EFFECT OF ORTHODONTIC BAND PLACEMENT ON

THE CHEMICAL COMPOSITION OF HUMAN

INCISOR TOOTH PLAQUE

R. CHATTERJH:and I. KLEINB~RG
Department of Oral Biology and Pathology, State University of New York. Stan! Brook
NY 11794. U.S.A.

Summary--The placement of orthodontic bands reduced the pH. calcium and phosphorus
levels and increased carbohydrate levels in the incisor plaques of 13 adolescent subjects. Maxil-
lary plaques showed lower pH, Ca and P levels and a tendency for higher carbohydrate
levels than corresponding mandibular plaques. The results are consistent with
the view that pH influences plaque composition. They also provide an additional explanation
concerning the trapping of food and plaque which increases dental caries susceptibility after
the placement of orthodontic bands.

IETRODUCTION in plaque Ca and P leveis. To test this possibility

Dental plaque contains high levels of Ca and P (Allen
and Moore, 1957: Dawes and Jenkins, 1962; Klein-
berg et ul., 1971, 1976: Schroeder, 1963; Ashley, 1975)
and X-ray diffraction studies suggest that some may
be present as an amorphous or poorly crystalline cal-
cium phosphate (Kaufman and Kleinberg, 1973).
Kleinberg et ul. (1971) suggested that these deposits
act as reservoirs of Ca and P which protect the en-
amel against dissolution by the acid produced during
bacterial degradation of ingested carbohydrate.
Present evidence suggests that this material originates
from salivary glycoproteins (Kaufman and Kleinberg,
1973: Silverman and Kleinberg, 1967) as a calcium
phosphate carbohydrate-protein (CPCP) complex or
aggregate and that its content of Ca, phosphate and
carbohydrate is influenced by the pH (Kleinberg et
nl., 1971: Cross, Chatterjee and Kleinberg, 1973). lfz-
citro experiments with whole and duct salivas show
that raising the pH from neutrality to between 8 and
9 results in a progressive increase in the formation
of CPCP aggregates with a high proportion of cal-
cium phosphate, whereas lowering the pH to between
3 and 5 favours progressive formation of aggregates
with a high carbohydrate content (Kleinberg et ul.,
1971 ; Cross rf 01.. 1973).
Chemical analysis of plaques removed from various
incisor surfaces of human subjects show a similar pH
relationship. In dentition sites where plaques showed
a higher pH. the Ca and P levels were higher and
carbohydrate values. although variable, were gener-
ally lower (Kleinberg VI al.. 1971). This variability was
attrihuted to bacterial synthesis of polysaccharide
from dietary carbohydrate (Wood, 1964) being added
to any carbohydrate deposited as part of glycoprotein
during plaque formation.
Balenseifen and Madonia (1970) showed that the
cementing of orthodontic bands results in a decrease
in the plaque pH, an increase in plaque carbohydrate
and changes in the microbial composition of the
plaque. The in-cirro and in-Gco experiments cited sug-
gested that this pH shift would also favour a decrease
and to examine further the relationship between
plaque pH, and plaque carbohydrate. Ca and P levels.
experiments similar to those of Balenseifen and
Madonia were carried out in dentition sites known
to vary significantly in their pH. The plaques selected
for examination were those on the labial and approxi-
mal surfaces of the maxillary and mandibular incisors
which show consistent differences in pH which in turn
have been related to differences in susceptibility to
dental caries. clinical calculus and inflammatory peri-
odontal disease (Kleinberg and Jenkins. 1964: Klein-
berg and Hall. 1969: Kaufman and Kleinberg. 1073).
rLIETHODS
Plaques from 13 subjects. 13-16 yr of age, undergo-
ing orthodontic treatment were examined 3 times,
twice before and once after the placing of edgewise
orthodontic appliances (Angle, 1928) on both the
maxillary and mandibular arches. Plaques were exam-
ined 1 and 2 weeks before insertion of the appliances
and were re-examined 4 weeks thereafter. As before
(Kleinberg 4r (I/., l97!; Kaufman and Kleinberg,
1973), subjects avoided oral hygiene procedures
for 3 days prior to the morning of plaque sampling.
Subjects refrained from eating or drinking for at least
12 h before plaque sampling between 09.00 and
IO.00 am. Figure 1 shows the relation of the ortho-
dontic bands to the sites where pH way measured
and plaques were sampled.
At each site. the pH of two plaques was measured
using antimony pH micro-electrodes (Kleinberg,
1958). 200-300~pg plaque samples were removed from
each site with a stainless steel spatula, transferred to
small, pre-weighed platinum boats, dried in an air
oven for 1 h at 100 C, and weighed on a Mettler UM7
ultramicrobalance. The samples were ashed in a muffle
furnace. 400 C. and analysed for Ca and P (Klein-
berg et (21.. 197 I ). A second set of plaque samples
from the same sites was immediately transferred to
5 x 50-mm Kimex test-tubes containing 50~~1 NaF
solution (1 per cent w v) chilled in cracked ice which
98 R. Chatterjee and I. Kleinberg

When individual areas were considered, most differ-

ences were significant either at p < 0.01 or p < 0.001.
The intra-oral patterns for pH, Ca and P were
essentially the same both before and after banding;
maxillary plaques, both labial and approximal,
showed lower values than their mandibular counter-
parts. The carbohydrate pattern differed. Whereas,
before and after banding, maxillary and mandibular
labial plaques were the same, approximal plaques
showed higher carbohydrate levels in maxillary than
in mandibular sites (p < 0.05).

Fig. 1. Dentition sites where the pH was measured and DISCUSSION

plaque samples were removed for the Ca, P, carbohydrate
and N analyses. In each subject, 8 samples were taken; In agreement with Balenseifen and Madonia (1970),
2 each from any of the maxillary labial and approximal our study showed that the insertion of edgewise or-
and mandibular labial and approximal sites shown. The thodontic bands in human mouths leads to a decrease
same sites were sampled in each subject, twice before and in plaque pH and an increase in the carbohydrate
once after the insertion and wearing of their edgewise
content. In addition, the Ca and P content of the
orthodontic appliance.
plaque decreased. These changes are those predicted
from in-oitro experiments showing that acidic pH
prevented plaque carbohydrate degradation (Sand- favours the formation in saliva of aggregates low in
ham and Kleinberg, 1969). All samples were analysed Ca and P and high in carbohydrate (Kleinberg et
for total carbohydrate (Kleinberg et al., 1971) and for al., 1971; Cross et crl., 1973) and agree with evidence
N, to determine the sample size (Silverman and Klein- indicating that these may be incorporated into plaque
berg, 1967). during its formation (Kaufman and Kleinberg, 1973).
They also confirm that maxillary labial and approxi-
ma1 plaques with lower pH levels than corresponding
RESULTS
mandibular plaques (Kleinberg and Jenkins, 1964)
Regardless of the area examined, plaque pH, Ca show lower Ca and P levels (Kaufman and Kleinberg,
and P levels decreased after the insertion of the ortho- 1973) and possibly higher carbohydrate levels (Klein-
dontic appliances, whereas the carbohydrate levels berg et al., 1971).
rose (Figs. 2 and 3). Analysis of variance showed all Clinically, it is obvious that orthodontic appliances
changes to be significant statistically at p < 0.001. favour food retention. As this includes dietary carbo-

CALCIUM
cl W/O BAtVDhW

PHospHoRus
l-h

hkul1
LABIAL A$TZfX-

MAXILLARY
ABIAL

MANDIBULAR
AWJ~X- rOTAL

MEAN

Fig. 2. Ca and P levels with SE of plaques from the labial and approximal surfaces of the maxillary
and mandibular incisors before (mean of 52 samples) and after (mean of 26 samples) the insertion
and wearing of orthodontic appliances for four weeks. The two visits before banding were combined
as they were statistically similar.
 Orthodontic banding and plaque composltion YY

1
60.0
z
g
E
z
g 40.0,
Z
8
T
=20.0 6.0

.._
IMAL SRX- 4B’AL
AF;
MAXILLARY MANDIBULAR IMAXILLARY MANDIBULAR MEAN
MEAN
CARBOHYDRATE
Fig. 3. Mean carbohydrate and pH levels with SE of plaques on the labial and approximal surface5
of the maxillary and mandibular incisors before and after the insertion and wearing of orthodontic
appliances for the 13 subrects. To exaress the carbohydrate values in terms of mg drb weight of
plaque. they”should be rkltiplied by IO (Silverman and Kleinberg. 1967).

hydrate (Kleinberg and Jenkins, 1964), one would The largest rise in plaque carbohydrate occurred
expect this to be the basis for the decreased plaque in the approximal sites of the maxillary incisors which
pH. Frequent retention of fermentable carbohydrate show the largest decrease in pH (Kleinberg and Jen-
would increase acid formation and decrease the pH, kins, 1964) and the largest carbohydrate increase
which, together with influencing the composition of when exposed to dietary carbohydrate (Kleinberg et
the plaque (favouring lower Ca and P and a higher al., 1971). This was attributed earlier to (i) the low
carbohydrate level) would favour the growth and pH favouring deposition during plaque formation of
emergence of a more acidogenic flora (Becks, Jensen a CPCP aggregate with a lower calcium phosphate
and Millarr, 1944). Balenseifen and Madonia (1970) and a higher carbohydrate composition, and (ii) the
demonstrated a rise in the Lactobacillus content of presence of some synthesized intra- and extracellular
the plaque after orthodontic band placement, as well polysaccharide (Saxton, 1969; Critchley et ul.. 1967;
as in Streptococcus sa/ic%mriu.sand especially in Strep. Gibbons and Socransky. 1962; Gibbons and Bang-
mitis. hart, 1967).
The higher carbohydrate levels observed after The unequivocal decrease in the pH and the de-
banding are unlikely to be due to residual dietary crease in both Ca and P levels after orthodontic band
carbohydrate at the time of sampling as the subjects insertion provides additional support for the existence
were examined at least I2 h after food intake; too of a direct relationship between plaque pH and
long for carbohydrate to remain unfermented (Klein- plaque Ca and P levels. The significance of lower
berg and Jenkins, 1964). Intracellular and/or extracel- levels of Ca and P in the plaque is that less of these
lular polysaccharide synthesized by the plaque bac- elements will be available to be solubilized in prefer-
teria while dietary carbohydrate was available might ence to the Ca and P of enamel during a plaque acid
still be present; if so, it is more likely to be extracellu- attack (Dawes and Jenkins, 1962: Kleinberg. 1970:
lar polysaccharides, particularly the poorly soluble Ashley, 1975; Kleinberg et ul., 1976). This. together
dextrans as these are thought to be broken down with the more acidogenic plaque favoured bv band-
more slowly than are the intracellular forms (Gibbons ing, explains why banding tends to increase &es sus-
and Banghart, 1967). However, salivary glycoprotein ceptibility. Of significance clinically IS the fact that
in dental plaque is a source of carbohydrate often adolescents without orthodontic bands have lower
overlooked (McGaughey and Stowell, 1966, 1967). levels of plaque pH, Ca and P than adults (Kleinberg
Some of this carbohydrate is fermentable (Leach and et al., 1971; Kaufman and Kleinberg. 1973). Conse-
Critchley, 1966) and could be a continual, replenish- quently. orthodontic banding. most commonly per-
able source for the plaque bacteria and thus respon- formed during adolescence. would increase the
sible for a lower fasting pH when the other forms already greater susceptibility of the adolescent to
of carbohydrate are not present. caries.
100 R. Chatterjee and 1. Kleinberg

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