed (Fournier et al., 1998; Ahn et al., 2005;
Self-ligating 7.24 2.09
Log-total count T2 Conventional 7.76 1.32 NS Papaioannou et al., 2007), and therefore, variations in
Self-ligating 7.24 2.09 surface-free energy in conjunction with other surface
Log-S. mutans T1 Conventional 4.53 1.02 NS properties of bracket raw materials (Eliades et al., 1995)
Self-ligating 3.98 0.87
Log-S. mutans T2 Conventional 4.66 1.45 NS may not produce a measurable effect on adhesion.
Self-ligating 4.48 0.83 Even though the attachment of plaque on bracket surfaces
constitutes a direct assessment of the effect of bracket
NS, non-significant. on microbial colonization, this approach presents major
S. MUTANS AND SELF-LIGATING BRACKETS 97

Table 3 Analysis of covariance for the salivary total microbial counts per millilitre of saliva of the subjects included in the study.

Source df Sequential sum Adjusted sum of Adjusted mean of F P level

of squares squares squares

Log-total counts 1 0.63 0.73 0.734 0.56 0.458 NS*

Bracket 1 0.34 0.34 0.335 0.26 0.615 NS†
Error 29 37.67 37.67 1.299
Total 31 38.63

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S = 1.13970 R2 = 2.49% R2(adjusted) = 0.00%

*NS, non-significant. The initial (T1) log-total bacterial counts are not a significant predictor of the log-total bacterial counts at T2 (after bonding).
†NS, non-significant difference on the log-total bacterial counts between the two bracket groups, adjusted for initial log-total bacterial counts.

Table 4 Analysis of covariance for the salivary Streptococcus mutans counts per millilitre saliva of the subjects included in the study.

Source df Seq SS Adjusted sum of Adjusted mean of F P level

squares squares

Log-S. mutans 1 6.09 5.47 5.47 5.25 0.033*

Bracket 1 0.16 0.17 0.17 0.16 0.694 NS†
Error 20 20.85 20.84 1.04
Total 22 27.10
S = 1.02095 R2 = 23.09% R2(adjusted) = 15.39%

*Significant. The initial (T1) log-S. mutans counts is a significant predictor of the log-S. mutans counts at T2.
†NS, non-significant difference on the log-S. mutans counts between the two bracket groups, adjusted for initial log-S. mutans counts.

Table 5 Means and standard deviations (SDs) of the ratio of log- follows that for a general assessment of microbial
Streptococcus mutans to log of total bacterial counts (TC) per colonization on tooth and bracket surfaces, salivary
millilitre saliva at baseline (T1) and following bonding (T2) for
sampling may be selected based on the assumption that
the bracket groups.
salivary levels of microbia may represent the variation of
those attached to bonded teeth. The available literature
Variable Bracket type Mean SD P level supports such a correlation between the presence of
S. mutans in saliva and plaque (Mundorff et al., 1990;
Log-S. mutans/log-TC@T1 Conventional 0.65 0.18 NS
Self-ligating 0.62 0.29
Sullivan et al., 1996). High counts in the saliva usually
Log-S. mutans T2/log@TC Conventional 0.59 0.17 NS correlate to more than 103 mean squares in the plaque. In
Self-ligating 0.61 0.11 the present study, the levels were around 104 before and
after bonding in both groups. This is most probably due to
NS, non-significant. the low levels of caries experience of both groups.
Other factors in the oral environment may further decrease
any possible variations due to the different surface
technical and methodological difficulties. First, microbial characteristics. One such factor for microbial colonization
accumulation may follow different rates at various intraoral of oral hard surfaces is the salivary or acquired pellicle,
sites as a result of the proximity of the bracket to the gingival which can form not only on tooth surfaces but also on
sulcus, the surface area of the labial enamel surface relative restorations, and prosthetic and orthodontic appliances.
to the bracket, and the position relative to the mandibular Therefore, the adhesion of oral microorganisms to the
glands. At low flow rates or under static conditions, the bracket surface may be influenced to a large extent by
grooves of rough surfaces may act as stagnation points, interactions between salivary components in the pellicle
thereby promoting biofilm maturation (Karino et al., 1987). and the properties of the different microorganisms, in
Also, elastomeric ligatures are frequently changed and addition to the adherent patterns of bacteria on the different
therefore, the time elapsed after their renewal may have an types of orthodontic brackets. The presence of an early
effect on bacterial attachment since the substrate for salivary pellicle has been found to reduce the number of
colonization is eliminated and a new cycle of colony adhering bacterial cells of S. mutans (Fournier et al., 1998;
formation is initiated on new material. Papaioannou et al., 2007).
On the other hand, direct assessment of microbes in situ An interesting observation relates to the interaction
and onto specific areas may not at present be feasible. It between different bacterial species in adhesion to a surface.
98 N. PANDIS ET AL.

Specifically, S. sanguinis, one of the initial colonizers of the For the self-ligating brackets, the data are extremely poor.
oral cavity, has been found to further reduce the number of Only one study is presently available and that focuses on
adhering S. mutans regardless of the type of surface. periodontal factors and associated bacteria. In that study
Streptococcus mutans and S. sanguinis would seem to have (van Gastel et al., 2007), an important local effect of bracket
an antagonistic relationship and early colonization by the type was found. Indeed, at the area around the brackets,
latter may have a significant effect on concentrations of there were significant alterations in both periodontal and
S. mutans (Quirynen and Bollen, 1995). A delayed colonization microbiological parameters, with the self-ligating Speed
by S. mutans may lead to less caries or caries susceptibility. brackets showing poorer scores.

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The morphology and design of orthodontic brackets, as The results of the present study suggest that bracket
well as the ligation mode may play a role by providing an design parameters may not have a significant effect on
increased number of retention sites as well as protection bacterial colonization on orthodontic appliances. This
from plaque-removing shear forces arising from masticatory could be attributed to the implementation of an oral hygiene
loads and fluid flow, thus facilitating dental plaque programme, which is taught at the early stages of
accumulation and maturation, and consequently increased orthodontic treatment, and the potential minute role of
levels of S. mutans in saliva. One of the proposed favourable bracket design to offer sites for microbial adherence when
aspects of self-ligating brackets is associated with the such oral hygiene is exercised. However, the initial
elimination of elastomeric or stainless steel ligatures. Teeth concentrations of S. mutans did exert a significant effect
ligated with elastomeric ligatures, as in the present study, upon the counts of this bacterium over time. This may be
have been found to harbour in the area of the brackets, an important factor to take into consideration when
higher numbers of bacteria than those where steel wire is determining the risk a specific patient may be exposed to,
utilized (Caufield et al., 2000). The type of bacterial thus necessitating a more individualized preventive
morphotypes, as detected in a scanning electron microscopy programme.
study, was not, however, found to differ between the Other approaches to alter the relationship between
two ligation methods (Sukontapatipark et al., 2001). ligature elastomers and dental plaque accumulation have
Türkkahraman et al. (2005), employing a split-mouth often been sought. The most common includes the use of
protocol, examined the effect of the two ligation modes fluoride-releasing elastomers (Wilson and Gregory, 1995;
(elastomeric rings and ligature wires) on the accumulation Benson et al., 2004). Stannous fluoride is the fluoride of
of specific cariogenic species (S. mutans and lactobacilli) as choice when the focus is placed on bacteria due to the
well as the periodontal status, before therapy and at 1 and 5 antibacterial properties it possesses (Camosci and Tinanoff,
weeks after treatment initiation. Slightly higher total counts 1984). A significant decrease in salivary levels was found
of bacteria around the elastomeric rings were found that, when fluoride-releasing elastomers were placed in a group
however, did not reach statistical significance, even though, of orthodontic patients; however, there was no significant
in all 21 patients, significant increases of bacteria counts effect after 2 or more weeks of retention of elastomers
were recorded. Finally, elastomeric rings appeared more (Wilson and Gregory, 1995). In a more recent split-mouth
conducive to gingival bleeding, perhaps due to their slightly crossover study (Benson et al., 2004), the bacteria that the
higher affinity to plaque. For this reason, those authors elastomeric rings retained were examined after 6 weeks of
suggested that the use of elastic ligatures should be avoided intraoral use. No significant differences in culture growth
in patients with inadequate oral hygiene. for streptococcal and anaerobic bacteria were found.
The hypothesis of the present study that self-ligating
bracket should have a beneficial effect due to the absence of
Conclusion
ligatures, is not confirmed. However, as shown (Table 2),
although the oral concentrations of S. mutans were found to Total bacterial counts in whole saliva did not differ
be slightly lower in patients with self-ligating compared significantly among patients with conventional and self-
with conventional brackets, this difference did not reach ligating brackets. Additionally, bracket type (conventional
significance. There seemed to be a small effect on the total versus self-ligating) does not seem to significantly alter the
bacterial load of the saliva, with the patients bonded with levels of S. mutans in whole saliva.
the self-ligating brackets showing a smaller increase of load
at T2 compared with the conventional group, but again no
Address for correspondence
significant effect was detected.
Based on the present findings, total facultative bacterial Theodore Eliades
and S. mutans counts in saliva do not seem to be significantly 57 Agnoston Hiroon
different between the bracket groups tested. Locally though, Nea Ionia 14231
i.e. in the tissues adjacent to brackets and peripheral Athens
marginal adhesive resin, the situation may be totally Greece
different and there may be an effect. E-mail: [email protected]
S. MUTANS AND SELF-LIGATING BRACKETS 99

References Mundorff S A, Eisenberg A D, Leverett D H, Espeland M A, Proskin H M

1990 Correlation between numbers of microflora in plaque and saliva.
Ahn S J, Lim B S, Yang H C, Chang Y I 2005 Quantitative analysis of the Caries Research 24: 312–317
adhesion of cariogenic streptococci to orthodontic metal brackets. Angle
Orthodontist 75: 666–671 Naranjo A A, Trivino M L, Jaramillo A, Betancourth M, Botero J E 2006
Changes in the subgingival microbiota and periodontal parameters
Attin R et al. 2005 Recolonization of mutans streptococci on teeth with before and 3 months after bracket placement. American Journal of
orthodontic appliances after antimicrobial therapy. European Journal of Orthodontics and Dentofacial Orthopedics 130: 275.e17–e22
Orthodontics 27: 489–493
Øgaard B, Rølla G, Arends J 1988 Orthodontic appliances and enamel
Benson P E, Douglas C W I, Martin M V M 2004 Fluoridated elastomers: demineralization. Part 1. Lesion development. American Journal of
effect on the microbiology of plaque. American Journal of Orthodontics Orthodontics 94: 68–73

Downloaded from https://academic.oup.com/ejo/article-abstract/32/1/94/506458 by Universitas Indonesia user on 05 April 2019

and Dentofacial Orthopedics 126: 325–330
Papaioannou W, Gizani S, Nassika M, Kontou E, Nakou M 2007 Adhesion
Camosci D A, Tinanoff N 1984 Anti-bacterial determinants of stannous of Streptococcus mutans to different types of brackets. Angle
fluoride. Journal of Dental Research 63: 1121–1125 Orthodontist 77: 1090–1095
Caufield P W, Dasanayake A P, Li Y, Pan Y, Hsu J, Hardin M 2000 Natural Quirynen M, Bollen C M L 1995 The influence of surface roughness and
history of Streptococcus sanguinis in the oral cavity of infants: evidence surface-free energy on supra- and subgingival plaque formation in
for a discrete window of infectivity. Infection and Immunology 68: man. A review of the literature. Journal of Clinical Periodontology 22:
4018–4023 1–14
Draper N, Smith H 1988 Applied regression analysis, 3rd edn. Wiley Sukontapatipark W, El-Agroudi M A, Selliseth N J, Thunold K, Selvig K A
Interscience, New York, pp. 138–140. 245–246 2001 Bacterial colonization associated with fixed orthodontic appliances.
Eliades T, Eliades G, Brantley W A 1995 Microbial attachment on A scanning electron microscopy study. European Journal of Orthodontics
orthodontic appliances: I. Wettability and early pellicle formation on 23: 475–484
bracket materials. American Journal of Orthodontics and Dentofacial Sullivan M K, Borgström L, Granath G, Nilsson M 1996 Number of
Orthopedics 99: 351–1175
mutans streptococci or lactobacilli in a total dental plaque sample
Forsberg C M, Brattström V, Malmberg E, Nord C E 1991 Ligature wires does not explain the variation in caries better than the numbers in
and elastomeric rings: two methods of ligation, and their association stimulated saliva. Community Dentistry and Oral Epidemiology 24:
with microbial colonization of Streptococcus mutans and lactobacilli. 159–163
European Journal of Orthodontics 13: 416–420
Türkkahraman H, Sayin M O, Bozkurt F Y, Yetkin Z, Kaya S, Onal S 2005
Fournier A, Payant L, Bouclin R 1998 Adherence of Streptococcus mutans Archwire ligation techniques, microbial colonization, and periodontal
to orthodontic brackets. American Journal of Orthodontics and status in orthodontically treated patients. Angle Orthodontist 75:
Dentofacial Orthopedics 114: 414–417 231–236
Gorelick L, Geiger A M, Gwinnett A J 1982 Incidence of white spot Van Dijk J, Herkstroter J, Busscher H, Weerkamp A H, Jensen H, Arends J
formation after bonding and banding. American Journal of Orthodontics 1987 Surface free energy and bacterial adhesion. An in vivo study in
81: 93–98 beagle dogs. Journal of Clinical Periodontology 14: 300–304
Harradine N W 2003 Self-ligating brackets: where are we now? Journal of van Gastel J, Quirynen M, Teughels W, Coucke W, Carels C 2007 Influence
Orthodontics 30: 262–273 of bracket design on microbial and periodontal parameters in vivo.
Karino T, Goldsmith H L, Motomiya M, Mabuchi S, Sohara Y 1987 Flow Journal of Clinical Periodontology 34: 423–431
patterns in vessels of simple and complex geometries. Annals of the Weerkamp A H, van der Mei H C, Busscher H J 1985 The surface free
New York Academy of Sciences 516: 422–441 energy of oral streptococci after being coated with saliva and its relation
Kim J S, Dailey R J 2008 Biostatistics for oral health care. Blackwell to adhesion in the mouth. Journal of Dental Research 64: 1204–1210
Munksaard, Copenhagen, pp. 217–221 Wilson T G, Gregory R L 1995 Clinical effectiveness of fluoride-releasing
Marsh P D 2003 Are dental diseases examples of ecological catastrophes? elastomers. I: Salivary Streptococcus mutans numbers. American
Microbiology 149: 279–294 Journal of Orthodontics and Dentofacial Orthopedics 107: 293–297